THE INTERNATIONAL JOURNAL OF MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY Int J Med Robotics Comput Assist Surg (2014) Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/rcs.1597
ORIGINAL ARTICLE
Case report of a robotic-assisted laparoscopic repair of a giant incarcerated recurrent inguinal hernia containing bladder and ureters
Lawrence N. Cetrulo1 Justin Harmon2 Jorge Ortiz1 Daniel Canter2 Amit R. T. Joshi1* 1
Department of Surgery, Einstein Healthcare Network, Philadelphia, PA
2
Department of Urology, Einstein Healthcare Network, Philadelphia, PA *Correspondence to: Amit R. T. Joshi, MD, FACS, Department of Surgery, Einstein Healthcare Network, 5401 Old York Rd., Suite 510, Philadelphia, PA 19141, USA. E-mail: [email protected]
ABSTRACT Background Robotic surgery is particularly useful in pelvic procedures, such as prostatectomy and low anterior resection. The paper describes a robotic-assisted repair of a giant bladder- and ureter-containing incarcerated inguinal hernia. Methods and Results A 53-year-old man had previously undergone repair of a left inguinal hernia. He presented to our clinic complaining of difficulty urinating and a large bulge in his left scrotum. CT revealed a giant left scrotal hernia containing the bladder and both ureters. The patient underwent robotic-assisted laparoscopic repair. The bladder and both ureters were carefully dissected free from the scrotum, while preserving the testicle and spermatic cord. A 6×4 inch pre-peritoneal polyester composite mesh was then used to repair the defect. Conclusion Incarcerated, recurrent inguinal hernias are challenging repairs. Robotic-assisted repair allows for fine dissection, and is an excellent alternative to open surgery for a difficult inguinal hernia. Copyright © 2014 John Wiley & Sons, Ltd. Keywords
inguinal hernia; bladder; robotic surgery
Introduction
Accepted: 7 May 2014
Copyright © 2014 John Wiley & Sons, Ltd.
The first recorded case of a herniation of the urinary bladder into an inguinal hernia dates from 1550 (1). The bladder is found in only 1–3% of all groin hernias, despite its proximity to the inguinal and femoral canals (2). Inguinal hernias of the bladder can be classified as paraperitoneal, intraperitoneal, and extraperitoneal. Paraperitoneal hernias are the most common presentation, where the herniated bladder remains extraperitoneal, but herniates alongside the more lateral peritoneum. Large bladder hernias can even include the ureteral orifices (3). Symptoms of bladder hernias include recurrent urinary tract infections, dysuria, and incomplete bladder emptying. A pathognomonic sign is two-phase micturition, where the normally-located bladder empties first, followed by emptying of the bladder contained within the hernia after manual pressure on the hernia sac (4). Diagnosis of a bladder hernia is
L. N. Cetrulo et al.
most easily made by computed tomography (CT), but it can also be augmented by cystoscopy (5). Repair of giant bladder hernias can be technically challenging, and has traditionally been performed with a midline laparotomy – in order to safely reduce the bladder and/or the ureters, which are intra-abdominal structures (6). Inguinal herniorrhaphy is now routinely performed laparoscopically either with a total extra-peritoneal (TEP) approach or a trans-abdominal pre-peritoneal (TAPP) approach (7). Robotic-assisted laparoscopic herniorrhaphy is well-described, as well (8). Pelvic surgery still remains the primary indication for robotic-assisted laparoscopy. Improved dexterity and three-dimensional visualization, afforded by the robot, are great assets in difficult and precise dissections within the pelvis. Radical cystectomy and radical prostatectomy are among the most common urologic robotic-assisted procedures performed (9). We describe the first report of a robotic-assisted reduction and repair of a giant inguinal hernia containing the bladder and both ureteral orifices.
Materials and methods A 53-year-old man presented with a recurrent left-sided scrotal hernia. He had undergone an open pre-peritoneal (Ugahary) repair with polypropylene mesh at another institution four years previously. He reported frequent urination, dysuria, and ability to urinate only by elevating his scrotum. Physical examination confirmed a large scrotal hernia. CT revealed that the hernia contained his bladder and both distal ureters (Figures 1 and 2). He agreed to undergo robotic-assisted laparoscopic repair of his hernia. After induction of general anesthesia, the patient was placed in the lithotomy position and the abdomen was insufflated using a Veress needle. We used the DaVinci 4S robotic surgical system (Intuitive Surgical, Sunnyvale, CA). A 12 mm camera port was placed through the umbilicus
Figure 1. Axial image of bladder filled with contrast in scrotum Copyright © 2014 John Wiley & Sons, Ltd.
Figure 2. Sagittal image of bladder filled with contrast in scrotum
with two 8 mm robotic ports placed to the right and left of the camera port, lateral to the rectus muscles and approximately 8 cm from the camera port. An additional 8 mm port was placed 8 cm lateral of this left port. An assistant 5 mm port was placed on the patient’s right side (Figure 3). The patient was placed in steep Trendelenberg position and the robot was docked. The peritoneum was incised from the midline 10 cm cephalad to the pubic symphysis laterally towards the anterior superior iliac spine. Through this, the space of Retzius was entered. Immediately, herniation of the bladder was noticed in the left groin and using a handover-hand technique (with the assistance of the third robotic arm), the anterior bladder was dissected free. This movement revealed the previous mesh used in the prior surgery. The mesh was noted to be adherent to the bladder and ureters, and so a careful 2 h dissection now ensued. The epigastric vessels were located and skeletonized. Next, the iliac and gonadal vessels were identified and preserved. Dissecting medially to laterally, and with the assistance of external manual pressure, the bladder and ureters were eventually reduced off the mesh and out of the hernia sac.
Figure 3. Diagram of robotic port placement Int J Med Robotics Comput Assist Surg (2014) DOI: 10.1002/rcs
Robotic repair of a giant inguinal hernia containing bladder
The third robotic arm was used to facilitate pulling the bladder from the hernia. The spermatic cord was located and led us to the large remaining direct hernia defect. The robot was now undocked to allow us to perform cystoscopy with a 21-French 30-degree cystoscope. No iatrogenic injury was identified. The right ureter and uretero-pelvic junction (UPJ) appeared normal. No urine was seen draining from the left ureter, so retrograde ureterography and pyelography was performed on that side, which revealed tortuosity of the left ureter and chronic UPJ obstruction. Accordingly, a double-J stent was placed into the renal pelvis to allow for adequate drainage of the left kidney. We then performed a laparoscopic TAPP repair of this direct hernia, using a 6×4 inch polyester mesh. The mesh was easily introduced through one of the 12 mm ports. The peritoneum was re-approximated using titanium tacks.
Results The patient was admitted overnight and discharged the following day. The patient’s preoperative urinary symptoms resolved. His ureteral stents were removed at his 2-week postoperative visit. At 12 months, he has suffered no recurrence of his hernia.
Discussion Robotic surgery offers significant advantages over traditional laparoscopy, particularly where fine dissection and
Copyright © 2014 John Wiley & Sons, Ltd.
dexterity are required. We have previously reported concurrent repair of inguinal hernias during robotic prostatectomy (10). We would advocate consideration for robotic repair of complicated hernias such as this one, as an alternative to open surgery.
References 1. Becker JA. A hernia of the urinary bladder. Radiology 1965; 84(2): 270–273. 2. Bacigalupo LE, Bertolotto M, Barbiera F, et al. Imaging of urinary bladder hernias. Am J Roentgenol 2005; 184(2): 546–551. 3. Butterman M. Urinary bladder herniation into the scrotum. Mt Sinai J Med 1972 Sep-Oct; 39(5): 517–521. 4. Mason LW, Pfisterer TR. Urinary bladder herniation: diagnosis and review of the literature. Ill Med J 1957 Jun; 111(6): 303–307. 5. Joseph JV, Rosenbaum R, Madeb R, et al. Robotic extraperitoneal radical prostatectomy: an alternative approach. J Urol 2006 Mar; 175(3 Pt 1): 945–950. 6. Finley D, Rodriguez E, Ahlering T. Combined inguinal hernia repair with prosthetic mesh during transperitoneal robot assisted laparoscopic radical prostatectomy: a 4-year experience. J Urol 2007 Oct; 178(4 Pt 1): 1296–1299. 7. Nakamura LY, Nunez RN, Castle EP, et al. Different approaches to an inguinal hernia repair during a simultaneous robot-assisted radical prostatectomy. J Endourol 2011 Apr; 25(4): 621. 8. Schlegel PN, Walsh PC. Simultaneous preperitoneal hernia repair during radical pelvic surgery. J Urol 1987 Jun; 137(6): 1180–1183. 9. Collins JN, Britt RC, Britt LD. Concomitant robotic repair of inguinal hernia with robotic prostatectomy. Am Surg 2011 Feb; 77(2): 238–239. 10. Joshi AR, Spivak J, Rubach E, et al. Concurrent robotic transabdominal pre-peritoneal (TAP) herniorrhaphy during roboticassisted radical prostatectomy. Int J Med Robot 2010 Sep; 6(3): 311–314.
Int J Med Robotics Comput Assist Surg (2014) DOI: 10.1002/rcs
ORIGINAL ARTICLE
Case report of a robotic-assisted laparoscopic repair of a giant incarcerated recurrent inguinal hernia containing bladder and ureters
Lawrence N. Cetrulo1 Justin Harmon2 Jorge Ortiz1 Daniel Canter2 Amit R. T. Joshi1* 1
Department of Surgery, Einstein Healthcare Network, Philadelphia, PA
2
Department of Urology, Einstein Healthcare Network, Philadelphia, PA *Correspondence to: Amit R. T. Joshi, MD, FACS, Department of Surgery, Einstein Healthcare Network, 5401 Old York Rd., Suite 510, Philadelphia, PA 19141, USA. E-mail: [email protected]
ABSTRACT Background Robotic surgery is particularly useful in pelvic procedures, such as prostatectomy and low anterior resection. The paper describes a robotic-assisted repair of a giant bladder- and ureter-containing incarcerated inguinal hernia. Methods and Results A 53-year-old man had previously undergone repair of a left inguinal hernia. He presented to our clinic complaining of difficulty urinating and a large bulge in his left scrotum. CT revealed a giant left scrotal hernia containing the bladder and both ureters. The patient underwent robotic-assisted laparoscopic repair. The bladder and both ureters were carefully dissected free from the scrotum, while preserving the testicle and spermatic cord. A 6×4 inch pre-peritoneal polyester composite mesh was then used to repair the defect. Conclusion Incarcerated, recurrent inguinal hernias are challenging repairs. Robotic-assisted repair allows for fine dissection, and is an excellent alternative to open surgery for a difficult inguinal hernia. Copyright © 2014 John Wiley & Sons, Ltd. Keywords
inguinal hernia; bladder; robotic surgery
Introduction
Accepted: 7 May 2014
Copyright © 2014 John Wiley & Sons, Ltd.
The first recorded case of a herniation of the urinary bladder into an inguinal hernia dates from 1550 (1). The bladder is found in only 1–3% of all groin hernias, despite its proximity to the inguinal and femoral canals (2). Inguinal hernias of the bladder can be classified as paraperitoneal, intraperitoneal, and extraperitoneal. Paraperitoneal hernias are the most common presentation, where the herniated bladder remains extraperitoneal, but herniates alongside the more lateral peritoneum. Large bladder hernias can even include the ureteral orifices (3). Symptoms of bladder hernias include recurrent urinary tract infections, dysuria, and incomplete bladder emptying. A pathognomonic sign is two-phase micturition, where the normally-located bladder empties first, followed by emptying of the bladder contained within the hernia after manual pressure on the hernia sac (4). Diagnosis of a bladder hernia is
L. N. Cetrulo et al.
most easily made by computed tomography (CT), but it can also be augmented by cystoscopy (5). Repair of giant bladder hernias can be technically challenging, and has traditionally been performed with a midline laparotomy – in order to safely reduce the bladder and/or the ureters, which are intra-abdominal structures (6). Inguinal herniorrhaphy is now routinely performed laparoscopically either with a total extra-peritoneal (TEP) approach or a trans-abdominal pre-peritoneal (TAPP) approach (7). Robotic-assisted laparoscopic herniorrhaphy is well-described, as well (8). Pelvic surgery still remains the primary indication for robotic-assisted laparoscopy. Improved dexterity and three-dimensional visualization, afforded by the robot, are great assets in difficult and precise dissections within the pelvis. Radical cystectomy and radical prostatectomy are among the most common urologic robotic-assisted procedures performed (9). We describe the first report of a robotic-assisted reduction and repair of a giant inguinal hernia containing the bladder and both ureteral orifices.
Materials and methods A 53-year-old man presented with a recurrent left-sided scrotal hernia. He had undergone an open pre-peritoneal (Ugahary) repair with polypropylene mesh at another institution four years previously. He reported frequent urination, dysuria, and ability to urinate only by elevating his scrotum. Physical examination confirmed a large scrotal hernia. CT revealed that the hernia contained his bladder and both distal ureters (Figures 1 and 2). He agreed to undergo robotic-assisted laparoscopic repair of his hernia. After induction of general anesthesia, the patient was placed in the lithotomy position and the abdomen was insufflated using a Veress needle. We used the DaVinci 4S robotic surgical system (Intuitive Surgical, Sunnyvale, CA). A 12 mm camera port was placed through the umbilicus
Figure 1. Axial image of bladder filled with contrast in scrotum Copyright © 2014 John Wiley & Sons, Ltd.
Figure 2. Sagittal image of bladder filled with contrast in scrotum
with two 8 mm robotic ports placed to the right and left of the camera port, lateral to the rectus muscles and approximately 8 cm from the camera port. An additional 8 mm port was placed 8 cm lateral of this left port. An assistant 5 mm port was placed on the patient’s right side (Figure 3). The patient was placed in steep Trendelenberg position and the robot was docked. The peritoneum was incised from the midline 10 cm cephalad to the pubic symphysis laterally towards the anterior superior iliac spine. Through this, the space of Retzius was entered. Immediately, herniation of the bladder was noticed in the left groin and using a handover-hand technique (with the assistance of the third robotic arm), the anterior bladder was dissected free. This movement revealed the previous mesh used in the prior surgery. The mesh was noted to be adherent to the bladder and ureters, and so a careful 2 h dissection now ensued. The epigastric vessels were located and skeletonized. Next, the iliac and gonadal vessels were identified and preserved. Dissecting medially to laterally, and with the assistance of external manual pressure, the bladder and ureters were eventually reduced off the mesh and out of the hernia sac.
Figure 3. Diagram of robotic port placement Int J Med Robotics Comput Assist Surg (2014) DOI: 10.1002/rcs
Robotic repair of a giant inguinal hernia containing bladder
The third robotic arm was used to facilitate pulling the bladder from the hernia. The spermatic cord was located and led us to the large remaining direct hernia defect. The robot was now undocked to allow us to perform cystoscopy with a 21-French 30-degree cystoscope. No iatrogenic injury was identified. The right ureter and uretero-pelvic junction (UPJ) appeared normal. No urine was seen draining from the left ureter, so retrograde ureterography and pyelography was performed on that side, which revealed tortuosity of the left ureter and chronic UPJ obstruction. Accordingly, a double-J stent was placed into the renal pelvis to allow for adequate drainage of the left kidney. We then performed a laparoscopic TAPP repair of this direct hernia, using a 6×4 inch polyester mesh. The mesh was easily introduced through one of the 12 mm ports. The peritoneum was re-approximated using titanium tacks.
Results The patient was admitted overnight and discharged the following day. The patient’s preoperative urinary symptoms resolved. His ureteral stents were removed at his 2-week postoperative visit. At 12 months, he has suffered no recurrence of his hernia.
Discussion Robotic surgery offers significant advantages over traditional laparoscopy, particularly where fine dissection and
Copyright © 2014 John Wiley & Sons, Ltd.
dexterity are required. We have previously reported concurrent repair of inguinal hernias during robotic prostatectomy (10). We would advocate consideration for robotic repair of complicated hernias such as this one, as an alternative to open surgery.
References 1. Becker JA. A hernia of the urinary bladder. Radiology 1965; 84(2): 270–273. 2. Bacigalupo LE, Bertolotto M, Barbiera F, et al. Imaging of urinary bladder hernias. Am J Roentgenol 2005; 184(2): 546–551. 3. Butterman M. Urinary bladder herniation into the scrotum. Mt Sinai J Med 1972 Sep-Oct; 39(5): 517–521. 4. Mason LW, Pfisterer TR. Urinary bladder herniation: diagnosis and review of the literature. Ill Med J 1957 Jun; 111(6): 303–307. 5. Joseph JV, Rosenbaum R, Madeb R, et al. Robotic extraperitoneal radical prostatectomy: an alternative approach. J Urol 2006 Mar; 175(3 Pt 1): 945–950. 6. Finley D, Rodriguez E, Ahlering T. Combined inguinal hernia repair with prosthetic mesh during transperitoneal robot assisted laparoscopic radical prostatectomy: a 4-year experience. J Urol 2007 Oct; 178(4 Pt 1): 1296–1299. 7. Nakamura LY, Nunez RN, Castle EP, et al. Different approaches to an inguinal hernia repair during a simultaneous robot-assisted radical prostatectomy. J Endourol 2011 Apr; 25(4): 621. 8. Schlegel PN, Walsh PC. Simultaneous preperitoneal hernia repair during radical pelvic surgery. J Urol 1987 Jun; 137(6): 1180–1183. 9. Collins JN, Britt RC, Britt LD. Concomitant robotic repair of inguinal hernia with robotic prostatectomy. Am Surg 2011 Feb; 77(2): 238–239. 10. Joshi AR, Spivak J, Rubach E, et al. Concurrent robotic transabdominal pre-peritoneal (TAP) herniorrhaphy during roboticassisted radical prostatectomy. Int J Med Robot 2010 Sep; 6(3): 311–314.
Int J Med Robotics Comput Assist Surg (2014) DOI: 10.1002/rcs
