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Ventral, Incisional, andAtypical Hernias
Using aRobotic Transabdominal
15
Preperitoneal Approach
StephanieBollenbach andConradBallecer
Introduction
It is from the laparoscopic transabdominal preperitoneal repair (TAPP) for the treatment of groin hernias that the robotic transabdominal preperitoneal repair (rTAPP)
for ventral hernias was adapted, integrating methods gained both from open and
conventional laparoscopic ventral hernia repairs. With the robot, the dissection of
the individual layers of the abdominal wall is done with greater visualization, ergonomics, and precision. The transabdominal preperitoneal approach is designed
around the placement of uncoated mesh in a preperitoneal position, providing protection from the intra-abdominal content. This allows decreased risk of visceral
adhesions to the mesh and potentially eliminating the requirement for signicant
xation of the mesh. In this chapter, rTAPP will be discussed for the repair of ventral hernias.
Anatomy
A full comprehension of the layers of the abdominal wall is a fundamental component of rTAPP.Beneath the transversalis fascia or posterior sheath, a preperitoneal
avascular plane is established with the initial dissection and further developed using
blunt and sharp dissection. A sufcient overlap of 5cm is created circumferentially
to the fascial defect. Once the hernia sac is reduced and the preperitoneal plane is
extended to allow an appropriately sized mesh, the dissection is complete. The use
of mesh allows for reinforcement and may be secured to the abdominal wall with
S. Bollenbach
Department of Surgery, Maricopa Integrated Health System, Phoenix, AZ, USA
C. Ballecer (
Department of General Surgery, Center for Minimally Invasive and Robotic Surgery, Abrazo
Arrowhead Hospital, Glendale, AZ, USA
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2019
S. S. Davis Jr. et al. (eds.), The SAGES Manual of Hernia Surgery,
https://doi.org/10.1007/978-3-319-78411-3_15
*)
193
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S. Bollenbach and C. Ballecer
sutures or tacks. The peritoneal ap is then re-approximated, providing coverage of
the mesh. The technique is most appropriate for ventral hernias of small to medium
size, as well as atypical hernias such as subxiphoid, suprapubic, ank, and Spigelian
defects.
Preoperative Considerations
In devising a plan for surgical repair, a thorough history and physical exam are
imperative. Comorbidities must be individually assessed, including BMI, smoking
history, prior hernia repairs, and immunocompromised states, which may be crucial
in determining optimal nonoperative versus operative approach. A thorough history
and physical exam are typically adequate in preoperative evaluation of those with
small primary hernias. CT imaging of the abdomen and pelvis may be helpful, particularly in patients with large and recurrent incisional hernias. In our practice, we
have found the rTAPP to be ideal for ventral fascial defects measuring 1–5cm in
any location. Defects greater in size, 5–8cm, may be more optimal for a robotic
Rives, and those measuring 8–16cm or those with midline and lateral defects are
often better served with the roboTAR technique. Older individuals or those with
signicant comorbidities or low functional capacity are good candidates for the
IPOM with or without closure of the fascial defect.
Operative Steps
1. Umbilical Hernias
Positioning, Port Placement, Docking, and Instrumentation
The patient is placed on the operating room table in supine position with both
arms tucked. Elevating the kidney rest located at the level of the umbilicus can
extend the space between the costal margin and the pelvic rim, allowing more
ideal separation between the trocars. The same goal may be accomplished by
exing the bed. Foley catheter placement may be considered, especially if the
case is expected to be prolonged.
Intra-abdominal access is obtained via a 5-mm Optiview trocar at Palmer’s
point in the left or right upper quadrant, with or without initial Veress insufation. Pneumoperitoneum is accomplished, with a pressure of 15 mmHg. A
12mm robotic port is placed under laparoscopic visualization in the mid-lateral
abdomen, at a minimum of 15cm from the defect. An 8-mm port is placed in the
left or right lower quadrant, after which the 5-mm Optiview port is exchanged
for an 8-mm robotic port (Fig.15.1).
Over the contralateral side, the robot is docked in line with the ports. A 30°
scope is used facing upward for initial dissection of the ipsilateral abdominal
wall. In order to better facilitate preperitoneal dissection on the contralateral
side, the scope may be adjusted to 0° or downward facing 30° scope.
15 Ventral, Incisional, andAtypical Hernias Using aRobotic Transabdominal
Fig. 15.1 Patient docking/
trocar placement for
umbilical/midline ventral
hernia
Fig. 15.2 Development of
preperitoneal space at least
5cm from hernia site
195
Preperitoneal Plane Dissection, Primary Repair of Defect, and Mesh
Placement
In order to fully visualize the hernia defect, adhesions are lysed with care.
Using monopolar scissors, the peritoneum is incised at a minimum of 5cm from
the nearest edge of the hernia defect (Fig. 15.2). The avascular preperitoneal
plane is dissected with blunt and sharp dissection, while using electrocautery
very cautiously in order to avoid peritoneal and posterior sheath rents. Dissection
of this plane may be done safely and easily with blunt sweeping and adequate
counter traction. With development of the preperitoneal plane both cephalad and
caudad to the fascial defect, the hernia sac is dened (Figs.15.3, 15.4, and 15.5).
The sac is reduced methodically in order to avoid tears in the peritoneum.
Once the hernia sac is fully reduced, the peritoneal plane is further established
on the contralateral abdominal wall. Dissection must be continued until an
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Fig. 15.3 Gentle
reduction of hernia
contents
Fig. 15.4 Continuation of
preperitoneal dissection
past hernia defect with use
of tension-countertension
S. Bollenbach and C. Ballecer
Fig. 15.5 Completed
preperitoneal dissection
with reduced hernia
15 Ventral, Incisional, andAtypical Hernias Using aRobotic Transabdominal
adequately sized mesh may be placed with a minimum of 5cm overlap in each
direction. The development of a large ap is benecial due to a redundancy in the
peritoneum, thereby facilitating its closure.
Once there is felt to be adequate preperitoneal dissection, the hernia defect is
closed, typically with absorbable barbed suture in continuous fashion (Fig.15.6).
The dead space of the hernia defect noted anteriorly may be obliterated with thin
bites of subcutaneous tissue, recreating an inverted umbilicus. Absorbable suture
may be used to close small peritoneal disruptions.
Through the 8 mm trocar, an appropriately sized uncoated mesh can be
inserted. After the mesh is positioned against the abdominal wall in the preperitoneal space, it is then xated with tacks or sutures positioned at cardinal points
(Fig.15.7). The peritoneum is then re-approximated with tacks or sutures, covering the mesh. Absorbable suture is used to close the fascia of the 12mm port site.
Fig. 15.6 Primary repair
of suture defect with
absorbable locking suture
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Fig. 15.7 Mesh xation
with tacker at cardinal
points on anterior
abdominal wall
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S. Bollenbach and C. Ballecer
2. Subxiphoid Hernias
Positioning, Port Placement, Docking, and Instrumentation
Subxiphoid, Morgagni, and other such atypical hernias are very appropriate
for the rTAPP approach. By positioning the mesh between layers of the abdominal wall, the lack of xation points does not cause any difculty. The patient is
placed on the operating room table in supine position with both arms tucked. In
order to attain more optimal space between trocars as well as separation from the
hernia site, a kidney rest may be used at the level of the umbilicus, or the table
may be exed should the patient have a short torso. A Foley catheter can be considered if a prolonged case is expected.
A midline camera port is situated at a minimum of 15cm from the hernia
defect in order to gain intra-abdominal access. Two 8 -mm ports are placed under
laparoscopic vision at or near the same level of the camera port. The robot is
brought in over the patient’s shoulder. A 30° upward scope is preferred for optimal visualization of the anterior abdominal wall.
Preperitoneal Plane Dissection, Primary Repair of Defect, and Mesh
Placement
Bowel and omental adhesions are dissected with care to in order to fully visualize the abdominal wall anatomy and the hernia fascial defect. The hernia is
safely reduced of any content in order to avoid iatrogenic injury. At a minimum
of 5cm from the edge of the facial defect, the peritoneum is incised with scissors. An avascular preperitoneal plane is established using blunt and sharp dissection in a caudal to cephalad direction. As mentioned before, cautery should be
utilized with caution in order to avoid peritoneal and fascial defects. The peritoneum is separated from the posterior sheath safely via meticulous blunt sweeping motions with appropriate traction and countertraction. The hernia sac is fully
reduced, continuous with the peritoneal ap. The falciform ligament may be
dissected from the anterior abdominal wall and mobilized in order for more optimal visualization. The ligament can then be used to cover any peritoneal defects.
After dissection is completed with at least 5cm overlap in all directions, the
fascial defect is closed primarily, typically with absorbable barbed suture in continuous fashion.
Through an 8 mm trocar, an appropriately sized uncoated mesh may be
inserted and placed in the preperitoneal space against the abdominal wall. The
mesh is secured with tacks or sutures at cardinal points and subsequently covered with the peritoneum re-approximated with tacks or sutures.
3. Suprapubic Hernias
Positioning, Port Placement, Docking, and Instrumentation
The rTAPP approach to atypical suprapubic hernias highlights the robot’s
ability to establish large preperitoneal planes, ultimately hiding the mesh from
visceral content with re-approximation of the peritoneal ap.
The patient is placed on the operating room table in a supine lithotomy position, with both arms tucked. A Foley catheter is recommended not only to optimize visualization but also to help with identication and possibly reduction of
the bladder from within the hernia.
15 Ventral, Incisional, andAtypical Hernias Using aRobotic Transabdominal
At least 15cm from the hernia defect, a midline camera port is placed in order
to gain intra-abdominal access. Two 8-mm ports are placed in the upper quadrants bilaterally and 10cm laterally from the midline port (Fig.15.8).
With the patient in Trendelenburg position, the robot is docked between the patient’s
legs (Fig.15.9). A 0 or 30° scope is used for visualization of the abdominal wall.
Preperitoneal Plane Dissection, Primary Repair of Defect, and Mesh
Placement
In order to fully visualize the abdominal wall anatomy and the hernia fascial
defect, bowel and omental adhesions are dissected with care. The hernia is safely
Fig. 15.8 Suprapubic
hernia trocar placement
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Fig. 15.9 Suprapubic
hernia trocar placement
and docking
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S. Bollenbach and C. Ballecer
reduced of any content to prevent iatrogenic injury. The peritoneum is incised
with scissors at a minimum of 5cm from the edge of the fascial defect. Blunt and
sharp dissection is done with a grasper and monopolar scissors. An avascular
preperitoneal plane is established, involving the medial umbilical ligaments
bilaterally at a minimum. Dissection is continued widely in the retropubic space
and the space of Retzius to allow adequate mesh coverage.
Thorough appreciation and visualization of the inguinal anatomy are important, including identication of the bladder and exposure of Cooper’s ligaments
within the retroinguinal space. The cautery should be used with caution while
establishing the peritoneal ap, in order to avoid peritoneal defects as well as
potential injury to the bladder, cord structures, blood vessels, and nerves.
Once dissection is complete with at least 5cm overlap surrounding the hernia,
the fascial defect can be repaired primarily, performed typically with absorbable
barbed suture in continuous fashion. Desufation of the pneumoperitoneum to
6–10mmHg may help in closing large suprapubic defects.
An appropriately sized uncoated mesh can be inserted through an 8mm trocar
and placed in the preperitoneal space against the abdominal wall. The mesh is
subsequently xated at cardinal points as well as Cooper’s ligaments. Fixation in
proximity to the bladder and triangles of doom and pain must be avoided. The
mesh is covered with the re-approximation of the peritoneal ap, secured with
tacks or suture. Absorbable suture is used to close the fascial defect of all port
sites larger than 8mm.
Conclusion
The management of ventral, incisional, and atypical hernias with rTAPP is an
emerging surgical method; therefore studies are currently ongoing. These evolving techniques stem from well-developed open and laparoscopic principles and
exhibit clear proposed benets. With the preperitoneal approach, the mesh is
protected from intra-abdominal contents, and full-thickness transfascial sutures
can be avoided. This repair requires access of a preperitoneal plane, without
which this technique is limited and other techniques may be applied. This is a
safe and adaptable method for repair of abdominal wall hernias. In comparison
to laparoscopic techniques, the robot allows enhanced ergonomics, precision,
and visualization, as well as comparable patient satisfaction and improved quality of life and physician satisfaction.
Bibliography
1. Halm JA, De Wall LL, Steyerberg EW, Jeekel J, Lange JF.Intraperitoneal polypropylene mesh
hernia repair complicates subsequent abdominal surgery. World J Surg. 2007;31:423–9.
2. Gray SH, Vick CC, Graham LA, Finan KR, Neumayer LA, Hawn MT. Risk of complications from enterotomy or unplanned bowel resection during elective hernia repair. Arch Surg.
2008;143:582–6.
3. Prasad P, Tantia O, Patle NM, Khanna S, Sen B. Laparoscopic transabdominal preperitoneal
repair of ventral hernia: a step towards physiological repair. Indian J Surg. 2011;73:403–8.
15 Ventral, Incisional, andAtypical Hernias Using aRobotic Transabdominal
4. Colavita PD, Tsirline VB, Belyansky I, Walters AL, Lincourt AE, Sing RF, Heniford
BT.Prospective, long-term comparison of quality of life in laparoscopic versus open ventral
hernia repair. Ann Surg. 2012;256:714–22.
5. Liang MK, Clapp M, Li LT, Berger RL, Hicks SC.Patient satisfaction, chronic pain, and functional status following laparoscopic ventral hernia repair. World J Surg. 2013;37:530–7.
6. Weir A, Ballecer C.Robotic transabdominal preperitoneal (rTAPP) hernia repair for ventral
hernias. Endoscopic Component Separation Techniques. 2017;263–72.
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Technique: Posterior Rectus
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Sheath Release
SamuelP.Carmichael II andJ.ScottRoth
Introduction
Approximately 4–5 million laparotomies are performed each year in the United
States, 2–20% of which are complicated by incisional hernia (IH) [1]. IH is the most
common complication of laparotomy requiring reoperation at a ratio beyond bowel
obstruction of 3:1 [2]. The vast majority of hernias develop 6months to 3years after
laparotomy and are associated with wound infection, obesity, tobacco abuse,
immune suppression, and suture closure technique [3, 4]. As such, roughly 200,000
incisional hernia repairs are performed annually with a recurrence rate of 45–50%
inclusive of all techniques and 20–30% with mesh repair in all-comers [1, 5, 6].
Factors impacting the success of operative repair include management and optimization of medical comorbidities (i.e., obesity, diabetes, smoking, pulmonary function, MRSA colonization) [2]. Tension-free mesh repair is currently the accepted
standard of care given prohibitively high recurrence with suture repair alone [1, 6].
However, despite the groundbreaking work of many herniorrhapists over decades of
research, the gold standard of mesh herniorrhaphy remains subject to debate [2].
Mesh herniorrhaphy of IH was rst introduced 60years ago at Baylor University
by general surgeon Dr. Francis Usher and colleagues with Marlex knitted polyethylene mesh placed deep to the rectus musculature [7]. Parallel to this, anatomist and
surgeon Jean Rives under the guidance of Bourgeon further delineated the implementation of this sublay technique with the use of Mersilene polyester ber at the
French University of Algiers [8]. Rives described ventral incisional hernia as a
16
S. P. Carmichael II
Department of Surgery, University of Kentucky School of Medicine, Lexington, KY, USA
e-mail: sam.carmichael@uky.edu
J. S. Roth (
Division of General Surgery, Department of Surgery, College of Medicine,
University of Kentucky, Lexington, KY, USA
e-mail: s.roth@uky.edu
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2019
S. S. Davis Jr. et al. (eds.), The SAGES Manual of Hernia Surgery,
https://doi.org/10.1007/978-3-319-78411-3_16
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