Synchronous robotic repair of anterior diaphragmatic (Morgagni) hernia & low anterior resection for rectal cancer

Abstract

Background

We present the case report of synchronous trans‐fascial repair of a large congenital Morgagni hernia (MH) and low anterior resection using a fully robotic approach.

Methods

A 61‐year old female presented with fresh red blood in her stool. She had a previous history of abdominal hysterectomy and a performance status of 0. Imaging revealed a low rectal cancer and incidental large MH.

Results

Using the Da Vinci X platform the procedure was successfully performed; total operating time of 450 min, <200 ml blood loss and 5 days hospital stay. Post‐operative scan at 6 months, 1 and 2 years showed no evidence of hernia or cancer recurrence.

Conclusion

We have demonstrated that complex multi‐visceral procedures can be safely performed on fully robotic platforms, even in previously disturbed surgical fields. The robotic approach may provide the opportunity for seamless multi‐speciality operating simultaneously in multiple body cavities.

1. INTRODUCTION

The use of fully robotic platforms in multi‐visceral procedures has been hailed as one of the advantages of this versatile and expanding technology. There are currently a handful of published case reports and series that have reported on multi‐speciality/multi‐visceral procedures combining colorectal & urological, ¹ , ² colorectal & upper gastrointestinal ³ and colorectal & gynaecological ⁴ organs. Satisfactory outcomes such as good oncological clearance, low morbidity & blood loss and acceptable recovery times without significantly increasing surgical operative time have been reported. ⁴ We have not encountered any reports of combined fully robotic thoracic and abdominal procedures as in the case we present here. MHs are rare and are often discovered incidentally. The first fully robotic Morgagni hernia (MH) repair as a single procedure was reported in 2017, ⁵ since then this technique has been further described in small series. ⁶ , ⁷ We hereby describe the synchronous repair of a large MH and anterior resection for rectal cancer.

2. MATERIALS & METHODS

Computed Tomography images of the thorax, abdomen and pelvis, MRI of the rectum and endoscopic images were reviewed at the colorectal Multi‐disciplinary team (MDT). Imaging revealed a 6 × 6 cm right‐sided anterior diaphragmatic hernia containing all of the transverse colon (Figure 1A) and a rectal lesion 7 cm from the anal verge (Figure 1B). Histological diagnosis of a rectal adenocarcinoma was made after colonoscopy. The Da Vinci X robotic system by Intuitive Surgical Inc (Sunnyvale, CA 94086‐5304, USA) was used to perform the procedure in its entirety. The patient provided written consent pre‐operatively for video recording and image capture for educational purposes.

FIGURE 1.

(A) coronal & (B) sagittal sections showing hernia defect and sac containing transverse colon. (B) sagittal section showing rectal tumour

3. SURGICAL TECHNIQUE

A 5 mm right upper quadrant visiport was used to gain pneumoperitoneum. This port was then converted to an assistant port for the hernia repair aspect. A 15 mm left iliac fossa port was further used as an assistant port and subsequently the extraction site. In total, five robotic ports were placed adhering to the Universal Port Placement Guidelines by Intuitive Surgical to enable a double docking. The patient was placed in the deck‐chair position to create counter traction on the hernia contents (Figure 2C). The hernia sac was dissected out in its entirety to define the diaphragmatic edges (Figure 2D). A porcine dermal collagen mesh; Permacol (Medtronic Limited, Watford, WD18 8WW United Kingdom) was deployed posterior‐laterally and sutured in an interrupted fashion (Figure 2E). The anterior component of the mesh was sutured trans‐fascially to the abdominal wall (Figure 2F). A 14Fr suction drain was placed in the hernia cavity adjacent to the pericardium. Using the same port configuration, the splenic flexure was completely mobilised. The Association of Coloproctologists of Great Britain & Ireland (ACPGBI) guidelines ⁸ on positioning in pelvic surgery were adhered to for the mitigation of the risk of lower limb ischaemia and compartment syndrome. This involved lowering the legs to a position below the heart for a minimum of 15 min for every 4‐h period. This recovery period was documented in the operation notes. Due to the length of the procedure this was an important consideration.

FIGURE 2.

(C) hernia defect with abdominal contents reduced. (D) sac dissection & defect measurement. (E) postero‐lateral mesh suturing. (F) trans‐fascial Permacol mesh application

The robot was then undocked and the patient placed in the Lloyd Davies position. The robot was re‐docked with an additional 12 mm right iliac fossa port in Standard Configuration for left sided colonic mobilisation. Using a medial to lateral approach, a low anterior resection with primary anastomosis was then performed. The patient had a background surgical history of a perforated bladder following a hysterectomy making the dissection within the pelvis challenging. Post‐operative scans at 6 months (Figure 3G), 1 and 2 years showed no evidence of hernia or cancer recurrence.

4. RESULTS

FIGURE 3.

(G) 6‐month post‐operative coronal & sagittal section of repair

5. DISCUSSION & CONCLUSION

Successful synchronous multi‐visceral procedures have been reported using earlier generation Da Vinci systems. Morelli et al, reported a series of 10 synchronous colorectal resections on the Da Vinci Xi system with minor port alterations and a single docking. ⁹ Park et al, have reported a case of synchronous radical prostatectomy and anterior resection with stated benefits of greater dissection precision, no complications, low morbidity and good oncological outcomes. ² MH are rare and traditional open techniques have been superseded by minimally invasive approaches. Although minimally invasive repair is widely reported in the paediatric populations, the literature on fully robotic repair in adults is sparse. A few authors have demonstrated robotic repair using various tension free techniques reinforced with biological mesh. ⁵ , ⁶ , ¹⁰ , ¹¹ One laparoscopic three‐case series ¹² reported good results using a primary closure technique followed by a buttressing onlay composite mesh anchored to fascia anteriorly and diaphragm postero‐laterally. We suggest that primary repair may not be feasible with larger defects and a bridging‐type repair may be more acceptable. In fact, a recent much larger series of 15 consecutive laparoscopic & robotic MH repairs reported 73% synthetic mesh bridging technique and 27% primary repair only. ¹³ The authors noted that the bridging technique was more appropriate for larger defects. These data suggest that the choice of repair technique are largely dependent on the defect size and minimally invasive modality, with the onlay technique least frequently used.

We have not found any reports combining MH repair with a low anterior resection for cancer. A unique feature of robotic operating platforms is the utility of performing multi‐visceral and multi‐cavity surgical procedures negating the need for separate surgical setups hence maximising operating room efficiency. There may be added benefits of shortening the time to adjuvant treatments in cases where there are synchronous neoplastic lesions in anatomically different regions. ⁴ In complex and lengthy multi‐visceral operations that may be mentally and physically exhausting on the surgeon, the robotic platform may provide an additional benefit of reducing cognitive and musculoskeletal fatigue. ¹⁴

Due to the small number of reported procedures making use of this versatility feature, there has been no standardised surgical approach as to the setup and surgical teams appear to modify their own techniques on a case by case basis. In this particular case the pre‐operative planning considered whether the MH should be repaired in the same sitting, taking into consideration the risks of iatrogenic injury to mediastinal structures. This was an important consideration as a major complication may reduce the opportunity for a curative resection. The decision to attempt a dual cavity procedure was heavily influenced by the requirement to mobilise sufficient transverse colon to allow for a tension‐free primary anastomosis. The MDT planning team also considered the risk of seroma formation adjacent to the pericardium post‐hernia repair. This risk was mitigated by positioning a drain within the reduced cavity and pre‐operative consultation with the cardiologists in the event that a percutaneous pericardial drain was required. In our experience the decision on a multi‐visceral/multi‐cavity approach would be dependent on thorough investigation and planning, taking into consideration patient suitability, feasibility and not compromising safety or efficacy to achieve the intended outcome. Consequently there were no thoracic or intra‐abdominal complications requiring intervention.

To our knowledge this is the first reported case of synchronous MH repair and anterior resection. In this report we have demonstrated that dual cavity procedures can be performed safely using a fully robotic platform. With appropriate patient selection, operative planning and surgical expertise these approaches may become more commonplace and may lead to technique standardisation.

AUTHOR CONTRIBUTION

Joel Lambert wrote the manuscript. Abdul Shugaba edited the manuscript. Michael Gill, Adnan Sheikh, edited the manuscript and verified technical details. All authors have reviewed and approved the manuscript.

CONFLICT OF INTEREST

For all the authors, the submitted work was not carried out in the presence of any personal, professional or financial relationships that could potentially be construed as a conflict of interest.

CONSENT FOR PUBLICATION

Written patient consent was gained for video recording and image capture for education & publication purposes.

GUIDELINES

CARE guidelines have been adhered to in the production of this manuscript.

Lambert J, Shugaba A, Sheikh A, Gill M. Synchronous robotic repair of anterior diaphragmatic (Morgagni) hernia & low anterior resection for rectal cancer. Int J Med Robot. 2023;19(1):e2481. 10.1002/rcs.2481

DATA AVAILABILITY STATEMENT

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.