Hidden Incisions Robotics (HIR)

hidden incisions robotics

Here you will find all you need to know to hide incisions during robotic pediatric urology procedures.

The procedures that can be done with hidden incisions, without sacrificing on exposure are:

  1. Extravesical reimplant

  2. Pyeloplasty (primary and redo)

  3. Ipsilateral Ureteroureterostomy (duplicated systems with either reflux, ectopia or ureterocele)

We have not figured out a way yet to do a transureteroureterostomy with hidden incisions without compromising exposure and collisions. Fortunately, TUUs constitute a small percentage of robotic cases.

What we describe here is done in babies as young as 2 months all the way to morbidly obese teenagers:

 

The concept of hidden incisions first described by Gargollo:

  1. Gargollo first came up with the concept of placing the robotic trocars inside the belly button and at the bikini line to “hide” the incisions. 
  2. Later, Micah Jacobs added one trick to the technique: keeping the skin incisions in the bikini line but moving the fascial incisions where they would be most appropriate:

How to HIR

HIR consists of making all skin incisions in the following locations:

  1. In the middle of the belly button in patients with an “outie” (babies and most younger children)
  2. Half moon incision inside the bottom of the belly button in more obese children or older children with an “innie”.
  3. Somewhere in the bikini line (corners, middle, in between corners and the middle)

Once the skin incisions are made, if the fascial incisions need to be superior to the skin incision the skin is freed around and using a zen retractor the skin is pulled up towards the desire fascial insertion.

The following video shows port placement in detail for robotic extravesical reimplant:

Port securement

For HIR to work, some ports need to be sutured to the skin because they will need to be burped up and away to create space:

And that is all there is to it!

In the following section, we will briefly describe the port location for each procedure.

 

Extravesical reimplant

  • Belly button (0 Degree camera)
  • 2 trocars on each corner of the bikini line with fascial incision 2-6 cm superior to skin incision (DeBakey and Monopolar scissors)

Pyeloplasty

  1. Belly button (Debakey Forceps)
  2. Ipsilateral corner of the bikini line, fascial incision same location. For infants, this port needs to be sutured and burped up and away.  (Monopolar Scissors)
  3. Middle of the bikini line with the fascial incision either in the same location for small children, or moved superiorly for taller children. Nowadays we tend to move the port slightly up in most. (30-degree camera)

Ureteroureterostomy

After trying multiple port variations we found the best port configuration for this procedure:

 

  1. Belly button (monopolar scissors)
  2. Middle of the bikini line, the fascial incision in the same place, and the port needs to be sutured to burp up and away (DeBakey)
  3. Contralateral corner of the bikini line (30 degrees down camera)

 

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