Upload
phamdat
View
214
Download
0
Embed Size (px)
Citation preview
ROBOTIC SURGERY IN
UMBILICAL HERNIA
LUCA FELICIONI MD
General Surgery Dept.
“Misericordia” Hospital – Grosseto, Italy
Minimally Invasive Surgery Unit
DIRECTOR P.BIANCHI MD
Usl Toscana sudest
ISHAWSInternational School
of Robotic SurgeryUIC CRSA Italia
Usl Toscana sudest ISHAWS
International School
of Robotic SurgeryUIC CRSA Italia
CONCLUSIONS
Umbilical hernia:
only a sort of ventral hernia ?
Ideal Ventral Hernia Repair
• Minimal wound morbidity
• Avoid extensive skin flaps
• Large prosthetic mesh
• Reconstruct midline
• Reproducible
• Resolve biomechanic problems and
embryonic residues in umbilical
hernia
Usl Toscana sudest
ISHAWS
Guttuso aranceto
Usl Toscana sudest
ISHAWSInternational School
of Robotic SurgeryUIC CRSA Italia
UMBILICAL
EMBRYONIC
RESIDUES
• Uraco(estrofia vescicale,fistole e cisti
dell’uraco,residui allantoidei)
• Arterie ombelicali(legamenti vescico-
ombelicali laterali)
• Vene ombelicali(legamento venoso,
legamento rotondo del fegato)
• Residui onfalo-mesenterici (fistola
entero-ombelicale,ernia del cordone,
laparoschisi,onfalocele)
Usl Toscana sudest ISHAWS
International School
of Robotic Surgery
Guttuso fichidindia
MUSCOLOCUTANEOUS PERFORATORS
Usl Toscana sudest
ISHAWSInternational School
of Robotic Surgery
Posterior component separation
with intramuscular dissection
Posterior component separation with TAR
POSTERIOR COMPONENT SEPARATION
Usl Toscana sudest
ISHAWSInternational School
of Robotic Surgery
Midline group of muscles
rectus abdominis
pyramidalis
Anterolateral group of muscles
EOM
IOM
TAM
Linea alba
Linea semilunaris
Arcuate linea
Space of Retius
Space of Bogros
ABDOMINAL WALL STRUCTURES
Novitsky 2016
AUSL Toscana Sudest
Gold standard open:
augmentation with retromuscolar sublay placement of a mesh
(Rives-Stoppa)
Gold standard VLS:
bridging with intraperitoneal onlay mesh repair
ISHAWS
GOLD STANDARD
Usl Toscana sudest
CRSA Italia ISHAWSInternational School
of Robotic Surgery
Posizione bracci preimpostata
Lavoro dei bracci in parallelo con
riduzione del conflitto muovendosi
anche in direzioni opposte
Asse ottico ruotabile
Sistema movimentazione bracci
“Grab and move”
Visione in fluorescenza integrata
Suturatrici robotiche
Sistema Da Vinci Xi
Vantaggi in Chirurgia di parete
AUSL Toscana Sudest
ISRS
ROBOTIC VENTRAL HERNIA
• Robotic component separation from open to robotic(retromuscolar)A.Carbonel
• Robotic preperitoneal repairs D.Lourie
• Robotic intraperitoneal repairs I.Milosevic
• AHSQC update on Robotic vs Open outcomes J.Warren
• Closing the defect and mesh fixation E.Parra Davilla (IPOM plus)
• Unusual situations T.Sigh
• Cost optimization A.Gonzales
Usl Toscana sudest ISHAWS
International School
of Robotic SurgeryUIC CRSA Italia
European General Surgery Robotics Summit
Monday
September 10, 2018
Royal Continental Hotel
Naples, Italy
Advanced da Vinci Lab Session
Tuesday
September 11, 2018
RAIN
Robotic Academy Intuitive Naples
Usl Toscana sudest ISHAWS
International School
of Robotic SurgeryUIC CRSA Italia
NEW EVIDENCES
Kaufmann R Lancet 2018
Usl Toscana sudest ISHAWS
International School
of Robotic SurgeryUIC CRSA Italia
• rProperitoneal flap single side docking
• rTARUP single side docking
• rCosta single sovrapubic docking
• rRives double side docking
• rRives+TAR double side docking
rUMBILICAL HERNIA
REPAIR
(rIPOM PLUS single side docking)
AUSL toscana sudest
ISRS
LAPAROSCOPIC VS ROBOTIC VENTRAL HERNIA REPAIR
- Laparoscopic ventral hernia surgery with no wide acceptance (27% in USA)
- Increased recurrence rate
- Bulging of the repair
- Complexity of the procedure
- Complex primary repair of the fascial defect
- Transabdominal sutures and tacks with postoperative pain
- Robotic dexterity in suturing the fascial defect and the mesh
- Complex procedures (midline reconstruction,posterior component separation,
transverse abdominis release AWR)
- Less recurrence rates(6% vs 20%)
- Less conversion rates(0.9% vs 5%)
- Longer operative times
- Cost competitive (robotic procedure $1,315,VLS using 1 tacking device $1,390,
VLS using 2 tacking device $1,880) Gerhart C Hernia 2015
post IPOM second-look follow up
• 45.23%adhesions free
• 42.06%minor adhesions (Muller I)
• 12.69%serosal adhesions(Muller II)
Usl Toscana sudest
ISHAWSInternational School
of Robotic SurgeryUIC CRSA Italia
IPOM COMPLICATIONS
Meyer R Int J Surg 2015
Chelala E Hernia 2016
Biondo-Simoes M Acta Cir Bras 2017
Usl Toscana sudest
ISHAWSInternational School
of Robotic SurgeryUIC CRSA Italia
PROPERITONEAL FLAP
rTAPP
OR setup and docking
Usl Toscana sudest
ISHAWSInternational School
of Robotic SurgeryUIC CRSA Italia
PROPERITONEAL FLAP
rTAPP
Usl Toscana sudest
ISHAWSInternational School
of Robotic SurgeryUIC CRSA Italia
rTARUP
Robust Hernia Project Ghent Muysoms F Hernia 2018
Usl Toscana sudest ISHAWS
International School
of Robotic Surgery
t“THE BEST OF TWO WORLDS” 2015
Quick hot spot by Thiago Costa:”Laparoscopic transabdominal midline reconstruction:
Technique and results”
Usl Toscana sudest
CRSA Italia ISHAWSInternational School
of Robotic Surgery
Costa TN Hernia 2016
Pros
• Retromuscolar space accessed
with minimally invasive technique
• Stapling instead of suturing
• Midline reconstruction
Cons
• To leave a redundant hernia sac
• risk of seroma
• Limitation for handling the stapler
Usl Toscana sudest
ISHAWSInternational School
of Robotic Surgery
THE BEST OF TWO WORLDS:
”THE BRAZILIAN TECHNIQUE”
Usl Toscana sudest ISHAWS
International School
of Robotic Surgery
“THE BEST OF TWO WORLDS”1976BOSSA NOVA BY STAN GETS & JOAO GILBERTO
Usl Toscana sudest
ISHAWSInternational School
of Robotic SurgeryUIC CRSA Italia
“THE BRAZILIAN
TECHNIQUE”
Usl Toscana sudest
ISHAWSInternational School
of Robotic SurgeryUIC CRSA Italia
“THE BRAZILIAN
TECHNIQUE”
Usl Toscana sudest
ISHAWSInternational School
of Robotic SurgeryUIC CRSA Italia
“THE BRAZILIAN
TECHNIQUE”
Usl Toscana sudest
ISHAWSInternational School
of Robotic Surgery
PROS AND CONS FOR
“THE BRAZILIAN TECHNIQUE”
• Medium sized defects
• Hernias from the umbilicus and upwards
• Retromuscolar space accessed using minimally invasive technique
• Stapling instead of suturing
• Minimize wound contamination
• To leave a redundant hernia sac
• Limitation for handling the linear cutter
• Closure of trasversalis gap
• Dissection of the area below the arcuate line preperitoneal
• Combining with endoscopic component separation
• Indications: all midline medium sized hernias (primary and incisional)
rectus diastasis/floppy abdomen
port site hernias in post bariatric surgery
Usl Toscana sudest
ISHAWSInternational School
of Robotic SurgeryUIC CRSA Italia
rRIVES TAR
OR setup and docking
ISRS
Preaortic lymphonode during sigmoid resectionRegulated liver resection
The Firefly system in Da Vinci for fluorescence guided
robotic surgery uses the different dye uptake by the
tissues
ICG FA reduces wound healing complications in transverse
abdominis release (AWR)P.Szotek Hernia 2015
“Grosseto” experienceInternational School of Robotic Surgery
84 robotic wall surgery procedures
Inguinal hernia repair TAPP 38
Monolateral recurrence/femoral 14
Bilateral 23
Groin pain sd. 1
Diafragmatic hernia 1
Postincisional hernia repair
Rives+TAR
IPOM PLUS
Properitoneal flap
Rives
Costa procedure
Ventral hernia repair
Properitoneal flap
IPOM PLUS
Costa procedure
TARUP
19
3
4
10
1
1
27
16
2
6
3
Jannuary 2016 – October 2018