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Journal of Minimally Invasive Surgery 2024; 27(1): 40-43

Published online March 15, 2024

https://doi.org/10.7602/jmis.2024.27.1.40

© The Korean Society of Endo-Laparoscopic & Robotic Surgery

Robotic transabdominal preperitoneal repair for bilateral obturator hernia: a video vignette

Sungwoo Jung , Hyung Soon Lee

Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea

Correspondence to : Hyung Soon Lee
Department of Surgery, National Health Insurance Service Ilsan Hospital, 100 Ilsan-ro, Ilsandong-gu, Goyang 10444, Korea
E-mail: soon0925@nhimc.or.kr
https://orcid.org/0000-0001-9825-8648

Supplementary video file: This article contains supplementary material (https://doi.org/10.7602/jmis.2024.27.1.40)

Received: July 20, 2023; Revised: October 4, 2023; Accepted: October 16, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Obturator hernias (OHs) are a rare cause of bowel obstruction that requires immediate surgical intervention to prevent morbidity and mortality. Patients with OHs present with acute intestinal obstruction secondary to incarceration, with a high morbidity and mortality rate due to delayed diagnosis and treatment. Although several surgical approaches have been reported, a standard approach for OH treatment has not yet been established. Here, we report the case of a 74-year-old woman who presented with bilateral OHs. The patient presented at our institution with pain in the left lower quadrant. Computed tomography revealed preperitoneal fat in both obturator foramen. Robotic transabdominal preperitoneal (R-TAPP) bilateral OH repair was performed, and a mesh was placed over both obturator foramen. The patient recovered without postoperative complications and was discharged on postoperative day 2. This suggests that the R-TAPP approach is safe for OH repair without incarceration.

Keywords Obturator hernia, Robotic surgical procedures, Herniorrhaphy

Obturator hernias (OHs) are an uncommon cause of intestinal obstruction typically seen in elderly, slender, and multiparous women and result from the laxity of pelvic tissue and decreased fatty tissue around the obturator foramen [1,2]. Symptoms in patients are usually vague, and physical examinations can be inconclusive, making diagnosis challenging in most cases [3,4]. Additionally, patients with a delayed diagnosis often have serious conditions and require intestinal resection, resulting in a high mortality rate [2].

Traditionally, incarcerated OHs have been treated with open surgery, but recent reports have suggested the feasibility of laparoscopic repair for incarcerated OHs [5]. Recently, the laparoscopic approach has gained popularity, reporting fewer complications and faster recovery times compared to traditional open surgery. Moreover, the laparoscopic approach has a decreased morbidity and mortality rate than the open approach [1]. Laparoscopy provides a superior view of the obturator foramen compared to laparotomy. Moreover, with the advancement of minimally invasive surgical techniques, robotic-assisted hernia repair has become increasingly popular, and despite some debate regarding its clinical benefits [6]. However, robotic repair of OH is rare. Herein, we report a case of bilateral OH repair using the robotic transabdominal preperitoneal approach (R-TAPP).

Patient

5A 74-year-old woman visited our outpatient clinic with left lower quadrant and left hip pain. She had a history of hypertension and endovascular coiling of a brain aneurysm one year ago and was treated with clopidogrel and valsartan. The patient had no previous history of abdominal surgery. Her height was 154 cm, her weight was 54 kg, and her body mass index was 22.7 kg/m2. The patient’s vital signs were normal. A physical examination revealed no abdominal tenderness. On physical exam, the Howship-Romberg sign was negative. The laboratory blood test results were normal. Abdominal computed tomography (CT) demonstrated fat tissue that was herniated into both obturator foramen (Fig. 1). Accordingly, we planned for an elective R-TAPP surgery for bilateral OH repair (Supplementary Video 1).

Fig. 1. An abdominal computed tomography scan revealed a fat tissue herniation within the bilateral obturator foramen (white arrows).

Surgical procedures

Under general anesthesia, bilateral R-TAPP repairs were conducted using the da Vinci Xi system (Intuitive Surgical, Inc.) employing a parallel-side docking approach. Prior to the procedure, the patient was instructed to empty their bladder, and no Foley catheters were inserted. The patient was positioned in a 10° Trendelenburg supine orientation, with both arms placed alongside the body. Entry into the abdominal cavity was accomplished using the open method. A three-arm technique was employed, with a 30° scope inserted through the midline at the umbilical incision, and two additional ports positioned 10 cm to the left and right. Three 8-mm trocars were utilized (Fig. 2). Docking and inspection of the pelvic cavity and groins revealed no evidence of ischemia or necrosis of the small intestine. Peritoneal dissection was initiated approximately 8 to 10 cm above the internal inguinal ring. Dissection was performed using monopolar scissors and a fenestrated grasper with the right and left hands, respectively. For precise mesh placement in the Retzius space, dissection extended downward toward the deep inguinal ring, laterally towards the psoas muscle, and maintained a minimum distance of 2 cm between Cooper’s ligament and the bladder. Careful dissection of the OH sac was carried out, with preservation of the round ligament of the uterus. After evaluating the myopectineal orifice and confirming the visibility of all anatomical structures, a 3DMax mesh (Bard Davol Inc.) was positioned around the round ligament, extending from the pubic symphysis to the anterior iliac spine on the lateral side. Mesh fixation was accomplished using fibrin glue. Closure of the peritoneal flap was performed using 4-0 V-Loc sutures (Covidien). The contralateral OH was repaired using the same technique. The incision was closed with absorbable 3-0 sutures using a subcuticular method. The operation time was 83 minutes, and the console time was 61 minutes.

Fig. 2. An 8-mm trocar for the camera at the umbilicus and two 8-mm trocars for the working arms were inserted.

The patient recovered without any postoperative complications. Diet was initiated on postoperative day 0, and clopidogrel was initiated on postoperative day 3. The patient’s left lower quadrant and left hip pain disappeared after surgery. The patient was discharged on postoperative day 2 without complications. Six months after the surgery, no signs of recurrence or chronic pain were observed.

Surgical repair is the gold standard for the treatment of OH. Various surgical approaches are available for the repair of OH [2]; however, a standard surgical procedure has not yet been established.

Recent findings have demonstrated the feasibility of laparoscopic repair for OH treatment [5]. Compared to laparotomy, laparoscopic repair for small bowel obstruction is associated with faster recovery, shorter length of hospitalization, and fewer postoperative complications [1]. Moreover, contralateral side hernias can be explored using the laparoscopic TAPP. However, laparoscopic repair has a few disadvantages, such as more challenging technology, a longer learning curve, and a longer operating time. A laparoscopic totally extraperitoneal repair cannot evaluate the incarcerated bowel, and laparoscopic TAPP repair has a higher risk of visceral organ injury. The laparoscopic approach makes it difficult to conduct the operation if bowel resection and anastomosis are required for OH [4]. Therefore, the laparoscopic approach is not the best treatment option for patients with OH.

Nevertheless, early CT scanning facilitates prompt OH diagnosis, reducing complications like bowel ischemia and the need for bowel resection during surgery [7]. Thus, an early CT scan can reduce morbidity and mortality associated with OH [4]. In this regard, minimally invasive surgery may be a treatment choice in patients with OH without bowel ischemia owing to early diagnosis. The da Vinci robotic system offers several advantages over laparoscopic surgery, including a magnified three-dimensional view, a stable platform, a superior range of motion, and enhanced grip and pulling capabilities [6]. Thus, a robotic approach may decrease the risk of damage to the obturator nerve and vessels by enhancing three-dimensional vision. Robotic instruments also offer greater grip and pulling strength than laparoscopic instruments, enabling them to handle complex situations that may pose challenges during laparoscopy [8]. Consequently, a robotic system may improve the outcomes of OH repair. However, the robotic approach needs to consider cost and benefit because the cost of the robotic approach is higher than that of the laparoscopic approach.

In the present case, R-TAPP repair of bilateral OHs was successfully performed. This suggests that the R-TAPP approach may be safe and effective for OH repair that does not have bowel incarceration. Thus, R-TAPP repair may be a viable treatment option for patients with OH who do not have bowel incarceration.

Ethical statements

This study was approved by the Institutional Review Board of National Health Insurance Service Ilsan Hospital (No. NHIMC2023-06-019). Informed consent was waived owing to the retrospective nature of this study.

Authors’ contribution

Conceptualization: HSL

Writing–original draft: All authors

Writing–review & editing: All authors

All authors read and approved the final manuscript.

Conflict of interest

All authors have no conflicts of interest to disclose.

Funding/support

None.

Data availability

The data presented in this study are available upon reasonable request to the corresponding author.

Supplementary materials

Supplementary materials can be found via https://doi.org/10.7602/jmis.2024.27.1.40.

  1. Schizas D, Apostolou K, Hasemaki N, et al. Obturator hernias: a systematic review of the literature. Hernia 2021;25:193-204.
    Pubmed CrossRef
  2. Burla MM, Gomes CP, Calvi I, et al. Management and outcomes of obturator hernias: a systematic review and meta-analysis. Hernia 2023;27:795-806.
    Pubmed CrossRef
  3. Li Z, Gu C, Wei M, Yuan X, Wang Z. Diagnosis and treatment of obturator hernia: retrospective analysis of 86 clinical cases at a single institution. BMC Surg 2021;21:124.
    Pubmed KoreaMed CrossRef
  4. Kwak JS, Lee SE, Park SM, et al. Which patients are a better candidate of laparoscopic repair in obturator hernia patients? J Minim Invasive Surg 2020;23:93-98.
    Pubmed KoreaMed CrossRef
  5. Kohga A, Kawabe A, Okumura T, Yamashita K, Isogaki J, Suzuki K. Laparoscopic repair is a treatment of choice for selected patients with incarcerated obturator hernia. Hernia 2018;22:887-895.
    Pubmed CrossRef
  6. Aiolfi A, Cavalli M, Micheletto G, et al. Robotic inguinal hernia repair: is technology taking over? Systematic review and meta-analysis. Hernia 2019;23:509-519.
    Pubmed CrossRef
  7. Khaladkar SM, Kamal A, Garg S, Kamal V. Bilateral obturator hernia diagnosed by computed tomography: a case report with review of the literature. Radiol Res Pract 2014;2014:625873.
    Pubmed KoreaMed CrossRef
  8. Yoo RN, Mun JY, Cho HM, Kye BH. One-year experience of robotic transabdominal preperitoneal approach in a single institute: 2 different surgeons with different levels of experience. Ann Surg Treat Res 2023;104:176-181.
    Pubmed KoreaMed CrossRef

Article

Video/Multimedia Article

Journal of Minimally Invasive Surgery 2024; 27(1): 40-43

Published online March 15, 2024 https://doi.org/10.7602/jmis.2024.27.1.40

Copyright © The Korean Society of Endo-Laparoscopic & Robotic Surgery.

Robotic transabdominal preperitoneal repair for bilateral obturator hernia: a video vignette

Sungwoo Jung , Hyung Soon Lee

Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea

Correspondence to:Hyung Soon Lee
Department of Surgery, National Health Insurance Service Ilsan Hospital, 100 Ilsan-ro, Ilsandong-gu, Goyang 10444, Korea
E-mail: soon0925@nhimc.or.kr
https://orcid.org/0000-0001-9825-8648

Supplementary video file: This article contains supplementary material (https://doi.org/10.7602/jmis.2024.27.1.40)

Received: July 20, 2023; Revised: October 4, 2023; Accepted: October 16, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Obturator hernias (OHs) are a rare cause of bowel obstruction that requires immediate surgical intervention to prevent morbidity and mortality. Patients with OHs present with acute intestinal obstruction secondary to incarceration, with a high morbidity and mortality rate due to delayed diagnosis and treatment. Although several surgical approaches have been reported, a standard approach for OH treatment has not yet been established. Here, we report the case of a 74-year-old woman who presented with bilateral OHs. The patient presented at our institution with pain in the left lower quadrant. Computed tomography revealed preperitoneal fat in both obturator foramen. Robotic transabdominal preperitoneal (R-TAPP) bilateral OH repair was performed, and a mesh was placed over both obturator foramen. The patient recovered without postoperative complications and was discharged on postoperative day 2. This suggests that the R-TAPP approach is safe for OH repair without incarceration.

Keywords: Obturator hernia, Robotic surgical procedures, Herniorrhaphy

INTRODUCTION

Obturator hernias (OHs) are an uncommon cause of intestinal obstruction typically seen in elderly, slender, and multiparous women and result from the laxity of pelvic tissue and decreased fatty tissue around the obturator foramen [1,2]. Symptoms in patients are usually vague, and physical examinations can be inconclusive, making diagnosis challenging in most cases [3,4]. Additionally, patients with a delayed diagnosis often have serious conditions and require intestinal resection, resulting in a high mortality rate [2].

Traditionally, incarcerated OHs have been treated with open surgery, but recent reports have suggested the feasibility of laparoscopic repair for incarcerated OHs [5]. Recently, the laparoscopic approach has gained popularity, reporting fewer complications and faster recovery times compared to traditional open surgery. Moreover, the laparoscopic approach has a decreased morbidity and mortality rate than the open approach [1]. Laparoscopy provides a superior view of the obturator foramen compared to laparotomy. Moreover, with the advancement of minimally invasive surgical techniques, robotic-assisted hernia repair has become increasingly popular, and despite some debate regarding its clinical benefits [6]. However, robotic repair of OH is rare. Herein, we report a case of bilateral OH repair using the robotic transabdominal preperitoneal approach (R-TAPP).

METHODS

Patient

5A 74-year-old woman visited our outpatient clinic with left lower quadrant and left hip pain. She had a history of hypertension and endovascular coiling of a brain aneurysm one year ago and was treated with clopidogrel and valsartan. The patient had no previous history of abdominal surgery. Her height was 154 cm, her weight was 54 kg, and her body mass index was 22.7 kg/m2. The patient’s vital signs were normal. A physical examination revealed no abdominal tenderness. On physical exam, the Howship-Romberg sign was negative. The laboratory blood test results were normal. Abdominal computed tomography (CT) demonstrated fat tissue that was herniated into both obturator foramen (Fig. 1). Accordingly, we planned for an elective R-TAPP surgery for bilateral OH repair (Supplementary Video 1).

Figure 1. An abdominal computed tomography scan revealed a fat tissue herniation within the bilateral obturator foramen (white arrows).

Surgical procedures

Under general anesthesia, bilateral R-TAPP repairs were conducted using the da Vinci Xi system (Intuitive Surgical, Inc.) employing a parallel-side docking approach. Prior to the procedure, the patient was instructed to empty their bladder, and no Foley catheters were inserted. The patient was positioned in a 10° Trendelenburg supine orientation, with both arms placed alongside the body. Entry into the abdominal cavity was accomplished using the open method. A three-arm technique was employed, with a 30° scope inserted through the midline at the umbilical incision, and two additional ports positioned 10 cm to the left and right. Three 8-mm trocars were utilized (Fig. 2). Docking and inspection of the pelvic cavity and groins revealed no evidence of ischemia or necrosis of the small intestine. Peritoneal dissection was initiated approximately 8 to 10 cm above the internal inguinal ring. Dissection was performed using monopolar scissors and a fenestrated grasper with the right and left hands, respectively. For precise mesh placement in the Retzius space, dissection extended downward toward the deep inguinal ring, laterally towards the psoas muscle, and maintained a minimum distance of 2 cm between Cooper’s ligament and the bladder. Careful dissection of the OH sac was carried out, with preservation of the round ligament of the uterus. After evaluating the myopectineal orifice and confirming the visibility of all anatomical structures, a 3DMax mesh (Bard Davol Inc.) was positioned around the round ligament, extending from the pubic symphysis to the anterior iliac spine on the lateral side. Mesh fixation was accomplished using fibrin glue. Closure of the peritoneal flap was performed using 4-0 V-Loc sutures (Covidien). The contralateral OH was repaired using the same technique. The incision was closed with absorbable 3-0 sutures using a subcuticular method. The operation time was 83 minutes, and the console time was 61 minutes.

Figure 2. An 8-mm trocar for the camera at the umbilicus and two 8-mm trocars for the working arms were inserted.

RESULTS

The patient recovered without any postoperative complications. Diet was initiated on postoperative day 0, and clopidogrel was initiated on postoperative day 3. The patient’s left lower quadrant and left hip pain disappeared after surgery. The patient was discharged on postoperative day 2 without complications. Six months after the surgery, no signs of recurrence or chronic pain were observed.

DISCUSSION

Surgical repair is the gold standard for the treatment of OH. Various surgical approaches are available for the repair of OH [2]; however, a standard surgical procedure has not yet been established.

Recent findings have demonstrated the feasibility of laparoscopic repair for OH treatment [5]. Compared to laparotomy, laparoscopic repair for small bowel obstruction is associated with faster recovery, shorter length of hospitalization, and fewer postoperative complications [1]. Moreover, contralateral side hernias can be explored using the laparoscopic TAPP. However, laparoscopic repair has a few disadvantages, such as more challenging technology, a longer learning curve, and a longer operating time. A laparoscopic totally extraperitoneal repair cannot evaluate the incarcerated bowel, and laparoscopic TAPP repair has a higher risk of visceral organ injury. The laparoscopic approach makes it difficult to conduct the operation if bowel resection and anastomosis are required for OH [4]. Therefore, the laparoscopic approach is not the best treatment option for patients with OH.

Nevertheless, early CT scanning facilitates prompt OH diagnosis, reducing complications like bowel ischemia and the need for bowel resection during surgery [7]. Thus, an early CT scan can reduce morbidity and mortality associated with OH [4]. In this regard, minimally invasive surgery may be a treatment choice in patients with OH without bowel ischemia owing to early diagnosis. The da Vinci robotic system offers several advantages over laparoscopic surgery, including a magnified three-dimensional view, a stable platform, a superior range of motion, and enhanced grip and pulling capabilities [6]. Thus, a robotic approach may decrease the risk of damage to the obturator nerve and vessels by enhancing three-dimensional vision. Robotic instruments also offer greater grip and pulling strength than laparoscopic instruments, enabling them to handle complex situations that may pose challenges during laparoscopy [8]. Consequently, a robotic system may improve the outcomes of OH repair. However, the robotic approach needs to consider cost and benefit because the cost of the robotic approach is higher than that of the laparoscopic approach.

In the present case, R-TAPP repair of bilateral OHs was successfully performed. This suggests that the R-TAPP approach may be safe and effective for OH repair that does not have bowel incarceration. Thus, R-TAPP repair may be a viable treatment option for patients with OH who do not have bowel incarceration.

Notes

Ethical statements

This study was approved by the Institutional Review Board of National Health Insurance Service Ilsan Hospital (No. NHIMC2023-06-019). Informed consent was waived owing to the retrospective nature of this study.

Authors’ contribution

Conceptualization: HSL

Writing–original draft: All authors

Writing–review & editing: All authors

All authors read and approved the final manuscript.

Conflict of interest

All authors have no conflicts of interest to disclose.

Funding/support

None.

Data availability

The data presented in this study are available upon reasonable request to the corresponding author.

Supplementary materials

Supplementary materials can be found via https://doi.org/10.7602/jmis.2024.27.1.40.

Supplementary materials

Fig 1.

Figure 1.An abdominal computed tomography scan revealed a fat tissue herniation within the bilateral obturator foramen (white arrows).
Journal of Minimally Invasive Surgery 2024; 27: 40-43https://doi.org/10.7602/jmis.2024.27.1.40

Fig 2.

Figure 2.An 8-mm trocar for the camera at the umbilicus and two 8-mm trocars for the working arms were inserted.
Journal of Minimally Invasive Surgery 2024; 27: 40-43https://doi.org/10.7602/jmis.2024.27.1.40

References

  1. Schizas D, Apostolou K, Hasemaki N, et al. Obturator hernias: a systematic review of the literature. Hernia 2021;25:193-204.
    Pubmed CrossRef
  2. Burla MM, Gomes CP, Calvi I, et al. Management and outcomes of obturator hernias: a systematic review and meta-analysis. Hernia 2023;27:795-806.
    Pubmed CrossRef
  3. Li Z, Gu C, Wei M, Yuan X, Wang Z. Diagnosis and treatment of obturator hernia: retrospective analysis of 86 clinical cases at a single institution. BMC Surg 2021;21:124.
    Pubmed KoreaMed CrossRef
  4. Kwak JS, Lee SE, Park SM, et al. Which patients are a better candidate of laparoscopic repair in obturator hernia patients? J Minim Invasive Surg 2020;23:93-98.
    Pubmed KoreaMed CrossRef
  5. Kohga A, Kawabe A, Okumura T, Yamashita K, Isogaki J, Suzuki K. Laparoscopic repair is a treatment of choice for selected patients with incarcerated obturator hernia. Hernia 2018;22:887-895.
    Pubmed CrossRef
  6. Aiolfi A, Cavalli M, Micheletto G, et al. Robotic inguinal hernia repair: is technology taking over? Systematic review and meta-analysis. Hernia 2019;23:509-519.
    Pubmed CrossRef
  7. Khaladkar SM, Kamal A, Garg S, Kamal V. Bilateral obturator hernia diagnosed by computed tomography: a case report with review of the literature. Radiol Res Pract 2014;2014:625873.
    Pubmed KoreaMed CrossRef
  8. Yoo RN, Mun JY, Cho HM, Kye BH. One-year experience of robotic transabdominal preperitoneal approach in a single institute: 2 different surgeons with different levels of experience. Ann Surg Treat Res 2023;104:176-181.
    Pubmed KoreaMed CrossRef

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