Dual docking technique for robotic repair of simultaneous inguinal and umbilical hernia: A preliminary single center experience

This study aimed to assess clinical results in terms of intraoperative outcomes, recovery and recurrence of our robotic technique for the treatment of patients affected by simultaneous inguinal and umbilical hernia, providing technical details to facilitate multiquadrant surgery in robotic hernia repair.


Multiquadrant procedures represent challenging interventions per-
formed with a totally robotic technique, and there is a paucity of data on the application of robotic surgery for multiquadrant approaches. 1 The recently developed robotic platform da Vinci Xi ® empowers the surgeon to perform robotic multiquadrant procedures and it can be considered a valid solution in the treatment of combined abdominal pathologies. 2 the setting of abdominal wall surgery, the robotic approach has emerged as an alternative technique to minimally invasive hernia repair with the aim of bringing benefits such as decreased postoperative pain related to mesh fixation (suturing opposed to tack fixation in traditional laparoscopic repair), and improved surgeon ergonomics. 3Furthermore, the learning curve for minimally invasive hernia repair is steep due to the degree of technical difficulty and the robotic platform contributed to an increase in the number of minimally invasive procedures, allowing surgeons to complete technically This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
-1 of 6 https://doi.org/10.1002/rcs.2586difficult interventions because of better visualisation and capability of wristed movements. 4e aim of this article is to show our experience in robotic surgery for the repair of simultaneous inguinal and umbilical hernia, providing technical details to facilitate multiquadrant surgery in robotic hernia repair.Phase II: The robotic arms are undocked, trocars 4 and 5 are placed, the boom is rotated 90°and the patient cart is docked according to the configuration for the inguinal hernia (Figure 2): endoscope through trocar 4, fenestrated bipolar forceps through trocar 5 and monopolar curved scissors through trocar 2; trocar 1 is used as assistant port for the insertion of mesh and sutures, suction/ irrigation, or any further traction.This second phase represents TAPP inguinal hernia repair.The peritoneum is incised between the anterior superior iliac spine and the medial umbilical ligament.The peritoneal flap size was estimated to fit the mesh comfortably (Figure 3B).The preperitoneal space is dissected to identify the spermatic cord, vas deferens and other important structures.Once the hernia sac is reduced and detached from the spermatic cord, a self-fixating mesh is placed (Figure 3C) and the peritoneal flap is closed with a running barbed suture (the large needle driver is inserted in place of the scissors during this step).

| MATERIAL AND METHODS
Phase III: Robotic arms are undocked, boom is rotated and the patient cart is re-docked to the configuration for the umbilical hernia; trocar four is partially removed to allow completion of TARUP hernia repair and trocar five is used as an assistant port.With the retromuscular flap already prepared, the umbilical fascial defect is sutured and a self-fixating mesh is placed in the retromuscular space (Figure 3D).Finally, the posterior rectus sheath and peritoneum are closed with a running barbed suture.
Continuous variables were reported as mean values, whereas dichotomous variables were expressed as percentages.The software package used for the management of references, statistics, and graphics included Microsoft SPSS v26.0.

| DISCUSSION
Robotic surgery has emerged as an alternative approach to minimally invasive hernia repair with the aim of bringing benefits such as decreased postoperative pain related to mesh fixation (suturing opposed to tack fixation in traditional laparoscopic repair), and improved surgeon ergonomics. 3Robotic surgery is also playing an important role in complex abdominal wall hernias, allowing surgeons to perform technically difficult interventions because of better visualisation and the capability of wristed movements.Furthermore, the learning curve for robotic hernia repair is less steep than laparoscopic procedures, contributing to an increase in the number of minimally invasive procedures for hernia surgery. 4,6In a 2022 review, Saito et al. stated that the experience of 25-43 cases of robotic TAPP has been reported as a benchmark for surgeons who have achieved the learning curve for TAPP. 7Muysoms et al. studied the operative time during the learning curve for robotic TARUP and stated that the decrease in operative time during the adoption of robotic TARUP was mainly related to the improved efficiency in the dissection phase of the procedure. 8spite its benefits, robotic surgery has been criticised for the restricted range of motion of the robotic arms, and inability to perform multiquadrant abdominal surgery.Total robotic techniques evolved but they required dual docking and involved cumbersome changes of position of the patient cart. 9The recently developed Xi system empowers the surgeon to perform robotic multiquadrant procedures, introducing a host of improvements: redesigned robotic arms allow closer port spacing while avoiding external collisions and the mobile boom along with single-button targeting removes tedious fine-tuning of arm placement to be successful in multiquadrant surgery. 10This latter feature makes da Vinci Xi ® potentially ideal for the treatment of simultaneous pathologies in the abdominal area.However, this concept is addressed in the literature especially for colorectal surgery, while less is known about multiquadrant surgery for the treatment of multiple hernias of the abdominal wall. 11Kudsi et al. analysed the outcomes of robotic ventral hernia repairs with concomitant procedures, deducing that incisional hernia repairs, nonabdominal wall procedures, and a history of wound infection were risk factors for postoperative complications. 12e repair of inguinal and umbilical hernia association is an underestimated concept in the surgical literature in the era of minimally invasive surgery.Bertozzi et al. described a case series of 26 children affected by simultaneous inguinal and umbilical hernia treated with laparoscopic herniorrhaphy of the inguinal defect associated with the repair of the umbilical hernia tightening a previously fashioned purse-string suture. 13Beyond the paediatric population, there is a lack in the literature of surgical techniques for the repair of simultaneous inguinal and umbilical hernias.
Transabdominal preperitoneal (TAPP) approach has gained space so the preperitoneal space has started to be endorsed in minimally invasive inguinal hernia repair. 14In a standardized operating setting, a camera port is inserted into the abdominal cavity after umbilical access and two 8-mm robotic ports are placed either side lateral to the umbilicus, slightly above or below the umbilical line, with a minimum of 10 cm lateral to the supraumbilical port and 10 cm superior to the anterior superior iliac spine. 15,16milarly, the operating setting for the robotic transabdominal retromuscular umbilical prosthetic hernia repair (TARUP) technique is performed in a standard way by the robotic surgeons: the first 8-mm trocar was placed in the left subcostal region (2 cm from the costal margin) at the midclavicular line.10][11][12][13][14][15][16][17] In our institution, this is the first case series of robotic repair of simultaneous inguinal and umbilical hernia and in this article we describe our experience with the robotic platform da Vinci Xi ® .Our dual docking technique combines the robotic TAPP approach for inguinal hernia with TARUP using five robotic trocars.In each phase of the operation, we have three operating trocars and one trocar for the assistant, allowing the procedure to be carried out comfortably.Through this study, we found that this surgical technique is feasible, reproducible and shows optimal postoperative outcomes, such as early mobilisation and short length of stay.
Although this article is limited to a single surgical group experience, the results are encouraging and increasingly lay the foundation for the use of the robotic platform even for complex surgical interventions.
Our study has to be considered a proof of concept and it provides an aid to surgeons performing multiquadrant robotic surgery for the treatment of abdominal hernias.

From
January 2018 to December 2021, 15 patients affected by simultaneous primary inguinal and umbilical hernia underwent robotic surgery.All procedures were performed using the da Vinci Xi ® platform.The collected information was retrospectively analysed and included demographic characteristics, intraoperative data and recovery outcomes.Twelve out of 15 patients were affected by umbilical hernia associated with unilateral inguinal hernia, while 3 patients presented with umbilical hernia associated with bilateral inguinal hernia.Intraoperative data analysed included overall operative time, each single docking phase time and mean mesh coverage area.We analysed length of hospital stay, time of mobilisation, 30-day readmission and recurrence.Postoperative complications have been classified according to the Clavien-Dindo classification. 5The patients were examined during follow-up with a standard physical examination on postoperative day 1, and at 1 week, 1 month, and every 6 months.No patients were lost to follow up.This study was conducted according to the Declaration of Helsinki and the guidelines of Good Clinical Practique (World Medical Association, 2013).Written informed consent was obtained from all patients.As an observational study, the Ethics Committee of our institution confirmed that no ethical approval is required.Entry into the abdominal cavity is gained at Palmers point (primary left upper quadrant) with placement of a Veress needle.Insufflation with CO2 to 15 mmHg is standard.Robotic trocars are placed along two perpendicular abdominal lines, as shown in Figures 1 and 2: the right midclavicular line (dashed yellow line) and the transverse umbilical line (dashed red line).Trocars 1, 2 and 3 are positioned along the right midclavicular line: the trocar 2 at the intersection with the transverse umbilical line, the trocar 1 superiorly in the right hypochondrium, and trocar three inferiorly in the right iliac region (both trocars 1 and 3 are placed 8 cm apart from trocar 2).Trocar four is placed through the umbilical defect and trocar five on the transverse umbilical line at the intersection with the left midclavicular line.The patient lies supine with moderate Trendelenburg.The da Vinci Xi ® patient cart is positioned on the patient's left side; side docking affords access to both inguinal regions as well as gives us the space to work in the midline region.Three robotic arms were used throughout the procedure.Phase I: Initially, only trocars 1, 2 and 3 are placed and the patient cart is docked according to the configuration for the umbilical hernia (Figure 1): endoscope through trocar 2, fenestrated bipolar forceps through trocar 1 and monopolar curved scissors through trocar 3. The retrorectus is dissected by incising the posterior rectus sheath (Figure 3A); the preparation of the retromuscular flap concludes the first phase of the procedure.In this way, trocar 4 (the umbilical one) can be inserted for the second phase without the risk of damaging the flap prepared during this first phase.F I G U R E 1 Configuration for umbilical hernia.Trocars 1, 2 and 3 are docked to the patient cart; trocar five is used as the assistant port.F I G U R E 2 Configuration for inguinal hernia.Trocars 2, 4 and 5 are docked to the patient cart; trocar 1 is used as the assistant port.
docking technique was used to treat 15 patients affected by simultaneous primary inguinal and umbilical hernia between January 2018 and December 2021 at our department of surgery.Eleven of the 15 patients were males (73.3%) with a mean age of 38.4 years (range: 32-50) and mean body mass index (BMI) of 26.8 kg/m 2 (range: 20.1-29.7 kg/m 2 ).Patient's demographic and preoperative variables are in Table 1.All the patients were affected by umbilical hernia, 12 of them (80%) in association with unilateral inguinal hernia and 3 (20%) in association with bilateral inguinal hernia.Robotic surgery was performed in all cases with the da Vinci Xi ® platform and no intraoperative complications occurred.Intraoperative data are summarised in Table 2. None of the patients were converted to laparoscopic or open techniques.The mean mesh coverage area was 172 cm 2 (range: 120-216 cm 2 ) for umbilical defects and 123 cm 2 (range: 100-180 cm 2 ) for inguinal defects.The mean overall operative time was 55 min (range: 45-80 min).Mean overall docking time was 17 min (range: 10-20 min): mean phase I docking time was 9 min (range: 8-11 min), mean phase II docking time was 6 min (range: 5-9 min) and mean phase III docking time was 3 min (range: 2-5 min).Postoperative outcomes are described in Table 3.All patients achieved complete mobilisation within 7 h (mean: 6.4 h).The mean length of hospital stay was 21.6 h (range: 12-36), with 5 out of 15 patients discharged on the same day of surgery.No surgical site infection occurred.There was one case of subumbilical seroma and one case of scrotal haematoma, both treated with conservative F I G U R E 3 (A) Preparation of retromuscular flap.(B) Preparation of peritoneal flap during the inguinal phase.(C) Placement of mesh after reduction of inguinal hernia sac.(D) Placement of mesh in the retromuscular space.T A B L E 1 Patients demographics and characteristics.was no major complication and no recurrence within the median follow-up period of 673 days (range: 180-1440 days).