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Diastasis surgery and robots: fact checking

I recently found this article which compares the various techniques of diastasis surgeryparticularly emphasising the merits of the robotic surgery compared to other methods.

Preamble: I have always maintained that the Da Vincithe surgical robotis an exceptional tool in surgery in general, perhaps more so in specialist branches such as urology, but also in digestive cancer surgery and abdominal wall surgery. However, I believe that surgery of the diastase and robots do not get along too well: and I have already written a article comparing the two methodsrobotics and endoscopy.

Why, therefore, return to the subject? Because the above article contains, in my opinion, some serious inaccuracies - I hope unintentional - and in attempting to advertise one technique over another risks giving inaccurate, and therefore misleading, information to patients.

Those who follow me on the blog and via my Facebook page knows that my primary interest is to make scientific information readily available to patients suffering from diastasis of the rectus: for this reason, I decided to submit to fact checking the article on diastasis surgery and robots referred to above.

"I had my first contact with the robot eleven years ago, when they were still barely known in Italy and it was thought that the latest in abdominal wall surgery was endoscopy or simple laparoscopy. And unfortunately, after all these years, there are still those who believe this (or try to convince themselves)'..

FALSE. Speaking of endoscopy, the main internationally validated technique, and published in scientific journals high impact factor is the REPA. The first case of REPA was realised in 2014 and the method was published in 2017 (although this has been talked about in surgical circles for a few years now). This short open access article makes a quick mention of the other (few) endoscopic techniques known today (it should be noted that the case described in the article is a REPA). These include, the most important is that of Bellon Luque et al.published in turn on a important magazinebut very little used today; Bellon Luque's article refers to interventions carried out between 2011 and 2012. Therefore, eleven years ago the author of the above article could not have been familiar with endoscopic techniques for the repair of diastasis of the rectus.

"Those who currently discredit the use of robotic surgery in the treatment of abdominal diastasis in Italy certainly have no experience in this field to be able to support or argue their criticism. He has probably never seen a robot up close and has never used one. He has certainly never seen a surgery I have performed with this technique and its post-operative course and result..

FALSE. I think this paragraph is dedicated to me, precisely because of the article comparing endoscopic and robotic techniques that I published some time ago. In the very operating theatre where I operate, I have a Da Vinci; I have done the training, I know the robot very well and I know how to use it. I had the opportunity to visit, maybe a month ago, a patient operated on by the author of the article (a paediatrician colleague working in Tuscany) who, having had a relapse about a year after surgery, had come to me for an opinion on her situation. So I know as much about the robot as I do about the postoperative results of robotic surgery, no different from those of other techniques. (This has little of the fact checkingbut it was something I wanted to point out).

"Robotic instruments are very delicate, miniaturised, and are moved by the surgeon with a precision of a fraction of a millimetre. Moreover, they have the fundamental characteristic of being articulated in all directions.
Endoscopic or laparoscopic instruments, on the other hand, are straight, non-articulating rods on which rather coarse instruments are mounted'..

FALSE. There are many articulable laparoscopic forceps. A this link you can find an example of such tools, produced by a French company, Lamidey Noury, which allow degrees of freedom of movement that are comparable to those of a robot. Similar tools are constantly being developed. Moreover, as in all things, the finesse and skill in performing an action (be it running after a ball or performing a laparoscopic suture) depends on personal ability, training and available technology. In laparoscopy, as well as in endoscopic diastasis surgery, a fineness of movement not dissimilar to that offered by the robot can be achieved, thanks in part to the use of articulable forceps similar to robotic forceps.

"They are 8 millimetres in diameter, but the skin incision is always 5 millimetres to allow for full adhesion and tightness."

FALSE. It is a trivial mathematical matter. The circumference (diameter x 3.14) of a circle with a diameter of 5 mm is 15.70 mm; that of a circle with a diameter of 8 mm is 25.12 mm. I defy anyone to get a tool with a circumference of more than 25 mm through a hole 15 mm in circumference. Admittedly, the skin is a very elastic tissue, but if subjected to such tensions, it expands and/or tears (and thus the initial incision inevitably enlarges).

"The absorption of Co2 gas occurs in both techniques.

FALSE. There are numerous articles on the alterations caused to the peritoneum e on changes in pCO2 and blood pH during laparoscopy. The links above are just one example. During laparoscopic/robotic procedures, CO2 is absorbed by the peritoneum. In endoscopic techniques, the same changes do not occur, as the tissues with which CO2 comes into contact do not possess the capacity to absorb it in significant quantities. The absorption of CO2, with the consequent alterations in the acid-base balance of the blood and in particular the decrease in pH, occurs significantly during laparoscopic/robotic surgery BUT NOT during endoscopic surgery.

"The surgery I perform belongs to the R.T.A.P. category, which stands for Robotic Trans-Abdominal Pre-Peritoneal and is based on the use of the pre-peritoneal space.
Space can only be prepared by the delicacy and precision of robotic instruments'.

FALSE. Transabdominal access to the preperitoneal plane (TAPP) is also easy in laparoscopy. Here is a video of a laparoscopic TAPP repair of an epigastric hernia performed by myself. Today, in fact, laparoscopic dissection of the preperitoneal plane is becoming increasingly common as a site for placing surgical nets, to avoid leaving foreign bodies (the nets) directly in contact with the abdominal viscera.

"In non-robotic anterior endoscopic methods the muscle approach suture is technically awkward both because of the instrumentation and because of the working space. It is performed only on the anterior side of the abdominal wall and not full-thickness on the medial margin of the rectus muscles, resulting in a clearly more fragile [...]"

FALSE. In the following photo, taken from one of the last interventions of Endoscopic diastasis surgery performed by me, it is evident that the rectus muscles are sutured at full thickness, not only on the fascia

Diastasis surgery

anterior. This is easy to do in endoscopy, because the linea alba, which is slack and redundant, invaginates with the suture, and can be used as a reinforcing band for suturing along the entire length of the muscle. This invagination of the linea alba, on the other hand, is difficult to achieve via TAPP, partly because the gas tends to push it outwards. In endoscopy, the muscle suture is always full-thickness, reinforced by the linea alba. The same is more complex to achieve in laparoscopy / robotics.

"Also, because of the anterior working compartment, there is not full control during the passage of the stitches even if the surgeon tries to stay light and take little tissue.
The passage of sutures is blind in the deep side with risk of damage to the viscera and intestines (some people have muscle walls only a few millimetres thick due to muscle-tendon dystrophy present in the advanced stages of diastasis)'.

FALSE. Also from the same photo, it is evident that the tissue being sutured is always completely under the visual control of the surgeon. Visceral damage in diastasis surgery is always possible (especially when working inside the abdominal cavity, as in robotics), but with the anterior prefascial approach, and with the perfect visual control of the suturing tissues well demonstrated by the previous photograph, this risk is close to 0.

"A type of super-light, self-fixing, partially resorbable mesh produced by the world's best company in the field is placed, with the aim of placing as little implant material as possible.

FALSE. The network mentioned is the Medtronic Progripa well-known British company active in the biomedical sector. Let us leave out theopinion (because that's all it is) that it is the best company in the world in the industry. The following image is taken from the product information brochure, released

diastasis surgery

by the same company and readily available on the web. As can be seen, the (partially resorbable) mesh weighs, at the time of implantation, 73 g/sqm, and at the end of resorption 38 g/sqm. This article, published in 2012, is the worldwide reference for the classification of surgical meshes according to weight: as can be seen, meshes between 35 and 70 g/sqm are classified as light, and between 70 and 140 g/sqm as standard; therefore, at the time of implantation, the network is a standard networkwhile at the end of resorption is light and not 'super light' (the correct term is ultralight) as claimed in the article. Incidentally, the net used in REPA weighs 19 g/sqm, so it is an ultra-light net in this case.

"In anterior non-robotic endoscopic techniques, one of the dreaded and irreversible drawbacks of the mesh is the risk of it being felt under the skin, especially by thin patients.

FALSE. The prefascial position used in endoscopic techniques was decribed by French surgeon J.P. Chevrel in 1979. This is probably the most widely used position in the world today for placing a mesh in abdominal wall repairs; in this recent article you can see how the complications related to this technique are few and the quality of life very satisfactory.

Ultimately, the fact checking on the article in question demonstrates the presence of many incorrect statements on the diastasis surgery, the robotic technology and theendoscopy.

The general principle, always valid, is that every surgeon should operate using the technique he or she feels most 'comfortable' with for the same results and patient safety. Unfortunately, if for the REPA there is already a fair amount of literature (incidentally, a large multicentre study on the results of this technique, to which I also contributed, is about to be published), I could not find, on the Medlineno article on diastasis of the rectus with robot surgery. If anyone finds one, please send it to me: it will be a pleasure for me to read it.

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