ROBOTIC SURGERY IN UMBILICAL HERNIA LUCA FELICIONI … · Parete Addominale Organo o Contenitore? Aspetti Funzionali. ... entero-ombelicale,ernia del cordone, laparoschisi,onfalocele)

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


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

ISRS

MUSCULOSKELETAL BIOMECHANICS

Parete AddominaleOrgano o Contenitore?

Aspetti Funzionali

AUSL9Grosseto

ISRS

PELVIC UNIT

Usl Toscana sudest



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


of Robotic Surgery

ABDOMINAL WALL SHEATS

Rosen 2012



of Robotic Surgery

Guttuso fichidindia

MUSCOLOCUTANEOUS PERFORATORS

Usl Toscana sudest


of Robotic Surgery

MUSCOLOCUTANEOUS PERFORATORS

Usl Toscana sudest


of Robotic Surgery

Posterior component separation

with intramuscular dissection

Posterior component separation with TAR

POSTERIOR COMPONENT SEPARATION

Usl Toscana sudest


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

AUSL Toscana Sudest

ISRS




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







NEW EVIDENCES

Kaufmann R Lancet 2018




• 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



IPOM COMPLICATIONS

Meyer R Int J Surg 2015

Chelala E Hernia 2016

Biondo-Simoes M Acta Cir Bras 2017

Usl Toscana sudest



PROPERITONEAL FLAP

rTAPP

OR setup and docking

Usl Toscana sudest



PROPERITONEAL FLAP

rTAPP

Usl Toscana sudest



rTARUP

2013

2018

Usl Toscana sudest



TARUP

Usl Toscana sudest



rTARUP

Robust Hernia Project Ghent Muysoms F Hernia 2018


rTARUP

Usl Toscana sudest



rTARUP



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


of Robotic Surgery

THE BEST OF TWO WORLDS:

”THE BRAZILIAN TECHNIQUE”



of Robotic Surgery

“THE BEST OF TWO WORLDS”1976BOSSA NOVA BY STAN GETS & JOAO GILBERTO

Usl Toscana sudest



“THE BRAZILIAN

TECHNIQUE”

Usl Toscana sudest



“THE BRAZILIAN

TECHNIQUE”

Usl Toscana sudest



“THE BRAZILIAN

TECHNIQUE”

Usl Toscana sudest


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



rRIVES TAR


2

1

MCL

MCL

Midlin

e

Camera

3

Intuitive Surg Inc.® 2017

Left Rives box

2

1

MCL

MCL

Midlin

e

Camera

3

Intuitive Surg Inc.® 2017

Right Rives box

ISRS

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

Usl Toscana sudest


of Robotic Surgery

Grazie

Documents

ROBOTIC SURGERY IN UMBILICAL HERNIA LUCA FELICIONI … · Parete Addominale Organo o Contenitore? Aspetti Funzionali. ... entero-ombelicale,ernia del cordone, laparoschisi,onfalocele)