Pelvic Defects

Abstract

Pelvic defects comprehend mainly the sciatic, obturator and perineal hernias. Although these types of diseases are rare and anatomically different, they have similarities in their treatment and uncommon presentation. They can be conservative managed or surgically treated either from the abdominal cavity or from the outside. In the case of postoperative perineal hernias, mostly plastic surgeons can make flap rotations or primary closure to treat them locally. These methods are difficult, individual dependent and controversial. Muscular mobilization and rotation are complexes. Oncologic patients have local changes because of their treatment and external approach must be considered having higher risks. When coming from inside, laparoscopy, the repair is mainly done with the use of intra peritoneal meshes.

Another important option is the use of the minimally invasive surgery from the abdominal cavity to treat both types of hernia, primary and postoperative. However, the laparoscopic approach has only a few cases reported, due to difficulties such as deep dissection, 2D view, and hard mesh placement and fixation. With the advent of robotic technologies with articulated forceps and 3D view optics those problems can be easily solved. Thus, in this chapter we present a standardized technique of robotic treatment of the pelvic defects.

Before starting the procedure it is important to have a good physical and radiological evaluation of the patient and defect to be treated. All the patients should have a CT (computed tomography) scan done before the repair. Clinical evaluation for the surgery is also needed.

After those evaluations it is time to prepare the patient and the operating room (OR) for the procedure. At this part it is important to place the robot and other parts of the OR considering the docking that will be done during the surgery.

When the docking is done, dissection of the defect can be started and caution must be taken in this process. Adhesiolysis around fixed bowels must be progressively slow, meticulous and calm. Those are possible with the stability of robotic arm. After the dissection the mesh is placed in the cavity. It is fixed as close to bone structures as possible, depending on the type of defect.

Complications can occur in most patients, such as: seroma, infection, adinamic ileus, and clinical problems. But in the majority of cases they are easily treated without any reinterventions.

Although there has been little evidence until now, the robotic treatment of pelvic defects seems to be a good approach in this rare and challenging disease. However, bigger case series and clinical trials have to be done to show the real advantages and disadvantages of this type of hernia repair.

Glossary

Abdominoperineal excision (APE)

Surgical procedure to treat distal rectal and anal carcinoma, in which an anastomosis cannot be done

Extralevator APE (ELAPE)

Surgical procedure proposed by Holms et al. to improve local tumor control and with the aim to reduce local recurrence