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P063: ROBOTIC INCISIONAL LUMBAR HERNIA REPAIR: TAPP APPROACH
Ana T Garcia Cabrera, MD1; Diego L Lima, MD1; Xavier Pereira, MD1; Leandro Cavazzola, MD, MChir, PhD, FACS2; Flavio Malcher, MD, MSc, FACS1; 1Montefiore Medical Center; 2Universidade Federal do Rio Grande do Sul- UFGRS
Objectives: To describe a surgical technique for robotic incisional lumbar hernia repair.
Methods: Retrospective data was collected from four patients who underwent robotic surgical repair of their lumbar hernias after open nephrectomies. The patients were a 53 year-old male patient with an incisional hernia in the right flank, a 41 year-old male with a recurrent left sided incisional hernia, a 77 years-old female patient with an incisional hernia on the left flank, and a 62 year old male with a right incisional hernia.
Surgical technique: A trans-abdominal preperitoneal approach (TAPP) was used in all cases. The patients were placed in lateral decubitus position contralateral to the hernia defect side. The abdominal cavity was entered via a Veress needle, followed by a 5 mm Optiview port through the ipsilateral subcostal area. One peri-umbilical 12 mm port and two 8 mm ipsilateral paramedian ports were placed and the robot was docked from the ipsilateral hernia side. The abdomen was explored until the lumbar herniating defects were encountered and the herniating fat and viscera were completely reduced. A peritoneal incision was made at least 5 cm medially to the edge of the defect followed by extensive dissection to create a large pre-peritoneal plane. The hernia sacs were completely dissected and reduced allowing for complete visualization of the hernia defect. The respective defect sizes were 11 x 10 cm, 11 x 16 cm, 4 x 5 and cm with a neighboring 1.5 x 2 cm defect, and 9 x 8 cm in size with the mean defect area of 99 cm2. All defects were primarily closed with V-Loc 0/1 running sutures; in the case of large defects over 9 mm releasing tension maneuvers and reduction of pneumoperitoneum were used to achieve a tension free repair. On one occasion, a Pro-grip mesh was placed overlying the primary repair to reduce tension on the suture line. Next, the preperitoneal space was measured and either Polypropyelene or Pro-Grip mesh was applied overlying the defect with a circumferential overlap of a minimum of 5 cm. The meshes were secured using either Vicryl #0 transfacial sutures, Evicel or a combination of both, no traumatic fixation devices were used. The peritoneal space was closed with running 2-0/3-0 Vicryl and no residual defects were noted in the peritoneum. The ports were removed, and the robot was undocked at this time. Average procedure length was 4 hours. Post-operative length of stay ranged from 0 to 2 days with only one post-operative complication consisting of post-operative readmission due to increased pain and a post-operative seroma, managed with adequate pain control and conservative management of the seroma, at an average 3 month follow-up.
Conclusion: The robotic approach is safe, feasible and effective for the correction of lumbar incisional hernias.
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