(a, b) Physical exam
In order to achieve the diagnosis a computed tomography (CT) scan of the abdomen and pelvis can be done as shown in Fig. 2.
(a, b) Computed tomography showing perineal hernia (axial and sagittal)
When the diagnosis is made the patient has to be evaluated as to the possible treatment, in this case, surgery. He has to be fit for surgery and a consultation with the clinician and anesthesiologist is necessary.
Patient Preparation and Positioning
The patient is hospitalized on the same day of the surgery, at least 2 h before the scheduled procedure. In the majority of cases, there is no need for bowel preparation. Then, he is taken to the operating room (OR) and the preparations can be seen in Table 1.
Colostomy closure (sterile drape)
He is placed on the surgical table with both arms and legs closed. Sometimes the legs can be opened in order to dock the robotic cart between them. General anesthesia is applied with orotracheal intubation. After that, the patient receives prophylactic antibiotics, urinary catheter and the peripheral lines are placed. The patient is always secured on the table with fixation straps and well protected with a chest protector and a head/eye protector. A heater device is used, placed on the chest of the client.
The asepsis is done using chlorexidine and the surgical drapes are placed exposing the entire abdominal area. The colostomy is closed using a separated sterile surgical drape.
After all that is done, cannulas, energy cables, and other parts of the OR patient safety components and accessories are secured so as not to cause any problems during surgery.
The surgery can then start after all the preparations described are done. The pneumoperitoneum is made at the left upper quadrant using a Veress needle with the pressure of 12 mm of Hg. Using a sterile pen the ports are programmed using the perineal area as the target. The first cannula to be placed is the optical one, 12 mm, positioned at 2 cm above the umbilicus and 2 cm to its right side, respecting the distance of minimum 20 cm from the target and aligned with the robotic arm cart that will come from the left thight or between legs, depending on the “size” of the pelvis. Technology development is decreasing and changing this distances, time after time.
When the optic is inserted, a first evaluation of the abdominal cavity is done, looking at the entire cavity, searching for adhesions, understanding the main hernia, and diagnosing other possible defects such as inguinal hernias, paracolostomic, or incisional/ventral. We can change trocars positions depending on multiple defects, but perineal problems are the main goal to be done.
The other 8 mm cannulas are placed following the rule of 10 cm distance from each other to avoid collision during the procedure. Number 1 is placed in the left flank, number 2 between the camera and number one, and number 3 in the right iliac fossa. A fourth cannula for the assistant is placed in the upper right quadrant or any strategic place behind the camera and arm 3 with space for support from the auxilary. Figure 3 shows the positioning of the cannulas. Caution must be taken to avoid lesions to the colostomy when it exists.
In other cases, such as combined hernias the optical cannula can be placed 4–5 cm above the umbilicus. In this setup arm 1 can be placed at the left upper quadrant, arm 2 in the right upper quadrant, and arm 3 in the right flank. The assistant port can be between arms 2 and 3 at the right side of the patient. In these types of hernias there is no need to worry about the colostomy, and most patients do not have previous surgeries.
When the cannulas are placed and checked for positioning it is time to dock the robot. Using the pelvic defect as the target the robot can come from many areas, but mainly from the legs.
Figure 4 shows the possible dockings that can be done in the pelvic hernia repair.
(a–c) Robotic docking
The robot can come from the left side, with the legs closed: this type of docking is used to treat left anterior pelvic hernias and perineal hernias in order to protect the colostomy and treat possible paracolostomic defects, often present in patients that have undergone APE or ELAPE (Fig. 4a).
In the case of a right anterior pelvic hernia the robot can come from the right with the legs closed (Fig. 4b).
The third option is the docking between the legs, as used in prostatectomies (Fig. 4c).
In case of emergency, the assistant must be ready to undock the robot and take whatever action is necessary to solve the problem that appeared.
The surgical technique can be divided into parts for better understanding of the procedure. Hence, it is separated in: dissection/adhesiolysis, closure of the defect, mesh placement, and fixation.
One of the most important parts of the dissection is the identification of the structures to be separated. Because one of the major complications of the perineal hernia repair is bowel injury, the adhesiolysis becomes even more important. The perineal defects are often accompanied by strong, firm adhesions, mainly in the pelvic area, but the entire abdominal cavity can present them. The robotic instruments with wrist movements along with the 3D view can facilitate management of these adhesions, as the penetration of CO2 between the conjuntive tissue, lowering the incidence of lesions and making the process faster. The instruments used are (Fig. 5):