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294
F. Gokcal and Y. Kudsi
Fig. 18.5 (a, b)
Limitation of instrument
movement and the
collision of the robotic arm
when trocar is placed close
to ASIS
a
b
compression of the hernia sac by the bedside assistant might aid the vision of surgeon. In general, the bipolar Maryland instrument is preferred if there is a need to
control bleeding near the bowel. Subsequent to the adhesiolysis and identication of
all defects, the peritoneal ap will be created.
With the use of monopolar scissors and a bipolar Maryland, the peritoneum is
grasped and cut at least 5cm from the defect on the side ipsilateral to the trocars to
18 Transabdominal Preperitoneal (rTAPP) Repair
Fig. 18.6 Trocar incisions
for subxiphoid hernia
295
Fig. 18.7 Preperitoneal
dissection and use of a
sponge on the peritoneal
ap
enter the preperitoneal space. Throughout the preparation of the peritoneal ap, the
peritoneum traction should be gentle to avoid tearing. For this purpose, dissection
of the peritoneal ap with an intra-abdominal sponge helps both to control minor
bleeding and minimizes the risk of peritoneal injury (Fig.18.7). During the dissection of the peritoneum of the hernia sac, separation of tissues without creation of
peritoneal defects may not be always possible. If disruption of peritoneal integrity,
occurs, this should be repaired with absorbable sutures. Peritoneal defects can result
296
F. Gokcal and Y. Kudsi
in the creation of an intraparietal hernia, which can result in acute incarceration or
strangulation of omentum or intestine. Preperitoneal dissection should extend at
least 5cm in all directions around the defect to provide adequate areas for proper
mesh positioning. It should be kept in mind that the wide dissection of the preperitoneal space allows a large, mobile peritoneal ap for covering the mesh. In some
cases, it may not be possible to prepare the appropriate peritoneal ap due to the fact
that the peritoneum is very thin. In this situation, as an alternative technique, retromuscular mesh placement should be considered after closure of the hernia defect. It
should be noted that it can be problematic during robotic TAPP that this dissection
can be especially difcult if one cannot remove any prior integrated mesh. Such
material can become part of the posterior layer as it is often fused and difcult to
separate.
18.7.3 Hernia Defect Closure, Mesh Placement,
Peritoneal Flap Closure
The purpose of the hernia defect closure is to make the abdominal wall anatomy
closer to the native and improve abdominal wall functions. Furthermore, closure of
the defect allows more fascial contact area for the mesh and leads to equalizing the
pressure and tension along the mesh and the abdominal wall. The choice of suture
material may vary, but in our practice, primary closure of the hernia defect is accomplished by running a long-lasting absorbable barbed suture (Stratax 0 on CT-1
needle, Ethicon, Somerville, NJ). Before closing the hernia defect, pneumoperitoneum is reduced to 6–8mmHg, anesthesiologist is asked for maximal relaxation of
the patient’s muscle tissues. The fascial defect size is then directly measured by an
intraperitoneally placed ruler. The authors follow the same guideline used for laparotomy closure which is the small bite technique. This is accomplished by taking
“bites” of fascia approximately 5–8mm from the fascial edge and placing these
stitches 5mm apart in a shoelace fashion [11] (Fig.18.8).
The robotic platform offers the ergonomic movements and dexterity of wristed
instrumentation that provides a strong technical ability to close the defect, which is
typically a challenge for the laparoscopic surgeons. It has been reported that the
closure of the fascial defect is accomplished in 69.3% of cases, even though many
robotic surgeons are at their initial experience [12, 13].
Following hernia defect closure, the next phase is mesh placement. The length
and width of the hernia defect are taken into account when determining the size of
the mesh to be implanted. The size of the mesh should provide the principle of
maintaining at least 5cm overlap in all directions.
The rolled or folded non-coated mesh is introduced into intraabdominal cavity
through one of the trocars. The robotic instruments are used to unroll or unfold the
mesh in the preperitoneal space without any wrinkles or folds. The aim of mesh
xation is to provide adequate tissue integration. In the TAPP ventral hernia repair
approach xation of the mesh is necessary in order to prevent mesh migration. For
this purpose many different techniques have been described such as tacker xation,
ab
cd
18 Transabdominal Preperitoneal (rTAPP) Repair
Fig. 18.8 Hernia defect closure with the use of the small stitch technique in shoelace fashion
297
Fig. 18.9 Mesh suture
xation
trans-fascial suturing, aerosolized brin sealant etc. The use of the circumferential
fascial suture technique with using barbed absorbable sutures may be the preferred
to secure the mesh to the posterior fascia (Fig.18.9).
After adequate mesh xation and control of any bleeding control are achieved,
the next step is the closure of the peritoneal ap. Rapidly absorbable barbed suture
(2–0V-lock; Medtronic, New Haven, CT) may be used for this purpose. A running
298
Fig. 18.10 Peritoneal
defect closure
F. Gokcal and Y. Kudsi
short stitch fashion reduces the chance for intraparietal hernia (Fig.18.10). During
this closure and at the end of the procedure, one must assure that the entire mesh is
covered with the peritoneal ap to protect the intra-abdominal structures from any
exposed mesh. The abdominal cavity is also evaluated for signs of bleeding or other
adverse events. The trocars are removed and the pneumoperitoneum is released. We
chose to close to suture close any trocar sites that are 10mm or larger to decrease
the risk of potential incisional hernia development in the future. A long acting local
anesthetic agent is injected to the trocar sites for management of postoperative pain.
18.8 Postoperative Care
The majority of patients who undergo rTAPP VIH repair are discharged home on
the same day after routine early postoperative care. Patients who require a hospital
stay are usually those with have preexisting comorbidities that need to be monitored
after general anesthesia.
In our experience, postoperative pain in the majority of patients is well controlled with oral nonsteroidal anti-inammatory agents (NSAIDS). A minority of
patients requires narcotics that average 20 tablets for these patients. Patients are
encouraged to resume normal activity after operation. It is advised to avoid lifting
heavy objects and doing exhausting activities for 4–6weeks.
18.9 Complications
18.9.1 Bleeding-Hematoma
Trocar bleeding usually stops with tamponade from the trocar itself. During adhesiolysis, bleeding may occur from the cut omentum or adhesive bands and it can be
controlled carefully with the use of a thermal energy device such as monopolar
18 Transabdominal Preperitoneal (rTAPP) Repair
299
scissors or bipolar Maryland. During mesh xation, identication of the epigastric
vessels to prevent injury is very important. Therefore these use of any deep sutures
near then should be avoided. If the vessel is injured, the bleeding is often controlled
by ligation of it with simply with the use of a “gure of eight” trans-fascial suture.
The hematoma, which is noticed during the postoperative period, usually self-limiting and generally requires no intervention unless infective complications occur [14].
18.9.2 Seroma
The seroma is caused by a uid collection localized generally between the mesh and
the hernia sac. It usually appears at postoperative week one or two and usually does
not require any intervention. Mostly, it reabsorbs and the cavity obliterates within
4–6weeks. For the patients who have symptomatic seroma formation and/or persist
for more than 3months, drainage or repeated aspirations of the seroma can be performed under sterile conditions. In case of complex sero-hematoma, an excision
might be necessary after 4–5 months. As a preventative strategy, some surgeons
prefer to place an abdominal binder for the compression of the hernia sac area, starting immediately postoperatively and continuing for at least 2weeks [14]. As mentioned earlier, closure of the hernia defect before mesh placement effectively
obliterates the anterior dead space, which may signicantly reduce or eliminate the
risk of seroma formation.
18.9.3 Intestinal Injury
Intestinal injuries might occur during trocar insertion or adhesiolysis. Despite the
rate of enterotomy reported in the literature was 1.78%, probably the true rate is
higher. The overall mortality of uncomplicated ventral hernia patients is 0.05%. The
mortality increases to 2.8% if an enterotomy complication occurs. An unrecognized
enterotomy is associated with higher mortality rate compared to a recognized enterotomy, 7.7% and 1.7% respectively [15]. Therefore, the surgeon should perform an
intra-abdominal inspection in order to identify any bowel injury that may have heretofore been unrecognized, once following adhesiolysis and once again upon completion of entire procedure. In the event of the recognition of intestinal injury
intraoperatively, a tailored approach should be used based upon the operative ndings and degree of contamination. Continuation of rTAPP VIH repair may be performed in the event of a bowel injury repaired immediately with minimal spillage.
If severe enteric contamination occurs and after bowel injury is repaired robotically,
a delayed hernia repair may be performed according to an observation period of
3–7days on intravenous antibiotic therapy if no evidence of infection is observed
[16]. During postoperative period, if any local or systemic infection sign occurs, the
surgeon should vigilant to recognize delayed enterotomy, which may include intraoperative intestinal injuries that were unnoticed or thermal injuries that were not full
thickness at the time of the procedure. These patients should be returned to the
300
operating room for intestinal repair, resection, and/or GI tract diversion. Strong consideration should be given to mesh removal at the time of re-operation [17].
F. Gokcal and Y. Kudsi
18.9.4 Chronic Pain
In laparoscopic surgery, acute and chronic postoperative pain is often associated
with the use of tack and trans-fascial suture xation of the mesh. One of the major
advantages of rTAPP VIH repair is that it eliminates the need for full-thickness
trans-facial suture xation. However, the fact remains that, during mesh xation, the
surgeon should avoid the use of deeply placed stitches at the lateral border of rectus
sheath where the intercostal nerves are most vulnerable for nerve entrapment.
18.9.5 Recurrence
It has been well known that the recurrence of the repaired hernia may occur due to
inadequate mesh xation, inadequate mesh overlap, or mesh failure. Recurrence
rates after ventral hernia repair are similar for laparoscopic and open methods, and
range from 1% to 17% [18]. Information regarding the recurrence rate of hernias
following robotic repair is limited as few centers have reported the results of the
technical feasibility of robotic ventral hernia repair in their cohort. For our initial
cohort of 46 cases completed entirely with the rTAPP VIH repair, all the patients
(100%) reached their 1-year follow-up and, when contacted, reported no hernia
recurrence [8].
18.10 Limitations
Limitations of the robotic technology include access to the robot, a steep learning
curve, the use of a specialized surgical team, and increased cost of robotic platform
and instrumentations. Other considerations are the need for the ability to trouble
shoot any issues whether they be technical or computer generated with the robot
itself.
With regard to the limitation of rTAPP VIH repair technique, large ventral hernias requiring the use of a ap that reaches over 15–20cm become technically challenging. In this situation the authors prefer the use of a retro-muscular repair.
18.11 Conclusion
The transabdominal preperitoneal (TAPP) repair has long been utilized for inguinal
hernia repair and is now being applied to VIH repair. The preperitoneal placement
of the mesh not only prevents the direct contact of the prosthesis with intraabdominal structures, but also eliminates the requirement for placing more costly coated
18 Transabdominal Preperitoneal (rTAPP) Repair
301
intraperitoneal mesh, and potentially minimizes the risk of complications with their
use. Future multicenter prospective trials could further elucidate the potential benets and the long-term outcomes of all types of robotic hernia repair surgery.
References
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sions. Hernia. 2015;19(1):1–24.
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outcomes. Surg Endosc. 2017;31(3):1342–9.
13. Gonzalez AM, etal. Laparoscopic ventral hernia repair with primary closure versus no pri-
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Stapled Closure forMid-Line Hernia
Repair
ThiagoNogueiraCosta andRicardoZugaibAbdalla
19.1 Introduction
Innovative surgical procedures envolve in the operative room because current procedural limitations expose technical demands that have an opportunity of improvements. In the operating room, surgeons combine their skill, knowledge, technical
acumen and the advent of new technologies to improve safety and provide better
results to their patients. The opportunity to solve problems makes all surgeons a
natural innovator. However, there is an enormous lag from the innovation to actual
procedure implementation. Recent innovations such as the benets of minimally
invasive video surgery with good anatomical reconstruction without the need to
deconstruct the components of the wall structures present opportunities.
The use of synthetic prostheses associated with video surgery has revolutionized
a previously undened treatment that was dependent, almost exclusively, on the
experience and expertise of each hernia surgeon [1]. Professor LeBlanc brought
intracavity mesh hernioplasty to video surgery in 1993 [2]. The laparoscopic treatment of abdominal wall weakness, with ventral and incisional hernias, has been
greatly used nowadays, but without a standard procedure [3].
Details of technique can be simulated in the laboratory, where anatomical references can be compared with “wet models”. This results of such studies are heavily
dependent upon multiple predisposing and precipitating factors, with subjective,
objective and variable characteristics [4]. Our project was developed from the use of
robotic technology for repair of anterior abdominal wall defects. We studied this
technique in a cadaver lab with the robot initially and subsequently simulated the
procedure in a porcine lab [5].
19
T. N. Costa · R. Z. Abdalla (*)
Department of Digestive Surgery,
Hospital das Clinicas of University of Sao Paulo Medical School, Sao Paulo, Brazil
e-mail: ricardo.abdalla@hc.fm.usp.br
© Springer Nature Switzerland AG 2019
K. A. LeBlanc (ed.), Robotic Assisted Hernia Repair,
https://doi.org/10.1007/978-3-030-23025-8_19
303
304
The operative approach to repair the abdominal wall is based on the retromuscular, pre-peritoneal reinforcement Rives-Stoppa Principles [6]. The procedure was
designed to reconstruct the mid-line from the peritoneal cavity, approximating the
rectus abdominal muscles at the same time that reconstructs the posterior sheath
suture line with a retro muscular space. Within this created space a mesh will be
inserted, using video surgery and linear stapling to avoid greater tissue detachments
and more difcult suturing efforts by the surgeon.
T. N. Costa and R. Z. Abdalla
19.2 Background
Incisional ventral hernia has increased as midline laparotomies have become more
prevalent. Laparoscopy, minimal invasive surgery (MIS), can avoid such complications, but it is estimated that up to 50% of open surgical patients develop incisional
hernias, with different presentations [7–10]. Multiple concomitant procedures can
develop ventral defects and incisional hernias with more than one areas of defects
such oncologic patients with a multitude of procedures involved in the treatments
of their disease. Bariatric surgery has been shown a high rate of ventral hernias and
wound occurrences especially when performed non-laparoscopically [11]. It is
clear that the most effective method of prevention of such hernias is an effective
method to close the midline incision [12]. Laparoscopic repair of incisional hernias
has grown signicantly in the last 20years but technical challenges are still under
consideration. It has become that the combination of laparoscopy, use of a large
mesh, fascial closure with suture and preoperative patient optimization are mandatory for these challenging presentations [13]. However there is no standardization
of these methods and techniques that are consistently used to repair these hernia
defects [14].
It is has been afrmed that defect closure with sublay mesh positioning has
consistently shown good results when performed with the technical demands of the
Rives-Stoppa repair [15–17]. The challenge has always been that it is technically
difcult to close the fascial defects laparoscopically compared to open surgery
[18]. Thus, in the era of robotic technology this procedure is a lot easier to perform
than before introduction of this platform [19, 20]. We have developed this technique to supplement the need of the robot, especially in situations where access is
difcult.
19.3 History
This methodology grew from our desire to develop new procedures using the robotic
technology in the cadaver lab. Many instruments and devices were tested to help the
procedure. During this process it appeared that the use of the endo-stapler was