Robotic Hernia Repair, Colorectal and Pelvic Floor Surgery

Robotic hernia repair places a mesh through small ports under a magnified view in which small vessels and nerves are visible. Dr. Rakesh Durkhure repairs umbilical and inguinal hernias on the robot and massive hernias robotically or laparoscopically, with a plain mesh in the preperitoneal space and a dual, composite mesh for the largest, and switches to open repair when the skin over the hernia is in poor condition.

Below the stomach, Dr. Rakesh Durkhure's practice covers three overlapping territories: the abdominal wall, the colon and rectum, and the female pelvic floor. In each, his argument is the same as elsewhere in his work in general and bariatric surgery at Artemis Hospitals, Gurugram: magnified vision and fine, wristed instruments allow operations that once required a long incision, or a long hospital stay, to be done through ports. He was equally explicit about the limits, showing a hernia he had to repair open and setting out where the indication for a pelvic operation belongs to a gynaecologist rather than to him.

Robotic hernia repair: from routine to massive hernias

Dr. Durkhure repairs the full range of hernias, inguinal (groin), incisional, lateral and hiatus hernias, as well as recurrent hernias after failed earlier repairs, and chooses the route and the mesh to suit the hernia and the tissue. Rather than an easy case, he showed the difficult ones. Hospital costs are listed on the hernia repair cost page.

Robotic preperitoneal repair of an umbilical hernia

In the first video, a robotic preperitoneal repair of an umbilical hernia, he lifts the peritoneum, the thin membrane lining the abdominal cavity, away from the abdominal wall as a separate, intact layer. The steps then follow in order:

1. Reduce the hernia and develop a plane large enough to take a mesh.
2. Suture the defect closed, using the backhand action of the robotic wrist.
3. Place a plain polypropylene mesh in the preperitoneal space, between the peritoneum and the muscle wall.
4. Close the peritoneum back over the mesh.

Because the mesh sits outside the peritoneal cavity, a simple mesh is sufficient: it does not lie against the bowel.

Robotic inguinal hernia repair

The inguinal repair he showed could equally be done laparoscopically, but the robotic view is the argument for the robot. In the groin, he said, every fibre and every miniature structure is visible: small vessels and nerves are clearly magnified. His view is that anyone contemplating this operation should do it on the robot. The mesh is placed to cover all the hernia orifices.

Large and complex hernias

For very large, massive hernias, Dr. Durkhure operates robotically or laparoscopically and uses a dual, composite mesh. He reported patients going home without infection, and for diabetic patients with hernias of this size he regards the laparoscopic route as the best method.

When open hernia repair is the better choice

He also showed the exception. In one patient the skin over the hernia was in such poor condition that he repaired it as an open operation. The choice of route follows the tissue, not a preference for technology.

For hernia repair he uses only American mesh, and he does not offer patients a choice of alternatives.

Ulcerative colitis and Crohn's disease: when J pouch surgery is needed

Surgery for inflammatory bowel disease follows when medical therapy fails, and for ulcerative colitis the definitive operation is an ileal J pouch. A patient with inflammatory bowel disease may first present with recurrent rectal bleeding without haemorrhoids, together with continuing weight loss and frequent stools containing blood. Diagnosis follows colonoscopy and biopsy of the colon.

The two diseases have different patterns. Crohn's disease produces skip lesions, patches of disease separated by normal bowel, whereas ulcerative colitis produces a continuous lesion. Initially, his medical gastroenterology colleagues treat the disease medically, and surgery follows when that therapy fails. He cautioned that many of these patients will have been on steroids, which do harm of their own.

For ulcerative colitis, the definitive operation removes the whole colon and rectum and reconstructs the bowel with an ileal J pouch joined to the anus, the ileal pouch-anal anastomosis (IPAA). The pouch acts as a new reservoir, and the operation preserves the anal sphincter muscles, so the patient retains control without a permanent stoma, an opening of the bowel onto the skin of the abdomen. Because Crohn's disease can recur anywhere in the gut, including the pouch itself, the ileal pouch is generally reserved for ulcerative colitis.

Laparoscopic total colectomy through three ports

The most recent case Dr. Durkhure presented shows how far laparoscopic colorectal surgery has moved. Using a camera port and just three working ports, he removed the complete colon: the caecum, ascending colon, hepatic flexure, transverse colon and descending colon. The specimen came out through one of the small port sites. The operation was entirely laparoscopic, without a laparotomy. Hospital costs for bowel resection are listed on the colorectal resection cost page.

Robotic rectopexy for rectal prolapse

Robotic rectopexy fixes a prolapsed rectum back in place, and rectal prolapse was the occasion for Dr. Durkhure's clearest illustration of robotic control in the pelvis. On the da Vinci, he said, every movement is controlled, with no vibration and no confusion. He enters the avascular plane behind the rectum, a natural tissue layer with few blood vessels, which he called the holy plane, and dissects within it so that the pelvic nerves are protected.

The operation he showed combines two fixations:

1. Posterior suture rectopexy. He fixes the rectum posteriorly with sutures.
2. Mesh fixation. He places a dumbbell-shaped mesh, fixes it anteriorly, and anchors it to the sacral promontory, the upper front edge of the sacrum.

In the case he showed, a woman's rectum had prolapsed about six inches; at the end of the operation it was securely fixed.

Fistula, fissure and haemorrhoid surgery

Dr. Durkhure treats haemorrhoids with laser, and treats fissures, small tears in the lining of the anal canal, as one-day-stay operations.

Fistula surgery and the seton

Fistulas, abnormal tunnels between the anal canal and the skin, are the harder problem. He uses a seton, a thread passed through the fistula tract to drain it and cut through or define it gradually. Healing rates depend on the type of fistula: simple low fistulas treated by fistulotomy heal in more than 90 percent of cases, while complex fistulas treated with sphincter-preserving techniques heal in roughly 60 to 70 percent. His own practice differs in one respect he regards as decisive: he and his team do all the dressings after surgery themselves rather than delegating them. As a result, he said, his patients do not go home, whether to another country or elsewhere in India, with a fistula still open; they leave when it is essentially cured. Hospital costs are listed on the fistula and seton surgery cost page.

Anal sphincter repair after injury

For patients whose anal sphincter has been destroyed by a bullet or blast injury, he repairs the sphincter, and with a plastic surgeon can construct a new one.

Gynaecological and pelvic floor surgery

Although he is a general surgeon, Dr. Durkhure operates alongside gynaecologists on complex pelvic cases. The indication is set by the gynaecologist, and the two operate together. The range he described includes:

• Very large fibroids, up to 25 centimetres, and adenomyomas.
• Severe (stage IV) endometriosis.
• Pelvic organ prolapse, treated by robotic or laparoscopic sacrocolpopexy, which suspends the vaginal vault from the sacral promontory with mesh.
• Stress urinary incontinence, the leakage of urine on coughing, sneezing or exertion, treated by Burch colposuspension.

Many women who have given birth by normal delivery go on to develop a rectocele, a cystocele or urinary incontinence, and these operations are designed for them. A rectocele and a cystocele are bulges of the rectum and of the bladder, respectively, into the vagina.

Burch colposuspension for stress urinary incontinence, step by step

Burch colposuspension lifts and straightens the junction of the urethra and bladder, and in Dr. Durkhure's view the robot is much better than laparoscopy for the suturing it requires in that narrow space. Asked in the live discussion how stress urinary incontinence is treated robotically, Dr. Durkhure began with the mechanism. In women the urethra is only about 4 centimetres long. The critical point is the internal urethral meatus, where the urethra joins the bladder. If that junction sags, the supporting muscle weakens and control at the internal meatus falls; a weakness at the external meatus matters far less. The aim of surgery is to lift the junction back up and straighten it.

In a Burch suspension:

1. He places three stitches in the anterior vaginal wall on each side of the urethra.
2. He lifts them and fixes them to the pectineal (Cooper's) ligament, a strong band along the pelvic bone, on each side.
3. This pulls the anterior vaginal wall upward and raises the internal meatus and urethra with it.

The robot's contribution is suturing in a very narrow space, where it is much better than laparoscopy.

Single-port laparoscopic surgery

Single-port surgery performs the whole operation through one small incision instead of several ports. Beyond conventional multi-port surgery, Dr. Durkhure performs single-port laparoscopic operations, including total laparoscopic hysterectomy, ovarian cystectomy, appendicectomy, gallbladder removal and bariatric surgery. The technique requires a thin patient.

His upper digestive tract and neck operations are covered in robotic Heller myotomy, thyroid and gallbladder surgery, and the broader picture of his robotic platform and department is set out in the complete guide to robotic and laparoscopic surgery.