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19 Robotic Transversus Abdominis Release: Tips andTricks
255
Midline Dissection
Dissection of the midline superior and inferior to the hernia defect is also of critical
importance. First, the retromuscular dissection is continued bluntly above and
below the level of the hernia defect without dividing the posterior sheath and peritoneum initially. The posterior sheath joins with bers from the anterior sheath to
create the linea alba, which must remain intact above and below the hernia for a
successful repair. There must also be adequate overlap of mesh in either direction to
reinforce the defect closure, meaning the separate retromuscular compartments
must be joined. This is accomplished by rst incising the peritoneum horizontally
and separating the peritoneum and preperitoneal fat away from the linea alba.
Importantly, when performing this from a lateral docking position, the peritoneal
incision runs a vertical course on the screen. Once this space is opened, the posterior
rectus sheath can be clearly seen and incised. This leaves the peritoneum attached to
the posterior sheath but creates a single space between the preperitoneal and retromuscular compartments. This should be extended at least 5cm above and below the
hernia defect. For hernias located in the epigastrium, dissection is continued into the
subxiphoid space, and the retromuscular dissection continued to the costal margin.
In the lower abdomen, the space of Retzius is opened, exposing Cooper’s ligaments
and the pubic symphysis.
Midline Dissection: Tips andTricks (Fig.19.5)
• The linea alba must remain intact above and below the hernia defect.
• The peritoneum along the midline should remain intact and attached to the pos-
terior sheath on each side above and below the hernia defect.
• The line of incision of the peritoneum is nearly vertical on the screen but ana-
tomically transverse.
• Superiorly, this may extend into the subxiphoid space.
• Inferiorly, this may extend into the space of Retzius.
Transversus Abdominis Release
After completion of the retromuscular dissection, the camera is turned to a 30° downward view for TAR.The TAR involves dividing the musculofascial TA complex from
within the posterior rectus sheath to enter the preperitoneal plane, facilitating both
mobilization of the anterior fascia and broad mesh overlap. As noted above, the critical landmark for initiating the TAR is the intercostal neurovascular bundles. These run
between the internal oblique and transversus abdominis muscles, penetrating the posterior lamina of the internal oblique fascia just medial to the semilunar line and entering the lateral aspect of the rectus muscle. Incision is made just medial to the nerves
in a downward direction, opening the posterior lamina of the internal oblique fascia.
In the upper abdomen, the TA is now plainly visible and is divided. In the upper
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Fig. 19.5 Midline dissection tips and tricks. (a) Lateral view of midline dissection cephalad to
hernia defect; solid line/hd hernia defect, dashed line linea alba, dashed triangle peritoneum and
preperitoneal fat remains attached to posterior sheath and separated away from linea alba, ra rectus
abdominis. (b) Midline view of dissection; solid arrows posterior sheath attached to linea alba,
dashed line linea alba, dashed triangle intact peritoneum. (c) Subxiphoid space; dashed line linea
alba, dashed arrow xiphoid process, dashed triangle intact peritoneum, solid arrow posterior sheath
(cut). (d) Space of Retzius; dashed arrow Cooper’s ligament, solid arrow inferior epigastric vessels
J. A. Warren and A. M. Carbonell
abdomen, the TA extends medially well beyond the semilunar line. As one progresses
caudad, the muscle belly becomes increasingly more lateral, leaving only its aponeurotic portion within the posterior rectus sheath. For this reason, we recommend beginning the TAR in the upper abdomen where the TA is easily identied. It is also helpful
to score the posterior sheath along the planned line of incision with a wide camera
view before bringing the camera closer for the ner dissection. This avoids extending
the dissection too lateral, where the semilunar line could be damaged, or too medial,
where the peritoneum tends to be thinner and more difcult to dissect. Once the TA is
divided, one of two spaces can be entered. Immediately below the TA lies the transversalis fascia. Just below the transversalis fascia is the peritoneum. There are minimal lmy attachments between the peritoneum and transversalis fascia, making
separation of this plane possible with only blunt dissection. However, the peritoneum
can be quite thin and sometimes difcult to maintain its integrity. Alternatively, the
pretransversalis plane can be developed, leaving both peritoneum and transversalis
fascia down. Dissection in the pretransversalis plane is slightly more tedious, as the
TA is more adherent to the transversalis fascia.
As the TAR progresses inferiorly, the TA layer becomes increasingly aponeurotic,
leaving four denable layers: the posterior lamina of the internal oblique, TA aponeurosis, transversalis fascia, and peritoneum. It can be difcult to identify and separate
these layers at times. As dissection progresses laterally, if muscle bers are noted deep
to the plane of dissection at any point, then the aponeurosis of the TA was not incised,
and the dissection is interparietal (between TA and internal oblique) rather than preperitoneal or pretransversalis. Below the arcuate line, dissection beyond the semilunar
19 Robotic Transversus Abdominis Release: Tips andTricks
257
line is easily accomplished with blunt dissection. Care must be taken to avoid the vas
deferens and spermatic vessels here. Though we typically advise initiating the TAR
more cephalad where the muscle belly is plainly identied, beginning below the arcuate line is also a reliable starting point. The lateral extent of the TAR is typically near
the midaxillary line. Typically, once the posterior ap is noted to be lying at across
the viscera, there is no need for further dissection.
TAR Tips andTricks (Fig.19.6)
• Dissection begins medial to the intercostal neurovascular bundles.
• Recommend beginning in the upper abdomen, where the TA muscle makes up a
signicant portion of the posterior sheath. This serves as a reliable landmark to
enter the correct preperitoneal plane.
a
d
b
e
c
Fig. 19.6 TAR tips and tricks. (a) Scoring the planned line of incision through the posterior
sheath and TA. Line of incision is medial to the neurovascular bundles (solid arrows). (b) TAR
performed by incising posterior lamina of internal oblique and TA muscle (dashed arrow) medial
to the neurovascular bundles (solid arrows); ra rectus abdominis. (c) Continuation of the TAR
medial to the neurovascular bundles (solid arrow) through the aponeurotic portion of the TA
(dashed arrow); dashed line junction of peritoneum (p) and transversalis fascia (tf). (d) Completed
TAR.The posterior sheath and peritoneum (p/ps) lie at across the viscera, and the TA bers are
seen along the lateral abdominal wall (ta); solid arrows intact neurovascular bundles. (e)
Demonstrating the four layers of the posterior rectus sheath; dashed arrows posterior lamina of the
internal oblique, ta transversus abdominis muscle, tf transversalis fascia, p peritoneum, solid arrow
neurovascular bundle, dashed line semilunar line, ra rectus abdominis
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J. A. Warren and A. M. Carbonell
• There are four layers that make up the posterior sheath: Posterior lamella of
the internal oblique, TA muscle or aponeurosis, transversalis fascia, and
peritoneum.
• Below the arcuate line, only transversalis fascia and peritoneum are present.
• It is helpful to score the fascia along the planned line of incision to keep proper
orientation and avoid extending the dissection too lateral, where the semilunar
line could be damaged, or too medial, where the peritoneum tends to be thinner
and more difcult to dissect.
• Pretransversalis or preperitoneal planes are appropriate.
• If muscle bers are seen deep to the plane of dissection at any point, you are in
the wrong layer.
• Medial and downward retraction.
• Avoid grasping peritoneum if possible to minimize risk of tearing.
• Extend laterally until the posterior ap lays at across the viscera.
• Close any defects in the posterior sheath created during dissection.
Contralateral Port Placement, Measuring andMesh Placement
Once the retromuscular and TAR dissections are completed, three new trocars are
placed in the left lateral abdomen in mirror image to the initially placed trocars.
These are placed under direct visualization directly into the dissected preperitoneal
space. Once in place, a metric ruler is passed, the camera is reoriented to 30° up, and
the hernia defect height and width is measured. The vertical length of the dissection
is measured at the midline, which should be at least 5cm above and below the hernia defect. Additional dissection can easily be done at this time if necessary. This
will be the vertical dimension of the mesh. To determine the horizontal dimension,
the distance from the left lateral abdominal wall to the left edge of the hernia defect
is measured. This is best accomplished by laying the ruler down across the posterior
sheath and then placing a spinal needle through the left edge of the hernia defect
perpendicular to the abdominal wall and down to the level of the ruler and posterior
sheath. Measuring along the curve of the abdominal wall will signicantly overestimate the width of mesh needed, as will measuring from the midpoint of the hernia
defect, as this will later be closed. The distance measured is equal to half of the
mesh width required.
Once the appropriate measurements are made, the appropriate mesh is selected.
We recommend using a bare, mid-weight, large-pore polypropylene mesh. This is
cut to the appropriate size to ll the dissected space. The mesh is marked with a
permanent marker horizontally at the midpoint of the mesh and then rolled along its
vertical axis, leaving 3–4cm unrolled that will be used to secure the mesh to the
lateral abdominal wall. The rolled mesh is then secured loosely to itself with an
absorbable suture, preferably dyed for ease of later identication, placed 2–3cm off
the midpoint of the mesh.
19 Robotic Transversus Abdominis Release: Tips andTricks
259
The mesh is brought into the dissected space, oriented properly, and the tail is
xed to the left lateral abdominal wall lateral to the new trocars. We prefer absorbable suture xation at two or three points to ensure proper alignment of the mesh
when is deployed later in the case.
Contralateral Port Placement Tips andTricks (Fig.19.7)
• Mirror image to initially placed trocars.
• Place directly into preperitoneal space.
Measuring Tips andTricks (Fig.19.8)
• Measure along the midline above and below the hernia defect to ensure adequate
overlap (at least 5cm).
a
b
Fig. 19.7 Contralateral port placement tips and tricks. (a) Contralateral ports are placed in mirror
image to the initial trocars. (b) Operative view of contralateral ports; ra rectus abdominis, solid
arrow neurovascular bundles, dashed arrows cut edge of TA, ta transversus abdominis muscle, ps
posterior sheath/peritoneal ap
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Fig. 19.8 Measuring tips and tricks. (a) Metric ruler used to measure the hernia (hd) width. (b)
Measuring the hernia height. (c) Measuring the vertical dimension of the dissected space, ensuring
at least 5cm overlap above and below the hernia defect. This will be the vertical length of the mesh.
ra rectus abdominis. (d) Measuring the horizontal dimension of the dissected space. A spinal needle
is passed through the edge of the hernia defect perpendicular to the ruler, which lays at across the
posterior sheath. This will be half the width of the mesh needed. ta transversus abdominis
J. A. Warren and A. M. Carbonell
• Measure the width of the mesh by placing the ruler down on the dissected poste-
rior sheath, and place a spinal needle vertically through the contralateral edge of
the hernia defect.
• Remember, the hernia defect will be closed, so measure from the edge, not the
middle.
• Measuring along the abdominal wall will overestimate the size of mesh needed
due to the effect of pneumoperitoneum.
• Measured width is half the nal width of mesh needed.
Mesh Placement Tips andTricks (Fig.19.9)
• Cut the mesh to the size measured.
• Roll the mesh in a single scroll fashion along the vertical axis.
• Leave a 3–4 cm tail for xation to the lateral abdominal wall and for easier
retrieval of the mesh later.
• Secure mesh to itself with a dyed, loosely tied suture.
• Secure mesh lateral to the newly placed trocars.
19 Robotic Transversus Abdominis Release: Tips andTricks
261
Fig. 19.9 Mesh
placement tips and tricks.
(a) Mesh is rolled in a
single scroll fashion,
leaving a 3–4cm tail and
marking along the
midpoint of the vertical
axis to ensure proper
orientation when
deploying. Secure with a
single absorbable suture.
(b) Mesh is placed lateral
to the newly placed trocars
and secured to the
abdominal wall
a
b
Double Dock, Contralateral Dissection
At this point, the robot is undocked from the right side and redocked on the left.
For Si users, this involves turning the patients’ feet 90° (45° in the opposite direction of initial setup) in order to bring the robotic cart in on the patients’ right side.
Turning in this manner keeps the head of the bed with anesthesia, minimizing risk
to the airway. For Xi users, this step is unnecessary and the arms can simply be
rotated on the boom. In either case, once the robot is redocked, dissection is performed on the right side in the same manner as on the left. There are a few points
of difference that should be noted. First, the midline dissection can be readily
extended at this point if needed. Any remaining peritoneum along the midline is
actually easier to visualize now, as a portion of it has already been dissected down
with the left posterior rectus sheath. The incision of the posterior sheath above
and below the defect should be extended on the right side to the same level as on
the left. Once completed, this should leave a segment of peritoneum extending
from the linea alba toward the hernia defect and still attached to the posterior
sheath on each side.
Secondly, the initially placed right lateral trocars will be brought back into the
TAR plane as the dissection extends laterally. As the dissection approaches the trocars, a bedside assistant should stand the trocars up vertically to keep from elevating
the peritoneum and obscuring the plane. Once the dissection reaches the trocar as it
passes through the peritoneum, it is simply redirected into the preperitoneal space
and dissection continues beyond the trocar as far as necessary.
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J. A. Warren and A. M. Carbonell
Double Dock Tips andTricks (Figs.19.10 and19.11)
• Keep the head of patient with anesthesia and swing feet 900.
• Initially placed trocars should be brought into the dissected space.
Fig. 19.10 Double-docking tips and tricks. (a) Initial patient positioning. (b) New patient posi-
tioning. The foot of the operating table is turned approximately 90°, leaving the patient’s head near
anesthesia cart (a), and robotic cart (r) is brought around to the other side of the patient for
docking
a
Fig. 19.11 Contralateral dissection tips and tricks. (a) Initially placed trocars will be encountered
during TAR; ra rectus abdominis, ta transversus abdominis. (b) Trocars are pulled back and
brought into the newly dissected space. (c) Elevating the trocar against the abdominal wall allows
dissection to easily progress beyond the trocar
19 Robotic Transversus Abdominis Release: Tips andTricks
b
c
263
Fig. 19.11 (continued)
• Stand trocars vertically, pull back, the readvance through the peritoneal defect
into the preperitoneal space.
• Close peritoneal defects from initial trocars.
Posterior Sheath Closure, Mesh Deployment, andDefect
Closure
Now that the dissection is completed, the posterior rectus sheath is closed. We prefer an absorbable, self-xating 2-0 suture sewn in a running fashion. Any signicant
(>1cm) defects in the posterior sheath or peritoneum should be closed using absorbable suture. Once the posterior sheath is closed, the mesh, which is now lying under
the trocars currently in use, is retrieved by pulling back the scrolled portion and
breaking or cutting the suture holding it in place. The mesh is then rolled across the
closed posterior sheath and afxed in similar fashion to the right lateral abdominal
wall. If the mesh is found to be too long for the dissected space, it can be easily
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J. A. Warren and A. M. Carbonell
trimmed and excess removed. Should it be too short, proceed with closure of the
defect, which will likely then allow the mesh to reach.
The hernia defect is now closed. We prefer a self-xating, absorbable suture in a
running fashion. Stratax™ Symmetric (Ethicon) is preferred, as this is currently
the only self-xating suture given a fascial closure indication and, in our experience,
performs much better for closure of larger hernia defects. Multiple bites of the hernia sac are included with the fascial closure to imbricate the tissue and decrease the
dead space. It can be difcult to identify the fascial edge on the ipsilateral side. The
muscle can sometimes simply be pushed aside to view the fascia for closure. If still
not plainly visible, the needle can be passed above the rectus and engage the overlying tissue, which can be visualized by deection of the muscle, and then pulled
medially; the needle will bring the fascial edge into view for closure. Finally, if
unsure if the fascia is included in the suture, grasping both ends of the needle while
engaged through the tissue and pulling medially will ensure that an adequate fascial
bite was taken; if the bite includes only muscle, it will pull through easily.
In order to maintain the loop of the suture and avoid tangling, retrieve the needle
and immediately begin the next throw, leaving the needle through the fascia only,
and then proceed to pull the suture through. It is helpful to pull downward on the
suture with one hand and sweep laterally with the other to more rapidly pull the
suture through. Then complete the throw and begin the next. Once the defect is
closed, the abdomen is desufated and trocars removed. Trocar site fascia is not
closed, as mesh covers each trocar site.
Posterior Sheath Closure Tips andTricks (Fig.19.12)
• 2-0 absorbable self-xating suture.
• Close any defects made in the posterior sheath or peritoneum.
• Closure does not need to extend as far as the dissection along the midline—only
as far as the level of peritoneum remaining attached to the posterior sheath.
Mesh Deployment Tips andTricks (Fig.19.13)
• Mesh is located below and lateral to the trocars you are currently working from.
• The 3–4cm tail left after scrolling the mesh facilitates mesh retrieval.
• If the mesh fails to fully reach the contralateral abdominal wall, close the anterior
defect and then reassess.
Defect Closure Tips andTricks (Fig.19.14)
• Absorbable, self-xating suture. Recommend Stratax™ Symmetric for larger
defects, as this is currently the only available self-xating suture with indication
for fascial closure.
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