Robotic transabdominal preperitoneal repair for recurrent inguinal hernia after Kugel hernioplasty: A case report

Abstract

Introduction and importance

The laparoscopic posterior approach adapts the advantages of Kugel hernioplasty, making it possible to perform it at the new layer even if the inguinal hernia is recurrent following the anterior approach, producing a high level of completion. However, in laparoscopic surgery for recurrent inguinal hernia using posterior approaches, dissecting the extraperitoneal space is difficult. Robotic surgery may enable precise dissection, even if the space is severely adhered. Here, we report a robotic approach after extraperitoneal approach for recurrent inguinal hernia, which developed after Kugel hernioplasty.

Case presentation

A 78-year-old Japanese man, who underwent left inguinal hernia repair (Kugel hernioplasty) 2 years ago, presented with recurrent reducible left inguinal swelling. A peritoneal incision was created above the deep inguinal ring to treat the primary right inguinal hernia. The pressure in the left inguinal region revealed a spermatic cord lipoma protruding from the internal inguinal ring as a recurrent inguinal hernia of the abdominal cavity.

Clinical discussion

Robotic transabdominal preperitoneal repair for recurrent inguinal hernia is effective, especially after posterior approach Kugel hernioplasty, in which dissection of the extraperitoneal space is difficult. In the present case, the peritoneal flap was conserved without removing the direct Kugel patch.

Conclusion

Kugel hernioplasty, which is a posterior approach, would result in severe extraperitoneal space adhesion. Essentially, a new and previously unused approach is preferable to the previous approach in patients with recurrent inguinal hernias.

Robotic approach is effective for recurrent inguinal hernias even if the space was severe adhesion.

Highlights

• •Robotic transabdominal preperitoneal repair for recurrent inguinal hernia is effective especially after posterior approach Kugel hernioplasty
• •The robotic platform dimensional visualization, offering an increased range of instrument motion and improved surgeon ergonomics seemed to be beneficial for recurrent case through three-
• •Robotic approach for recurrent inguinal hernia is rare, especially after Kugel hernioplasty.

1. Introduction

Laparoscopic surgery for inguinal hernias has been established as one of the gold standard procedures and is currently the standard treatment for bilateral inguinal hernias [1]. Laparoscopic surgery has a major advantage for treating recurrent inguinal hernias [2]. The laparoscopic posterior approach adapts the advantages of Kugel hernioplasty [3], making it possible to perform it at the new layer even if the inguinal hernia is recurrent following the anterior approach, producing a high level of completion [4]. However, in laparoscopic surgery for recurrent inguinal hernia using posterior approaches, such as transabdominal preperitoneal (TAPP) and totally extraperitoneal Kugel hernioplasties, dissecting the extraperitoneal space is difficult [2,4]. Robotic surgery may enable precise dissection, even if the space is severely adhered.

Here, we report a robotic TAPP (R-TAPP) after extraperitoneal approach for recurrent inguinal hernia, which developed after Kugel hernioplasty, and introduce our robotic surgical technique for a hard recurrent inguinal hernia. This case has been reported in line with the SCARE 2023 criteria [5].

2. Case presentation

A 78-year-old Japanese man, who underwent left inguinal hernia repair (Kugel hernioplasty) 2 years ago, presented with recurrent reducible left inguinal swelling.

He has no past medical history without last inguinal hernia operation. Family history and medical history were nothing to note.

Physical examination and abdominal computed tomography revealed recurrent inguinal hernia with cord lipoma (Fig. 1). We were thinking this recurrent case was difficult. So using the Da Vinci Xi (Intuitive Surgical Inc. Sunnyvale CA) robot, R-TAPP was performed for recurrent left inguinal hernia, which developed after Kugel hernioplasty. The robot was positioned to the left of the patient. We used three robotic ports as the three arms for a bipolar fenestrated grasper, monopolar scissors, and suture cut needle driver (Fig. 2).

Fig. 1.

Abdominal computed tomography.

The last mesh was detected on the membrane of the bladder.

The left recurrent inguinal hernia was suspected to be fatty tissue.

Fig. 2.

Device used for robotic transabdominal peritoneal repair.

Three robotic parts are used as three arms for a bipolar fenestrated grasper, monopolar scissors, and suture cut needle driver.

A 12 mm incision (R2: camera trocar) was created above the umbilicus, and other 8 mm trocars such as R1 and R3 were inserted in the right and left upper quadrants, respectively (Fig. 3). The patient was positioned at 15° Trendelenburg, and the robotic arms were docked.

Fig. 3.

Port replacement.

A 12 mm incision (R2: camera trocar) is created above the umbilicus, and other 8 mm trocars such as R1 and R3 are inserted in the right and left upper quadrant, respectively.

Laparoscopic examination revealed no obvious hernial sacs. Therefore, a recurrent left inguinal hernia was not confirmed, and the sigmoid colon was covered with an inguinal lesion (Fig. 4); however, a right inguinal hernia was confirmed (primary L2 according to the EHS classification) [6]. The direct Kugel patch was visible. We used a TAPP approach through a peritoneal incision above the deep inguinal ring to treat the primary right inguinal hernia. We dissected conserving the peritoneum, and fat tissues were dissected on the abdominal side. The peritoneum with a direct Kugel patch was dissected as a peritoneal flap. The pressure in the left inguinal region revealed a spermatic cord lipoma protruding from the internal inguinal ring as a recurrent inguinal hernia of the abdominal cavity. Spermatic cord lipomas are often found during inguinal hernia surgery through an inguinal incision; however, they are difficult to detect during laparoscopic hernia repair surgery and may be overlooked. We diagnosed recurrent left inguinal hernia with spermatic cord lipoma (recurrent L2 according to EHS classification) [6]. The spermatic cord lipoma was resected, and the indirect inguinal hernia was dissected (Fig. S5). The cord structures were isolated for parietalization, and 3DMAX™ (3D Mesh: C.R.Bard.Inc. USA) was then easily placed in the preperitoneal space. The mesh was sutured diagonally for fixation by 3-0vicryl at the Cooper ligament and the outside transversalis fascia. The peritoneal flap, without removing the direct Kugel patch, was sutured and closed using 3-0 Vloc (Covidien) (Fig. S6). The space was deflated under direct visualization.

Fig. 4.

Operative findings 1.

Recurrent left inguinal hernia is not confirmed because the sigmoid colon is covered with an inguinal lesion, and a direct Kugel patch is visible (black arrow).

The total operative time was 292 min, and intraoperative blood loss was 10 mL. The patient had a good postoperative course and was discharged from our hospital in remission 1 day postoperatively. No chronic pain or recurrence of bilateral inguinal hernia and bulging were noted during the follow-up after 3 months.

3. Discussion

R-TAPP is about to be covered by insurance in Japan. The laparoscopic approach for inguinal hernia has several advantages [1] such as the reduction of postoperative pain and disability, mesh placement in the preperitoneal space where the hernia is produced, bilateral repair by single access, and the possibility of simultaneous repair of unexpected contralateral hernias [7].

However, the robotic approach has not been proven to be superior to the laparoscopic approach. Robotic approaches, such as use of the Da Vinci systems X, Xi, and SP, have been criticized in terms of operation times and cost-effectiveness [8]. Indeed, the first randomized trial regarding the robotic approach for inguinal hernia, the RIVAL randomized clinical trial [9], showed no clinical benefit of the robotic approach in inguinal hernia repair compared with the laparoscopic approach. New technologies may be rapidly adopted in the absence of supporting evidence to establish their superiority over existing procedures such as other robotic surgeries [9]. The advantages of robotic approach for inguinal hernias are as follows: The robotic approach is popular because it provides easy maneuverability for performing a wide variety of procedures by the three-dimensional visualization and advanced surgeon ergonomics. Many surgeons have reported this to be an advantage [10]. The surgeon's ergonomics is an important factor, but is not an evidence.

We performed R-TAPP for recurrent inguinal hernia that developed after the posterior approach Kugel hernioplasty, which would be extremely difficult to dissect in the extraperitoneal space. If the laparoscopic approach for recurrent inguinal hernia is performed after an anterior approach, such as Lichtenstein repair and Rutkow Mesh Plug repair, the rational choice is to adopt a posterior approach with almost no adhesions; however, Kugel hernioplasty, which is a posterior approach, would result in severe extraperitoneal space adhesion. Essentially, a new and previously unused approach is preferable to the previous approach in patients with recurrent inguinal hernias. Robotic approach is effective for recurrent inguinal hernias even if the space was severe adhesion. If a previous operation using the anterior approach did not involve the preperitoneal space, TAPP can be easily performed.

Some surgeons have noted the advantage of the robotic approach for more complex operations, such as recurrent inguinal hernia repair [11]. In this approach, the peritoneal flap can be conserved without removing the direct Kugel patch. The robotic platform seemed to be beneficial for complex hernia cases because it is easier to perform a detailed procedure through three-dimensional visualization, offering an increased range of instrument motion and improved surgeon ergonomics. This case report is only a case presentation and is not an evidence base; however, it is valuable because a robotic approach for recurrent inguinal hernia is rare, especially after Kugel hernioplasty. The advantage of robotic technology such as wristed instruments may expand the application of minimally invasive hernia repair for complicated cases [12], like this case. We believe that this case experience and case-matched analysis strengthen the clinical value of this case report.

The following are the supplementary data related to this article.

Fig. S5

Operative findings 2. The spermatic cord lipoma (white arrow) is resected and the indirect inguinal hernia is dissected.

Fig. S6

Operative findings 3. The peritoneal flap is sutured and closed using 3-0 Vloc (Covidien) without removing the direct Kugel patch (white arrow).

Consent

Written formal consent was obtained from the patient for the publication of this case and the accompanying images.

Ethical approval

Not applicable.

Funding

None of the authors has any conflict of interest to declare

Author contribution

All authors contributed equally to the data collection and preparation of this article and are in agreement with the publication of its final version.

Guarantor

Toshikatsu Nitta.

Conflict of interest statement

None of the authors has any conflict of interest to declare.

Data availability

Not applicable.