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INDICATIONS

The indications for inguinal hernia repair have been described in the preceding chapters. Robot-assisted repair may be applied to indirect, direct, or femoral hernias. Robotic inguinal herniorrhaphy is contraindicated in the presence of intraperitoneal infection and irreversible coagulopathy and in patients who are poor risks for general anesthesia. Relative contraindications include large sliding hernias that contain colon, long-standing irreducible scrotal hernias, ascites, incarceration, and bowel ischemia. A thorough knowledge of the anatomy of the inguinal region is essential when it is approached posteriorly using robotic assistance. The view of this area as seen from the intraperitoneal perspective is shown in Chapter 114. In addition, the surgeon should have demonstrated and verified expertise, skill, and proficiency with the use of robotic devices and must be credentialed to use these devices for surgical assistance.

PREOPERATIVE PREPARATION

The patient must be a suitable candidate for general anesthesia. Anticoagulation, aspirin, and antiplatelet drugs such as clopidogrel bisulfate (Plavix) must be discontinued in advance of the procedure in order to avoid postoperative hematoma formation. Preoperative antibiotics should be administered intravenously within 1 hour of the incision.

ANESTHESIA

General endotracheal anesthesia is required.

POSITION

Patients are placed in the supine position, and the arms are tucked. The operating room setup and port placements are shown in FIGURES 1 and 2.

OPERATIVE PREPARATION

Skin hair is removed with a clipper. A catheter is placed in the bladder if deemed necessary by the surgeon, and it is removed at the end of the case. Sterile drapes are applied according to the surgeon’s specifications. Then a time-out is performed.

INCISION AND EXPOSURE

Room setup is in the standard fashion with the patient supine and arms tucked, if possible (FIGURE 1). A supraumbilical incision is made, and the abdomen is entered in the surgeon’s preferred technique. A robotic trocar is placed here, and the abdomen is viewed for any pathology. The second and third trocars are placed in a horizontal line approximately 10 cm from the initial trocar on either side (FIGURE 2). The robot is then docked, and the operation can begin.

DETAILS OF THE PROCEDURE

The operation begins by creating a flap on the side of the hernia. This flap incision should be large enough to accommodate the intended mesh. The incision can be carried out either medial to lateral or lateral to medial depending on the surgeon’s preference (FIGURE 3). Once the incision is complete, the dissection should be carried down to the pubic bone medially, exposing Cooper’s ligament. Direct hernias should be reduced at this time, and the medial aspect of the internal ring is exposed. Laterally, a large area should ...

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