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Limitations of the robot-assisted technique are obvious. Large ventral hernias, as they approach the working ports and camera, make

Obtaining a thorough history and physical is mandatory to coordinate an operative plan. Specifi cally, comorbidities such as diabetes, obe­sity, smoking, and collagen vascular disease may critically affect the operative plan. A CT scan of the abdomen and pelvis is critical to preoperative

• IPOM after primary closure of the defect

• Preperitoneal placement of mesh

• Placement of retromuscular mesh with or without posterior components separation

Another consideration is the accessory port. The accessory port is used to aid with the mesh introduction and orientation, suture introduction and removal, and suture cutting. We found that using the accessory trocar for the larger mesh introduction under direct visualization was safer and more effi cient than introducing the mesh and sutures through the 12 mm camera port. The acces­sory port is less useful for the repair of smaller ven­tral hernias, where the orientation of the mesh and the retraction of the mesh for exposure during suture placement are less cumbersome.

There are a myriad of options to secure the mesh to the abdominal wall including reproduc­ing standard LVHR technique with a combina­tion of tacks and full thickness transfascial sutures versus intracorporeal partial thickness suture fi xation, or securing the mesh to the abdominal wall with circumferential suture fi xa­tion. With the mesh positioned on the abdominal wall by using a scroll technique or using mesh equipped with a positioning device (Ventralight ECHO, CR Bard, Cranston, RI), a full length nonabsorbable 00 or 0 monofi lament suture is introduced into the intra-abdominal cavity through the same trocar as the needle holder. The external end of the suture situated outside the tro­car is secured with a hemostat. This technique avoids excessive suture in the intra-abdominal cavity, thereby facilitating fi xation. In a running fashion, the suture is then placed around the cir­cumference of the mesh. It may be necessary to use more than one suture for larger prosthetics. Upon completion of mesh fi xation, the robot is undocked. Only the 10–12 mm trocar fascial sites are closed with a suture passer under direct lapa­roscopic vision.

The robotic transabdominal preperitoneal (TAPP) VHR was developed based on the TAPP inguinal hernia repair and involves dissection of the preperitoneal plane, reduction of the her­nia sac, primary closure of the defect, place­ment of mesh, and reperitonealization of the mesh (Fig. 26.5 ).

mum in all directions) is insured. The mesh is secured to the abdominal wall with four absorb­able tacks placed at the cardinal points of the mesh or with sutures as per surgeon’s preference. Once adequate fi xation and hemostasis is achieved, the peritoneal fl ap is re-approximated to cover the mesh with a continuous 00 absorb­able running suture or tacks (Fig. 26.8 ).

Traditionally, subxiphoidal hernias have been diffi cult to repair laparoscopically because of the diffi culty in reliably securing the mesh to the lower thoracic outlet. The preperitoneal tech­nique obviates the need for full thickness trans­fascial sutures because the mesh is effectively