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subcostal trocar is then replaced with a 12mm standard length disposable trocar. The 8mm subcostal trocar is then moved to the lower lateral abdominal wall medial to the anterior superior iliac spine. Care should be taken to stay a few centimeters medial to the anterior superior iliac spine to avoid nerve injury. An 8mm trocar is placed inside the 12mm port (“piggybacked”) and the robot is then docked to all three 8 mm trocars. No monopolar energy should be used through the “piggy­backed” trocar arrangement to avoid capacitive coupling and possible thermal injury. To avoid this piggybacked arrangement, alternatively three 8mm trocars can be placed followed by a 12mm assist port on the other side to assist with mesh and suture insertion. It is important to burp each robotic trocar before heading to the operative console. This is the last step I perform on EVERY robotic case before leaving the bedside. The reason for this is if the trocars are docked under tension a larger trocar site defect will be created due to arm motion possibly leading to a tro­car site hernia. Burping all of the robotic arms creates no pre-existent traction on the abdominal wall and minimizes trauma to the abdominal wall from arm motion.

pre-peritoneal space. This avoids direct mesh exposure to the underlying bowel. The proposed advantage is less adhesion formation to the bowel. Additionally, uncoated mesh is less expensive than the coated versions used in IPOM.The hernia sac is reduced as well which can lead to a decreased incidence of postoperative seroma formation by not leaving a mesothelial lined sac in the tissues anterior to the fascial closure. The down side to this approach is that it takes longer to perform than an IPOM. The dissection of the peritoneum especially over the ipsilateral posterior rectus sheath can be tenuous. The peritoneum tends to be very thin in this area which can lead to the creation of multiple defects. If not excessive, these defects can be closed primarily. Figure-of eight sutures are recommended vs. simple inter­rupted. The gure-of eight sutures create a more robust peritoneal closure which is less likely to breakdown vs. the simple interrupted suture. Alternatively, a 3-0 run­ning barbed suture can be used if the peritoneal defect is larger. The peritoneum is opened far enough laterally on the trocar side of the defect to allow for a 5cm mesh overlap. The dissection needs to provide enough space for the mesh to seat nicely without wrinkling which can lead to adhesion formation. Usually, sharp scissor dis­section is used along with counter-traction to develop the plane of dissection. Care must be taken to ensure an adequately sized pocket has been created, and the mesh overlap is not being compromised in order to t into a pocket that is too small (Fig.12.9). If the peritoneum is not salvageable, the bail out procedure is to proceed to an IPOM.Next the fascia is closed primarily using running barbed suture (V-loc, Strattax symmetrical) which can be done robotically or laparoscopically as previ­ously described. Alternatively, a suture passer can be used to close to fascia in an interrupted fashion.

The mesh can be xed in place with tacs, laparoscopic suturing, or stay sutures if performed laparoscopically. If proceeding robotically, the mesh is sutured in place using cardinal point interrupted sutures or running barbed suture can be used. Alternatively, some surgeons use brin glue to x the mesh in place while still oth­ers use no xation and rely on the form tting pocket to keep the mesh in place after the peritoneum is closed. Laparoscopic closure of the peritoneum can be accom­plished using a tacker or by suturing the peritoneum back together based on surgeon preference. The peritoneum is closed using running 2-0 or 3-0 barbed suture (V-loc, Strattax spiral) when closing robotically. The ports are then removed and the 12mm trocar fascial defect closed.

The endoscopic total extra-peritoneal (eTEP) approach avoids the Achilles heel of the Rives Stoppa repair by avoiding the posterior fascial closure. Trocar position and the number of trocars is quite variable depending on the width of the rectus space and the hernia location. Trocars are placed just outside of the linea semiluna­ris and angled medially and inserted into the posterior rectus space. The initial tro­car can be placed superiorly, laterally, or inferiorly depending on hernia location. The trocar may be placed optically or with a cutdown technique. Blunt dissection then ensues using the camera or by placing a balloon dissector. A second trocar is placed once space is developed and used to dissect out the retro-rectus space. The medial rectus sheath is opened and a pre-peritoneal dissection is made until the contralateral retro-rectus space is entered. A third trocar can be placed to help with dissection to the contralateral side or it can be performed with one instrument and a third trocar placed in the opposite retro-rectus space. Instrument choices include sharp scissor dissection, hook cautery, harmonic scalpel, or Ligasure. Dissection is then carried to the defect which is reduced along with preserving the hernia sac if possible. The posterior ap consists of the posterior rectus sheaths with the perito­neum in between. The posterior rectus sheaths can be re-approximated, but gener­ally are not to prevent tension. That layer is generally just used to keep the mesh isolated from the bowel. Laterally, the nerves are preserved at the linea semilunaris. An adequate space is created for mesh placement. The anterior fascial defect is closed. The mesh is placed and spread out smoothly and the trocars are removed.