A retrospective chart review was performed after institutional review board (IRB) approval was obtained. All patients with a history of prostatectomy that underwent TAPP RIHR with mesh by a single surgeon at a university-affiliated community hospital between March 2017 and October 2021 were identified. Demographic information (i.e. age, body mass index, etc.), prior pelvic and abdominal surgeries, and radiation history was reviewed for each patient. Intraoperative data including total operating times were analyzed along with need to convert to open repair and any intraoperative complications. Post-repair data was also gathered including pain, recurrences, and any post-operative complications.
All surgeries were performed with use of a da Vinci Xi or Si Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). The following is a general description of the TAPP surgical technique performed in these cases including specific considerations for this patient population.
Preoperative Foley catheter is avoided to preserve any urethral strictures that may be protective for these patients in terms of maintaining urinary continence. Pneumoperitoneum is initially established with use of a Veress needle via supraumbilical transverse curvilinear incision. After establishing pneumoperitoneum to 12–15 mmHg, an 8mm robotic port is placed in the supraumbilical midline. Two additional 8mm ports are then placed approximately 8cm lateral to the midline port on each the right and the left with each port positioned slightly more cephalad than the midline port. The patient is placed in a Trendelenburg position and the robot is docked with camera targeting the internal ring of the affected side for a unilateral hernia or in the pelvic midline for bilateral hernias. For instrumentation, a fenestrated bipolar grasper is used in the left hand and monopolar scissors are used in the right hand. For patients with a large hernia sac where reduction is challenging, a Caudiere grasper is exchanged for the scissors for the reduction. At the conclusion of the repair, a large needle-driver is used in the right hand for mesh positioning and re-approximation of the peritoneal flap.
The initial dissection begins with a transverse peritoneal incision 4cm above the internal inguinal ring extending from the median umbilical ligament to the level of the anterior superior iliac spine. That peritoneal flap is then developed in the avascular plane down to the pelvic floor with the goal of exposing the testicular vascular bundle, the vas deferens, the psoas muscle, and the iliac artery. Interestingly, the vas deferens often appears normal even in patients who have undergone prostatectomy with vas deferens division. This suggests that the clipped vas deferens still provides one of the typical three sources of blood supply to the testicle (testicular artery, vas deferens via inferior vesicle artery, and small arterial branches from the inferior epigastric artery (cremasteric artery)). In post-prostatectomy patients, this aspect of the dissection is usually similar to patients without any prior pelvic surgery.
The medial dissection is usually more challenging in these patients, especially if the patient has received radiation treatments. Post-treatment tissue planes are distorted and firm. Tips to minimize risk of injury to surrounding structures include identifying the pubic tubercle early in the dissection, closely following that bone to the pubic symphysis, and being mindful of the iliac vein which can be retracted into a more medial position than normal. The most critical aspect of a TAPP dissection, in general, is the inferior medial dissection to ensure that the mesh in that location is not displaced by a distended bladder. This is the same location in which the iliac vein can become medialized. The data in the present study suggest that the surgeon has developed this space just large enough to accommodate circumferential coverage of the myopectineal orifice with a 10x15cm piece of mesh but limits further dissection that would accommodate the placement of the preferred size of mesh (12x16cm). The presenting surgeon favors the minimized risk of injury to surrounding structures over the benefit of larger mesh use in this patient population. Regardless of mesh size, assurance that the mesh lays flat with wide circumferential coverage of the myopectineal orifice along with assurance that the mesh does not roll or migrate with replacement of the peritoneal flap is key to minimize hernia recurrence. The conclusion of this repair occurs with peritoneal re-approximation with complete coverage of the mesh prosthetic. Scarring, especially with radiation treatment, can cause peritoneal fibrosis and contraction which limits the forgiveness of peritoneal stretching common in ‘normal’ TAPP repairs. Often the peritoneum will approximate without undue effort, but occasionally it will require patching with vicryl mesh with care taken to avoid any gaps or holes.