PMC3015473_01
PMC3015473_02
Three trocars are used in this procedure. A 12 mm disposable trocar for the stereo-optical telescope is inserted on the right anterior axillary line at the level of the umbilicus. Two 8 mm reusable trocars are inserted on the right mid-clavicular line. The right and left-hand instruments of the robot are inserted through these trocars.
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F1
A 12-mm disposable trocar (Ethicon Endosurgery, Cincinnati, Ohio) was inserted on the right anterior axillary line at the level of the umbilicus (Figure 1).
The tower that suspends the three robotic arms is brought in from the left side of the patient. It approaches the surgical table at a 45-degree angle from the foot of the table.
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F2
The da Vinci Robotic Surgical System was advanced toward the surgical table at a 45-degree angle from the foot of the bed and attached to the 3 trocars (Figure 2).
The small intestine was densely adherent to the anterior abdominal wall in Patient 2. Cadiere graspers in the robot's right hand provided traction on the bowel. Scissors in the robot's left hand divided the adhesions.
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F3
When the small intestines were tightly adherent to the abdominal wall or hernia sack, the adhesions were divided by using robotic scissors (Figure 3).
The surgeon sits at the surgeon's console. The console is separated from the patient but required by the FDA to be within the same operating room. The console houses the robot's computer and binocular stereoscopic video system. The surgeon places his/her hands into the "master" (insert), which translates the surgeon's hand motions into the motions of the telerobotic surgical instruments.
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F4
This portion of the operation was accomplished in a solo manner by the surgeon operating at the surgeon's console (Figure 4).
The bed-side assistant surgeon used a suture passer (Karl Storz Endoscopy America, Santa Barbara, California) to pull the #,0 Gore-Tex suture (W. L. Gore & Associates, Flagstaff, Arizona) through the abdominal wall. The surgeon used a Cadiere grasper and needle holder to place the suture in the suture passer.
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After the eight transabdominal wall sutures are tied, the edges of the mesh are secured to the abdominal wall with 5 mm tacks (Autosuture ProTack, Autosuture, Norwalk, Connecticut). This prevents bowel from migrating between the mesh and the abdominal wall. The mesh sits flatly against the abdominal wall covering the incisional hernia of Patient 2. The intraabdominal pressure is 6 mm of mercury during this portion of the operation.
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F6
This ensured that bowel could not pass between the abdominal wall and mesh between the sutures (Figure 6).
Patient 1 at the end of the operation. Plastic dressings cover the three trocar sites on the right side of the abdomen and the eight 2 mm stab incisions through which the transabdominal sutures were passed and then tied. The margins of the two hernia defects are marked with small x's. Two concentric ellipses encompass the two defects. The outer ellipse marks the 2-inch overlap of the mesh around the hernia defects.
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F7
Each wound was covered with an adhesive dressing (Figure 7).