Overview
Definition:
Robotic transabdominal preperitoneal (rTAPP) inguinal hernia repair is a minimally invasive surgical technique utilizing a robotic platform to address inguinal hernias
It involves accessing the preperitoneal space through the abdominal cavity to place a prosthetic mesh for repair
This approach aims to leverage the enhanced dexterity, 3D visualization, and tremor filtration offered by robotic surgery to improve outcomes and potentially reduce recurrence rates compared to laparoscopic or open methods.
Epidemiology:
Inguinal hernias are extremely common, affecting an estimated 25% of men and 2% of women at some point in their lives
While open repair remains the most frequent method globally, minimally invasive techniques, including laparoscopic and robotic approaches, are gaining traction due to benefits like reduced postoperative pain and quicker recovery
The incidence of robotic surgery for hernias is increasing with technological advancements and surgeon adoption.
Clinical Significance:
rTAPP offers potential advantages in complex hernia cases, recurrence repairs, and for surgeons seeking enhanced ergonomic benefits
Proper setup and meticulous docking are paramount to safe and effective robotic surgery, directly impacting operative efficiency, instrument maneuverability, and ultimately, patient safety and surgical outcomes
For DNB and NEET SS candidates, understanding the nuances of robotic setup and docking is crucial for managing cases involving this modality.
Setup
Patient Positioning:
Patient is typically placed in a supine position
A slight reverse Trendelenburg with left-sided tilt (if operating on the right side) or right-sided tilt (if operating on the left side) may be employed to allow abdominal contents to gravitate away from the surgical field and improve exposure
Careful padding and securing of the patient are essential to prevent pressure injuries, especially during longer procedures.
Robotic System Preparation:
The robotic console, patient cart (with robotic arms), and vision cart are positioned strategically around the operating table
The patient cart is docked to the table, typically spanning the patient laterally
Instruments are prepared and attached to the robotic arms according to the surgeon's preference and the specific procedure
Sterilization of instruments and accessories is verified
The camera and energy devices are connected and tested.
Trocar Placement Strategy:
A typical rTAPP setup involves three or four trocars
A primary 12mm trocar is usually placed in the supraumbilical region or within the umbilicus for the camera
Two 8mm trocars are then placed in the left or right iliac fossa, approximately 8-10 cm apart, to house the robotic instrument arms
These should be positioned to allow for adequate triangulation and instrument articulation without collision
An additional 5mm or 8mm assistant port may be placed in the epigastrium or between the primary ports for retraction or triangulation if needed.
Insufflation And Initial Access:
Pneumoperitoneum is established, typically to a pressure of 12-15 mmHg, using a Veress needle or direct trocar insertion
The abdominal cavity is inspected for any intra-abdominal pathology or adhesions before proceeding
The initial access ports are then secured and insufflation is maintained throughout the procedure
Careful attention is paid to avoid injury to intra-abdominal organs during trocar insertion.
Docking
Docking Sequence And Considerations:
Docking involves coupling the robotic arms to the trocars
The surgeon uses the console to guide the robotic arms to the desired ports
The order of docking can vary, but generally, the instrument arms are docked first, followed by the camera arm
Key considerations include ensuring that the robotic arms can achieve optimal triangulation for dissection and mesh placement, avoiding instrument collision, and maintaining good access for the assistant surgeon.
Surgeon Console Setup:
The surgeon sits at the console, which provides a high-definition 3D view of the operative field
Instrument controls are manipulated with finger and wrist movements, translating into precise robotic movements at the patient's side
The console settings for camera control, energy activation, and instrument selection are confirmed before initiating the procedure
Ergonomics and surgeon comfort are optimized.
Instrument Selection And Articulation:
Specialized robotic instruments, such asMaryland dissectors, fenestrated bipolar graspers, and needle drivers, are used
These instruments offer a greater range of motion (7 degrees of freedom) compared to laparoscopic instruments
The surgeon ensures that the selected instruments allow for adequate dissection, retraction, and suturing within the confines of the preperitoneal space
Articulation of instruments is tested to confirm full range of motion.
Troubleshooting Docking Challenges:
Common docking challenges include insufficient space between trocars, interference with patient anatomy or other surgical equipment, and robotic arm collisions
These can often be resolved by adjusting trocar positions, repositioning the patient cart, or modifying the docking sequence
The operating room team must communicate effectively to troubleshoot these issues promptly to maintain operative flow and patient safety.
Preoperative Preparation
Patient Evaluation:
Comprehensive history and physical examination to confirm the diagnosis of inguinal hernia, assess for associated comorbidities, and identify any contraindications for robotic surgery
Preoperative imaging may be considered in select cases, particularly for recurrent hernias or if intra-abdominal pathology is suspected
Patients are counseled on the procedure, risks, benefits, and alternatives.
Anesthesia Considerations:
General anesthesia is typically required for rTAPP
Anesthesia management involves ensuring adequate muscle relaxation for pneumoperitoneum and maintaining hemodynamic stability
Consideration should be given to prolonged operative times that may be associated with robotic procedures
Postoperative pain management strategies are initiated preoperatively.
Informed Consent:
Detailed discussion with the patient regarding the rTAPP procedure, including its advantages (e.g., enhanced visualization, dexterity) and potential disadvantages (e.g., cost, specialized equipment)
Specific risks such as bleeding, infection, injury to adjacent structures (bowel, bladder, nerves), recurrence, and conversion to open surgery are explained
Consent for mesh placement and potential need for additional procedures is obtained.
Procedure Overview RTAPP
Mesh Placement And Fixation:
Once the preperitoneal space is adequately dissected and the hernia sac is reduced or ligated, a prosthetic mesh is introduced into the preperitoneal space and positioned to cover the entire myopectineal orifice
The mesh must be adequately sized and oriented correctly
Fixation of the mesh is typically achieved using absorbable tacks, sutures, or fibrin glue, depending on surgeon preference and the specific hernia characteristics
Over-dissection or excessive fixation can lead to nerve injury and chronic pain.
Closure Of Peritoneotomy:
After mesh fixation, the small incision in the peritoneum (peritoneotomy) is meticulously closed, usually with a running absorbable suture
This step is crucial to prevent bowel entrapment within the preperitoneal space and to minimize the risk of internal herniation
Careful visualization and secure closure are paramount
The adequacy of the closure should be confirmed by insufflating the peritoneal cavity and observing for any air leaks.
Exsufllation And Wound Closure:
The pneumoperitoneum is released, and the robotic instruments are undocked
Trocars are removed under direct vision to check for bleeding or herniation at the port sites
The skin incisions are then closed with subcutaneous sutures or surgical tape, depending on the size of the trocar site
Steri-strips may be applied for added support
A sterile dressing is applied over the incisions.
Postoperative Care And Follow Up
Early Postoperative Management:
Patients are typically monitored in a recovery room until they are hemodynamically stable and pain is adequately controlled
Early ambulation is encouraged to prevent venous thromboembolism and promote recovery
Fluid intake is advanced as tolerated, and patients are usually discharged on the same day or the next day, depending on their recovery and social support
Pain management typically involves oral analgesics.
Discharge Instructions:
Patients receive clear instructions regarding wound care, activity restrictions (avoiding heavy lifting for 4-6 weeks), dietary recommendations, and signs/symptoms of potential complications (e.g., fever, increased pain, redness at incision sites, nausea, vomiting)
They are advised to follow up with their surgeon as scheduled.
Long Term Follow Up:
Routine follow-up appointments are scheduled to assess wound healing, monitor for recurrence, and evaluate long-term outcomes
The frequency of follow-up varies but typically includes checks at 1-2 weeks, 1-3 months, and potentially at 1 year postoperatively
Patients are encouraged to report any concerns or symptoms of recurrence promptly
Long-term recurrence rates for rTAPP are generally comparable to other minimally invasive techniques, though data continues to evolve.
Key Points
Exam Focus:
Understanding the strategic placement of trocars in rTAPP for optimal triangulation and instrument maneuverability
Recognizing the importance of meticulous peritoneal closure to prevent complications
Knowing the sequence of docking and potential troubleshooting
Awareness of patient positioning to facilitate abdominal retraction
DNB/NEET SS often test practical aspects of minimally invasive procedures.
Clinical Pearls:
Always ensure adequate space between ports for instrument articulation and to avoid collisions
Use a slight left-sided tilt for right-sided hernias and vice-versa to enhance gravity-assisted retraction
Confirm peritoneal closure thoroughly before exsufllation
Consider nerve pathways and avoid excessive dissection or fixation to prevent chronic groin pain
Preoperative imaging is beneficial for recurrent or complex hernias.
Common Mistakes:
Inadequate port placement leading to poor triangulation or instrument collision
Failure to adequately visualize and close the peritoneotomy, increasing risk of bowel entrapment
Insufficient mesh coverage of the myopectineal orifice leading to recurrence
Over-aggressive dissection causing nerve injury
Not addressing intra-abdominal pathology identified during access
Ignoring ergonomics at the console leading to surgeon fatigue.