Pneumoperitoneum : Veress needle
The other cannulas, one for the robotic optic and two for work arms, are located under direct view, preferably 20 cm away from the main adhesion point or center, calculating enough space for instruments to begin work (Fig. 2a, b). They could be in one lower quadrant, left or right with the camera in the middle or with the camera on the corner of the abdomen on the left lower quadrant between two robotic arms, one on the left flank and the other on hypogastrium, 2 cm above the pubic bone. At this position we can almost do any adhesiolysis with defect suturing. Docking for this rational is from the left shoulder or from the head. The initial steps of this dissection have the image pretty close to the camera. The adhesions are penetrated by the CO2 and the limits from the bowel seromuscular layer and abdominal wall appear isolated for safe dissection. Electric cautery must be avoided. We used a bipolar fenestrated instrument on the left hand and a monopolar scissor on the right. The scope is 30° up view at this time.
(a) Trocars positioning : before docking. (b) Trocars positioning: after docking
During this total adhesiolysis an inadvertent or even strategic bowel opening must be immediately closed by suture (Fig. 3a–c). These lesions can become completely hidden afterwards if left to be treated at the end. All the instruments’ movements should point the anterior abdominal wall; it looks like a painter painting the ceiling lying on a flat scaffold. All the traction is over a slight angle, almost parallel to the inverted surface, to expose adhesions for the scissor lamina to work, blunt and sharp dissections. It is a step-by-step procedure when the adhesion is too firm (Fig. 4). The camera is very close at these moments (Fig. 5). The patient-side surgeon must help push the abdominal wall to produce a flat condition for dissection, sometimes bringing the hernia contents to the camera view or against the instruments’ tip reach (Fig. 6).
(a) Adhesiolysis : traction and contra-traction. (b) Adhesiolysis: bowel injury. (c) Adhesiolysis: bowel repaired after injury
(a) Adhesiolysis : instruments usage. (b) Adhesiolysis: instruments usage
Adhesions close to the camera
(a) Assistant’s help: inside view. (b) Assistant’s help: outside view
Adhesions are common findings in abdominal surgery and even in surgery-virgin patients. They are not an emergent condition; they can occur as normal recovery, however, they can present as complications such as bowel obstruction, pain, or other emergencies . When needed, minimally invasive surgery can help with the use of the pneumoperitoneum and better postoperative outcomes . Robotic surgery with 3D view and articulated movements could facilitate this type of procedure even more , although care must always be taken to diminish the rate of conversion .
Robotic adhesiolysis is an evolution in minimally invasive procedures for such complex situations.
It needs persistence and patience to achieve a comfort zone.
The most important surgical time for the procedure is its preoperative plan and it depends on the characteristic of each patient and each disease. Each patient is his or her own hypothesis creator; we must separate patients instead of classifying them to one standard.
We must release all adhesions before defect repair. We must reach an open wide cavity with any bowel lesion treated before hernia repair.
You may also need