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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_874_Библиотеки_им_академика_М_И_Перельмана.pdf
262
J. T. Watson and K. A. LeBlanc
• Robotic Instruments: Robotic 30 degree camera, fenestrated bipolar, scissors,
mega, mega suture cut or large needle drivers, and possibly a Cartier grasper
• Sutures: #1 double-armed, non-absorbable polypropylene barbed suture to close
fascia and the secure mesh
• Mesh Selection: The authors prefer a coated medium-weight wide-pore perma-
nent mesh for intraperitoneal placement. One should always double check that
the mesh is the correct size prior to bringing it onto the operative eld
• Open Options: Although the conversion rate is <5%, one should have all standard
open equipment available if necessary in case of need for conversion to open
operation.
15.4 Patient Positioning andPrep
Once the patient is intubated, the robotic team should position the patient appropriately to ensure the most effective use of the robotic system, while also minimizing
the potential risk of injury. The patient should be supine under general anesthesia.
Preferably, both arms should be tucked, with padding around hands and elbows to
protect the ulnar nerve, wrists and ngers as pictured in Fig.15.2.
Fig. 15.2 Typical patient position
15 Operating Room Setup andIntraoperative Considerations forRobotic Ventral…
If tucking both arms is not possible secondary to body habitus, then it is advisable to tuck the arm on the side where one plans to place the robotic ports. Pubic and
abdominal hair should be clipped, and the patient should be prepped using chlorhexidine from the pubis to nipples, and as far laterally as possible. A nasogastric tube
and use of urinary drainage catheter is recommended. The patient should be paralyzed by anesthesia during the entire procedure.
263
15.5 Port Placement
Well-designed port placement is a critical step to performing an efcient robotic
ventral hernia repair. If planning to place ports in the right anterior axillary line, the
author gains access in the right upper quadrant (unless prior operations make this
location prohibitively risky), immediately adjacent to the costal margin, using an
optical view trocar and a zero degree laparoscopic camera. Once the abdomen is
insufated, you will have a better understanding of the best locations for insertion
of the robotic ports. For most procedures, the fourth arm will not be needed and can
be stowed prior to docking the robot. This author would also encourage using a
12mm balloon bariatric length trocar for the camera port if using the SI.It is important to be at least two centimeters superior and medial to the ASIS with the inferior
port. Although, almost all midline hernias may be approached from the vertically
oriented trocars in the anterior axillary line, the small lower midline hernia or epigastric hernia may be optimally approached with the robotic trocars situated laterally across the upper abdomen or lower abdomen respectively. Alternatively, the
robotic trocars can be placed on the left side of the patient if adhesions prevent the
location on the right (Fig. 15.3).
15.6 Intraoperative Considerations
The patient cart, as previously discussed, should be placed in the most optimal room
location to allow straight-line access to its planned bedside position. In the majority
of cases, the cart should be placed at a ninety-degree angle to the patient. Arm
adjustment should be considered to ensure equal spacing and minimize inter-arm
collision. “Burping” the arms after attachment to the ports gives more room and
alleviates the pressure applied to the patient. It is important to leave access to the
assistant port for the surgical assistant for passage of mesh and sutures. If required
by the room conguration, the laparoscopic camera towers and room lights can be
removed prior to robot docking.
The circulating nurse and surgical technician should master the assembly and docking of both the laparoscopic and robotic components needed for the operation. This
assures an efcient transition from laparoscopic to robotic equipment after gaining
access to the abdomen. Although the surgeon’s ability to drive the camera from the console obviates the need for an experienced laparoscopic camera driver, the presence of a
well-trained and technically excellent robotic scrub assistant is crucial. The scrub
264
J. T. Watson and K. A. LeBlanc
4°
3
2
Is the initial access port with
5 mm laparoscope
Port 3 is the da Vinci endoscope port
Target anatomy at the hernia defect
Fig. 15.3 Alternate trocar positions if unable to access the right side of the abdominal cavity
assistant should be able to manipulate the arms of the robot intra- operatively to assist in
minimization of arm collision and/or enhancement of optical visualization. The assistant
should also be skilled in introduction of sutures and mesh and the retrieval of needles
from the ports using laparoscopic instruments. An assistant that is able to accomplish
these tasks will diminish the need for the robotic surgeon to scrub throughout the case.
15.7 Conclusion
The robotic approach is an efcient and safe technique to ventral hernia repair. It
allows for an easier primary facial closure, potentially decreasing the risk of
recurrence, pseudo-recurrence and seroma formation as compared to a traditional
laparoscopic approach in which the fascial defect is not closed. It is a more
15 Operating Room Setup andIntraoperative Considerations forRobotic Ventral…
265
ergonomically sound platform for the surgeon and allows for increased autonomy
regarding visualization and camera manipulation. Articulation of the arms may
also allow for more precise lysis of adhesions or hernia reduction. Despite these
benets, the operative room setup and turnover can be a frustrating aspect of this
repair modality. The authors hope that the content of this chapter may assist others
in developing streamlined processes for operative preparation that could improve
intraoperative and postoperative outcomes.
References
1. Deldi G, Ipaktchi R, Wagner M, etal. Laparoscopic ventral hernia repair is safe and cost effec-
tive. Surg Endosc. 2006;20:92–5.
2. Gonzalez A, Escobar E, Romero R, Walker G, Mejias J, Gallas M, Dickens E, Johnson CJ,
Rabaza J, Kudsi OY.Robotic-assisted ventral hernia repair: a multicenter evaluation of clinical
outcomes. Surg Endosc. 2017;31(3):1342–9.
3. Gonzalez AM, Romero RJ, Seetharamaiah R, Gallas M, Lamoureux J, Rabaza JR.Laparoscopic
ventral hernia repair with primary closure versus no primary closure of the defect: potential
benets of the robotic technology. Int J Med Robot. 2015;11(2):120–55.
4. LeBlanc KA. Incisional hernia repair: laparoscopic techniques. World J Surg.
2005;29(8):1073–9.
5. LeBlanc KA.Robotic ventral hernia repair. In: Kingsnorth A, LeBlanc KA, Sanders DL, edi-
tors. Management of abdominal hernias: Springer; 2018.
6. Liang MK, Subramanian A, Awad SS.Laparoscopic transcutaneous closure of central defects in
laparoscopic incisional hernia repair. Surg Laparosc Endosc Percutan Tech. 2012;22(2):e66–70.
7. Liang MK, Holihan JL, Itani K, Alawadi ZM, Gonzalez JR, Askenasy EP, Ballecer C, Chong
HS, Goldblatt MI, Greenberg JA, Harvin JA, Keith JN, Martindale RG, Orenstein S, Richmond
B, Roth JS, Szotek P, Towgh S, Tsuda S, Vaziri K, Berger DH.Ventral hernia management:
expert consensus guided by systematic review. Ann Surg. 2017;265(1):80–9.
8. Nguyen DH, et al. Primary fascial closure with laparoscopic ventral hernia repair: Systemic
Review. World J Surg. 2014;38:3097–104.
9. Orenstein SB, Dumeer JL, Monteagudo J, Poi MJ, Novitsky YW. Outcomes of laparoscopic
ventral hernia repair with routine defect closure using “shoelace” technique. Surg Endosc.
2011;25(5):1452–7.
Diastasis Recti: Robotic Extended-View
Totally Extraperitoneal (eTEP) Access
16
Hernia Repair Technique
IgorBelyansky, RichardLu, andAlexAddo
16.1 Robotic Extended-View Totally Extraperitoneal Access
Rives-Stoppa Technique (r-eTEP)
The eTEP technique was popularized by Dr. Jorge Daes in 2012 as an enhanced
approach to conventional TEP procedures. This approach was expanded to ventral
and incisional hernia repairs by Belyansky and colleagues in 2017.
Table 16.1 lists preferences in equipment when performing robotic eTEP access
for Rives-Stoppa repairs.
16.2 Operative Technique
16.2.1 Patient Positioning andOperating Room Setup
Patients are positioned supine with both arms tucked at the sides in order to facilitate docking on either side. The patient is extended to approximately 30° to maximize the distance between the anterior superior iliac spine and subcostal margin,
thus preventing robotic arm collision (Fig.16.1).
Before incision, we recommend marking the relevant anatomy to identify the
xiphoid process, bilateral subcostal margins, symphysis pubis, linea alba, and linea
semilunaris (Fig.16.2).
I. Belyansky (*)
Abdominal Wall Reconstruction Program, General Surgery, Anne Arundel Medical Center,
Annapolis, MD, USA
Department of Surgery, Anne Arundel Medical Center, Annapolis, MD, USA
e-mail: ibelyansky@aahs.org
R. Lu · A. Addo
Department of General Surgery, Anne Arundel Medical Center, Annapolis, MD, USA
e-mail: rlu@aahs.org; aaddo@aahs.org
© Springer Nature Switzerland AG 2019
K. A. LeBlanc (ed.), Robotic Assisted Hernia Repair,
https://doi.org/10.1007/978-3-030-23025-8_16
267
268
Ant
Table 16.1 Recommended equipment for robotic eTEP access
Laparoscopic
equipment
• 5-mm 30-degree scope
• Monopolar hook dissector
• Laparoscopic needle driver
• Two blunt graspers
• 5-mm Kii Fios First Entry
®
(Applied Medical, Rancho Santa
Margarita, CA) port (also used for robotic approach)
Robotic equipment • 10-mm 30-degree and 0-degree scopes
• Two 8-mm robotic ports (three for the da Vinci Xi system)
• 12-mm bariatric port for robotic camera
• ProGrasp™ grasper (Intuitive Surgical, Sunnyvale, CA)
• Monopolar scissors
• Mega Suture Cut™ needle driver (Intuitive Surgical)
• Monopolar cord
• Bipolar cord (optional if bipolar fenestrated grasper is used)
Fig. 16.1 The patient is
placed in 30° extension to
expand the retrorectus
space and to prevent
robotic arm collision
I. Belyansky et al.
Fig. 16.2 Relevant
Landmarks. (a) Subcostal
margins, (b) Linea alba, (c)
Linea semilunaris, (d)
Xiphoid, (e) Pubis
erior Rectus Sheath
Rectus Abdominis
d
a
b
c
e
16 Diastasis Recti: Robotic Extended-View Totally Extraperitoneal (eTEP) Access…
269
16.2.2 Access
Initial entry and port placement is done with standard laparoscopy. A 5-mm skin
incision is made in the area overlying the anterior rectus sheath. The position of this
incision is dependent upon robot docking which will be discussed later in this chapter. An optical trocar is used to penetrate the anterior rectus sheath (Fig.16.3a).
Once the muscle bers of the rectus abdominis are visualized, the surgeon’s hand is
dropped such that the direction of port advancement is almost parallel to the abdominal wall. This prevents inadvertent entry into the peritoneal cavity, which may
greatly complicate the remainder of the procedure. The posterior rectus sheath is
encountered and the retrorectus space is developed using blunt dissection of the
areolar tissue with the laparoscope (Fig. 16.3b). Care is taken to not avulse the
crossing branches of the inferior epigastric vessels, which should be carefully
dissected off of the posterior rectus sheath.
Fig. 16.3 (a) Entry of
anterior rectus sheath with
direct visualization. (b)
Initial blunt dissection of
retromuscular space
a
Anterior Rectus Sheath
b
Areolar Tissue
Rectus Abdominis
Rectus abdominis
Posterior Rectus Sheath
270
Table 16.2 Port placement and relative contraindications
Defect location
Upper midline Bottom docking below
Lower midline Upper docking above
Paraumbilical Lower/upper/side
Docking position
umbilicus/side docking
umbilicus/side docking
docking positions
Relative contraindications to port placement
History of Caesarean section, pelvic surgery, or
prostatectomy, or morbidly obese habitus with
large pannus
History of upper midline surgeries, or Kocher or
chevron subcostal incisions
Narrow retrorectus space (specic to side
docking)
I. Belyansky et al.
16.2.3 Port Placement
Dynamic port placement, based on the area of interest, is perhaps the most important concept to understand for the performance of a successful eTEP dissection.
Consideration of relevant anatomy, location of the defect, and past surgical history
is critical in determining port placement. Physical examination and CT imaging are
used to elucidate anatomy preoperatively. Table 16.2 lists the most common port
placement based on defect location and relative contraindications.
16.2.4 Relevant Anatomy andthePrinciples ofCrossover
Understanding of the preperitoneal space in relation to the retrorectus space is paramount. The peritoneal layer is the most posterior layer of the abdominal wall.
Medially, prominent adipose contributions are given by the falciform ligament and
the umbilical ligament.
16.2.5 Upper Midline Defects (Lower Dock Setup)
When dealing with upper midline defects, we prefer to perform the crossover to the
contralateral retrorectus space below the level of the umbilicus. Relative contraindications to docking the robot inferior to the umbilicus for upper midline defects
include history of caesarean section, pelvic surgery, prostatectomy, or morbidly
obese habitus with large pannus (Table16.2). Figure 16.4 demonstrates the port
position for upper midline defects. Four trocars are usually placed. For a righthanded surgeon, we recommend that the rst incision be made in the right upper
quadrant (RUQ) in the region overlying the right rectus muscle. An optical entry
technique is used to enter the right retrorectus space, as outlined in Fig. 16.3.
Figure16.5a–d demonstrate the typical sequence of port placement.
The rst port (RUQ) is used as an assistant port later in the procedure. Attention
should be given to locate the right inferior epigastric vessels, which travel parallel
and medial to the linea semilunaris (Fig.16.5a). Next, under direct vision, a right
lower quadrant (RLQ) port is placed just lateral to the inferior epigastric vessels and
approximately 3–4cm below the level of the umbilicus (Fig.16.5b). The RLQ port
An
ab
cd
Inf.epigastric vessels
16 Diastasis Recti: Robotic Extended-View Totally Extraperitoneal (eTEP) Access…
Fig. 16.4 Port placement
for lower docking. Red:
assistant port, Blue: robotic
working ports, Green:
camera port
Inferior epigastric vessels
terior Rectus Sheath
Rectus Abdominis
8-mm Robotic Port
271
Right rectus muscle
12-mm camera port
Linea alba
Left rectus muscle
Left rectus muscle
8-mm robotic port
Pubis
Fig. 16.5 (a) A RUQ port is placed for initial dissection of the right retrorectus space. (b) Insertion
of a RLQ robotic port lateral to the inferior epigastric vessels. (c) Insertion of a lower midline
12-mm camera port. (d) Insertion of a LLQ robotic port
is further used to develop the space of Retzius with a blunt grasper. A 12-mm camera port (used with the Si) is then placed under direct vision in the lower midline,
followed by placement of the left lower quadrant (LLQ) port entering the space just
lateral to the left inferior epigastric vessels (Fig.16.5c, d).
272
I. Belyansky et al.
The robot is docked and a robotic 30-degree scope in the up position is used to
start the dissection. Dissection proceeds with division of the medial contributions of
the posterior rectus sheath to the linea alba bilaterally from the caudal to cephalad
direction (Fig.16.6).
Medially, peritoneal contributions by the falciform and umbilical ligaments to
the posterior layer should be preserved. Continuation of this dissection joins the
bilateral retrorectus spaces with the preperitoneal space medially.
As dissection continues, the neck of the hernia sac will be encountered (Fig.16.7).
In a true incisional hernia, the layers surrounding the neck of the sac may be fused
and difcult to differentiate. A preoperative CT scan is an invaluable aid for identifying the hernia and its contents. An attempt may be made in some cases to reduce
the entirety of the sac by separating it from its distal attachments; however, this is
commonly not done in our practice. We frequently consider sharply opening the
peritoneal layer just proximal to the neck of the sac to reduce the visceral contents
under direct visualization and perform adhesiolysis as needed. Any defects in the
posterior layer can be xed primarily with a 2-0 absorbable suture. Once the hernia
contents are reduced, retromuscular dissection continues to the level of the xiphoid
process (Fig.16.8).
The linea alba is then reconstructed using 0V-Loc™ (Medtronic, Minneapolis,
MN) suture, medializing the healthy edges of rectus abdominis muscle to oppose
each other. The hernia defect is closed as part of the linea alba reconstruction
(Fig.16.9). Decreasing insufation pressure from 15mm Hg to 10mm Hg or less
assists in cinching of the suture line. The suture is cut after taking at least three bites
with the V-Loc™ suture over the previous suture line. A ruler is then used to measure the entire retromuscular space and a medium-weight macroporous mesh is
trimmed to size. This mesh is then advanced into the retromuscular space and
Right retrorectus space
Preperitoneal space
Right post. retctus sheath
Fig. 16.6 Division of bilateral posterior rectus sheaths
Left post. retctus sheath
Left retrorectus space