Image Inversion during Xi Robotic ventral hernia repair: making it even more effective

ABSTRACT Introduction: currently, there are several clinical applications for robot-assisted surgery and in the hernia scenario, robot-assisted surgery seems to have the ability to overcome laparoscopic ventral hernias repairs limitations, facilitating dissection, defect closure, and mesh positioning. Exponentially grown in numbers of robotic approaches have been seen and even more complex and initially not suitable cases have recently become eligible for it. An appropriate tension-free reestablishment of the linea alba is still a major concern in hernia surgery and even with the robotic platform, dissecting and suturing in anterior abdominal wall may be challenging. This article reports a technical image artifice during a da vinci Xi-platform robotic ventral hernia repair allowing the surgeon to establish a more familiar and ergonomic manner to perform dissection and suturing in anterior abdominal wall. Technical Report: a step by step guided technique of image inversion artifice is described using detailed commands and figures to assure optimal surgical field and ergonomics whenever acting in robotic ventral hernias repair with the da Vinci Xi-platform. Our group brief experience is also reported, showing an easy and reproducible feature among surgeons with safe outcomes. Conclusion: we consider that image inversion artifice is a simple and reproducible feature in robotic ventral hernia repair. Through a step-by-step guide, this report enables the creation of an artifice providing a comfortable operative field and allowing the surgeon to achieve its best proficiency in hernia surgery.


INTRODUCTION
V entral hernia repair (VHR) is one of the most common operations performed by general surgeons 1 . The optimal technical approach to this condition is still in perspective having the majority of these elective repairs carried out through conventional midline approach 2 .
Due to high incidence of wound morbidity associated with open hernia repairs, the laparoscopic approach was initially seen as a possible technique to decrease these complications 3 .
Minimally invasive surgery has revolutionized surgical treatment of diseases for a variety of pathologic conditions with shortened hospitalizations, less pain, decreased recovery time, faster return to activity, improved cosmesis, and reduction in wound morbidity.
Specific to VHR, laparoscopic approach revealed less surgical site infections and wound morbidity. However, recurrence rates were not negligible, ranging from 7 to 18% 4-6 . The increased recurrence rate seen in laparoscopic surgery is likely due to the degree of technical difficulty to close the midline fascia, creating an appropriate large mesh overlap despite the big learning curve.
Da Vinci robotic surgical system has brought huge evolution to minimally invasive surgery, and

A B S T R A C T A B S T R A C T
Introduction: currently, there are several clinical applications for robot-assisted surgery and in the hernia scenario, robot-assisted surgery seems to have the ability to overcome laparoscopic ventral hernias repairs limitations, facilitating dissection, defect closure, and mesh positioning. Exponentially grown in numbers of robotic approaches have been seen and even more complex and initially not suitable cases have recently become eligible for it. An appropriate tension-free reestablishment of the linea alba is still a major concern in hernia surgery and even with the robotic platform, dissecting and suturing in anterior abdominal wall may be challenging. This article reports a technical image artifice during a da vinci Xi-platform robotic ventral hernia repair allowing the surgeon to establish a more familiar and ergonomic manner to perform dissection and suturing in anterior abdominal wall. Technical Report: a step by step guided technique of image inversion artifice is described using detailed commands and figures to assure optimal surgical field and ergonomics whenever acting in robotic ventral hernias repair with the da Vinci Xi-platform. Our group brief experience is also reported, showing an easy and reproducible feature among surgeons with safe outcomes. Conclusion: we consider that image inversion artifice is a simple and reproducible feature in robotic ventral hernia repair. Through a step-by-step guide, this report enables the creation of an artifice providing a comfortable operative field and allowing the surgeon to achieve its best proficiency in hernia surgery.

Surgeons console steps
Using the display at the robotic console, more three steps must be done to enable INV feature. First step is performed by reassigning robotic instruments to opposite hands. Display should be unlocked, followed by a click in the "manual command" button, which will display the button to get the reassignment of the robotic arms shown in Figure 3 (Figure 3c, d). After doing it, the second step is done by taping the swap pedal to confirm the new configuration. The third and final step is then fulfilled by flipping the endoscope 30° lens in the opposite direction.
By completing these both bedside and surgeon's console guided steps, an image inversion artifice is generated resulting in any movement that would previously be performed in the upper space of the surgical field ("ceiling") is transformed into movements in the lower field ("floor"), more familiar and effective and easily done in a forehand suture (Figure 4, 5, 6).

Morrell
Image Inversion during Xi Robotic ventral hernia repair: making it even more effective

DISCUSSION
Although initial laparoscopic VHR decreased wound morbidity, it didn't grant an optimal fascial defect closure with adequate tissue approximation 11 . The gold standard parameter of any hernia repair is recurrence rate. Open and laparoscopic repairs carry not negligible recurrence rates of 32% and up to 18% in the literature, respectively 18,19 . Many studies have shown RVHR to be durable in the short term with recurrence rates < 1% 8,16,17,20 . One of the clear advantages of robotic VHR is the possibility for posterior component separation to be performed in more complex cases with lower morbidity and hospital length of stay 21 .
Cost is a frequently cited deterrent to the application of robotics to general surgery, which is often related to an initial higher capital expense with the robotic system. In a more efficient long-term scenario, any feature enabling surgeons to be faster and safer could bring better results and save costs with lesser