Robotic surgery is the biggest technological advancement in minimal invasive surgery since laparoscopic surgery clinically evolved in the 1980s. Bringing the robot into the operating room has enabled the surgeon to be more precise and objective in relation to an operative resection. Just like a computer, robotic surgery continues to evolve or 'upgrade' which requires continuous extensive and specialized training by the surgeon. Instead of surgeon's hands holding the minimal invasive instruments, robot arms are brought in to hold the instruments and the surgeon controls the operation on a robot console. Robotic surgery offers the most advanced optics, best instrumentation and the most refined suture technique to the surgeon. It is up to the surgeon in consultation with the patient to choose which surgical technique is most appropriate.
Robotic Inguinal Hernia Repair
An inguinal hernia occurs when tissue, such as part of the intestine, protrudes through a weak spot in the abdominal muscles. In the case of an inguinal hernia, the weak spot is a narrow opening in the inguinal canal in the groin. The resulting bulge can be painful, especially when one coughs, bends over or lifts a heavy object. An inguinal hernia does not improve on its own and can lead to life-threatening complications. A robotic inguinal hernia repair uses three small incisions for two working ports and a camera. The surgeon operates right next to the patient on a robot console. Robotic inguinal hernia repair offers more advanced sewing and better optics for more difficult repairs. The operation returns any protruding tissue to its normal anatomic location, permanently reduces the bulge and patches the defect with screen or mesh. The mesh allows for the strongest possible repair with the least amount of recurrences. Typically, Dr. Muffoletto's patients return to normal activity within two weeks of the repair.
Abdominal Wall Hernia Repairs
The abdominal wall hernias are defects that occur in different anatomical locations on the abdominal wall. The three most common are the umbilical, ventral and incisional hernias. I have explained a little about each below but it is important to note that there are different ways to robotically repair these hernias. The robotic IPOM or intraperitoneal onlay mesh technique closes the hernia from within the abdominal cavity and places a special mesh material that is designed to be placed facing the intra-abdominal structures. Large hernias and large pieces of mesh can be used with this repair. The R-TAPP or robotic-assisted transabdominal preperitoneal technique closes the hernia from within the abdomen but a preperitoneal pocket must first be formed. A simple polypropylene mesh product can then be placed in the developed pocket so that it is not facing any intra-abdominal structures. This is a nice technique because it eliminates any potential for adhesions, scar tissue, to stick to the mesh product. The R-TAPP is sometimes limited to lesser size hernias because it is difficult to create a large preperitoneal pocket from within the abdomen depending on where the hernia is on the abdominal wall. The robotic e-TEP or robotic assisted enhanced view-totally extraperitoneal technique is the best of both worlds. This hernia repair starts off in the retromuscular plane, totally extraperitoneal, and it allows you to close very large defects without exposing the large mesh material to any intra-abdominal structures. This technique requires a lot of skill and experience by the operating surgeon. Today, this is my preferred technique for large abdominal hernias. An extension to the e-TEP repair is the TAR, transversus abdominis release, technique. While in the retromuscular plane, additional muscle/fascia relaxing incisions can be made in order to close the very large abdominal wall hernias. I often use these incisions during my e-TEP repairs to close complicated large abdominal wall hernias. I will try and update my video library to illustrate all these techniques.
Robotic Umbilical Hernia Repair
An umbilical hernia occurs when part of the intestine or fatty tissue bulges through the muscle near the belly button (navel, umbilicus).The robotic repair requires only three small incisions in order to return all bulging tissue to its normal anatomy and sew a mesh over the defect helping to prevent future hernias. Robotic surgery allows the surgeon to sew upside down on the undersurface of the abdominal wall; a skill too difficult to be performed laparoscopically.
Robotic Ventral Hernia Repair
A ventral hernia results from a weakness in the midline of the abdominal wall. Typically, a bulge will occur above the belly button and below the breast plate. The bulge is a result of tissue and/or intestine that is protruding through the midline defect. The robotic repair uses three small incisions to dissect out all tissue from the hernia site and closes the defect prior to sewing mesh over the closure site. Trying to suture the defect closed without mesh quite often leads to a recurrence.
Robotic Incisional Hernia Repair
An incisional hernia occurs as a result from a complication from conventional open surgery. Open surgery must use large incisions unlike minimum invasive surgery. These larger incisions create a weakness in the abdominal wall which may not fully heal. This weakness results in tissue or intestine bulging through the incisional scar which can be potentially life threatening. The robotic incisional hernia repair uses three small incisions in order to dissect all protruding tissue, scar tissue or intestinal structures out of the hernia defect. This dissection can often be very challenging which is where robotics can offer superior visualization and refined minimal invasive technique to accomplish the task. The defect is then sewed closed and mesh material is sewed over the closure site to prevent recurrences. This once difficult operation has now become an outpatient procedure.
Robotic Paraesophageal/Hiatal Repair
The hiatus is a normal opening in the diaphragm which allows important structures such as the esophagus and the aorta to pass between the chest cavity and the abdomen. The diaphragm is a muscular wall that separates these two cavities. When the muscles surrounding the hiatus get overly stretched, structures like the stomach are able to abnormally herniate through the hiatal opening. A paraesophageal hernia is when part of the stomach comes along side of the esophagus and squeezes through the hiatal hernia up in to the chest. These types of hernias can be dangerous because the part of the stomach stuck in the hernia may be cut off from its normal blood supply leading to injury. Symptoms include: chest pain, epigastric pain, cardiac arrhythmia, shortness of breath, difficulty swallowing and ulcer formation. This condition will need to be corrected by dissecting the stomach out of the chest and positioning it back into the normal abdominal cavity. The muscles of the hiatus will need to be sewed back together and sometimes patched with a biological mesh. Robotic surgery offers superb sewing capability and excellent optics to help make the surgery easier and more precise. This procedure can be done through small incisions using four robot arms and advanced instrumentation.
Robotic Nissen Fundoplication/Hiatal Hernia Repair
A robotic nissen fundoplication is a minimal invasive technique used to treat debilitating gastroesophageal reflux disease, or GERD. GERD may develop when part of the stomach slides through a hiatal hernia up into the chest and allows for stomach acid to reflux more readily into the esophagus. This acid can be very corrosive to the esophagus and cause mucosal injury and pain. A nissen fundoplication repairs the hiatal hernia and wraps part of the stomach around the esophagus in order to create a greater pressure zone at the gastroesophageal junction and prevent acid from refluxing back up.