LAUSR

Dear Sir, The importance of femoral hernia is that emergency presentations are relatively common [1]. Minimally invasive groin herniorrhaphy has better postoperative outcomes compared to an open approach [2,3]. In addition, laparoscopic herniorrhaphy for femoral hernia has lower reoperation rates compared to open [1]. However, evidence regarding the role of the robotic approach for emergency operations is lacking. Some promising advantages of the robotic technology to overcome laparoscopic shortcomings may be useful in emergency situations also [2]. Besides, rapid and accurate evaluation of bowel viability is important in emergency settings. Fluorescence imaging could be utilized in assessing the blood flow to the incarcerated bowel segment [4]. Herein we would like to present a case of incarcerated femoral hernia that underwent emergency robotic transabdominal pre-peritoneal (TAPP) hernia repair under the guidance of indocyanine green (ICG) dye. A 58-year-old female patient was admitted to the emergency room with complaints of abdominal pain, vomiting and right groin mass. Physical examination revealed incarcerated right femoral hernia. Imaging studies demonstrated intestinal obstruction due to incarcerated femoral hernia. The patient underwent emergency robotic right femoral hernia repair with the TAPP approach. The patient was placed in the supine Trendelenburg position. A laparoscopic exploration was undertaken and a non-reducible small bowel loop was encountered within the right femoral canal. Then, the da Vinci Xi (Intuitive Surgical Inc., Sunnyvale, California, USA) robot was docked from the left side of the patient. Three 8 mm robotic trocars were used during the procedure. No assistant trocar for the bedside surgeon was utilized. After reduction of the strangulated bowel, a Richter’s hernia was encountered. The anti-mesenteric bowel wall was ischaemic. For the assessment of bowel viability, ICG dye was injected intravenously. After confirmation of the bowel vascularization no further intestinal intervention was performed. Conventional right inguinal herniorrhaphy with ProGrip (Covidien, Tr evoux, France) mesh completed the operation. The docking and operative times were 3 and 80 min, respectively. The operative blood loss was 2 ml. The patient was discharged on postoperative day 5 uneventfully. The robotic approach for emergency incarcerated femoral hernia is feasible. To the best of our knowledge, this is the first one stage emergency femoral hernia repair performed with a robotic platform. ICG dye fluorescence imaging may aid in differentiating between ischaemic and necrotic bowel segments [4]. Main limitations to robotic inguinal herniorrhaphy are the limited access to the robotic system and the high cost of the procedure [2]. Although evidence regarding the robotic approach for elective inguinal herniorrhaphy exists, to assess its role in emergency settings like incarcerated femoral hernia needs further investigation.