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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_874_Библиотеки_им_академика_М_И_Перельмана.pdf
326
J. Daes
Fig. 20.6 Set up for a unilateral Subcutaneous ECS.A 12mm camera port has been placed lateral
to the previously marked semilunar line in the lower lateral quadrant. The space is maintained with
CO
2
Fig. 20.7 An additional 5 mm working port has been placed laterally and slightly superior to
camera port
20 Endoscopic Component Separation Techniques
Fig. 20.8 The external
oblique aponeurosis is
incised laterally to the left
semilunar line, using the
marking on the skin as a
guide
327
Fig. 20.9 Exposure of the
fatty tissues without
visualization of muscle
ensures entry into the
correct plane. In certain
cases the external muscle
is divided on purpose
(presence of ileostomy or
defects close to the
semilunar line)
328
J. Daes
Fig. 20.10 A cross-sectional view of the abdomen that shows a comparison of the subcutaneous
and subfascial techniques of component separation for both the balloon dissection and the division
of the external oblique fascia (blue arrow)
20.6 Pearls andPitfalls
1. ECS can be performed rst when used as an adjunct to minimally invasive AWR
if clinical examination and CT scanning provide thorough information; other-
wise, robotic or laparoscopic exploration should precede it.
2. Many times there is no need to perform a bilateral ECS.We have been able to
laparoscopically close most defects 6–15cm in width with a unilateral subcuta-
neous CS without dehiscence or abdominal wall asymmetry.
20 Endoscopic Component Separation Techniques
3. ECS can be used to repair any suitable lateral defect, not just central defects.
4. When defects are close to the semilunar line, ECS can be performed on the same
side by dividing the external oblique muscle more laterally, thus avoiding the
division of the semilunar line.
5. A vertical posterior rectus fascia release may be added to an ECS to assist in
relieving tension on the closure.
6. Mesh should be used to cover the ECS site during IPOM plus, at least while
surgeons are learning the procedure and when in doubt.
329
20.7 Evaluation ofResults
We published a prospective evaluation of endoscopic subcutaneous ACS, with
long- term clinical and imaging follow-up [8]. Twenty consecutive patients
between 2012 and 2015 were evaluated. These patients had defects 6–15cm in
size, with length greater than width, and without skin dystrophy, loss of domain,
or active infection. None of these patients had undergone multiple previous
repairs/meshes and there was no reasonable suspicion of severe adhesions. Most
ECSs were performed unilaterally as adjuncts to IPOM plus repairs. Primary
closure of defects was performed with slowly absorbable barbed sutures. All of
the cases were followed clinically and by CT imaging for up to 38months (mean,
21months). In 19 of these patients, the repair remained sound clinically and by
CT imaging, whereas one patient had a small limited disruption well protected
by the underlying mesh. In eight patients, in whom the area was not covered by
mesh, there was no defect at the CS site. Morbidity was low, with no development of a surgical site infection (SSI) or mesh- related complication. Cosmetic
results were excellent; in particular, despite almost all ECSs being unilateral, we
did not observe abdominal wall asymmetry and the degree of patient satisfaction
was high.
20.8 Conclusions
Complex ventral hernia repairs remain a frequent and intricate problem with
satisfactory results requiring a combination of techniques, technologies and
materials. Primary closure of defects as part of the AWR has been an essential
part of open repairs and recently also of minimal invasive approaches because
it attempts to recreate the anatomy and physiology of the abdominal wall while
reducing dead space and its consequences. The posterior component separation
owns it present popularity to a natural extension from the Rives-Stoppa technique. However, the anterior endoscopic component separation remains as a
safe and effective technique in selected patients as an adjunct to roboticassisted and laparoscopic AWR as well as for open repairs and other
indications.
330
J. Daes
References
1. Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-
wall defects: an anatomic and clinical study. Plast Reconstr Surg. 1990;86:519–26.
2. Harth KC, Rosen MJ. Endoscopic versus open component separation in complex abdominal
wall reconstruction. Am J Surg. 2010;199:342–7.
3. Lowe JB, Garza JR, Bowman JL, Rohrich RJ, Strodel WE.Endoscopically assisted “compo-
nents separation” for closure of abdominal wall defects. Plast Reconstr Surg. 2000;105:70–729.
4. Maas SM, de Vries RS, can Goor TS, van Goor H, de Jong D, Bleichrodt RP.Endoscopically
assisted “components separation technique” for the repair of complicated ventral hernias. J Am
Coll Surg. 2002;194:388–90.
5. Rosen M, etal. Laparoscopic component separation in the single-stage treatment of infected
abdominal wall prosthetic removal. Hernia. 2007;11:435–40.
6. Daes J, Chen D.Endoscopic components separation techniques. In: Hope W, Cobb W, Adrales
G, editors. Textbook of hernia. Basel: Springer; 2017. p.243–8.
7. Daes J. Endoscopic subcutaneous approach to component separation. J Am Coll Surg.
2014;218:e1–4.
8. Daes J, Dennis RJ.Endoscopic subcutaneous separation as an adjunct to abdominal wall recon-
struction. Surg Endosc. 2016;22:1–5.
Robotic Retro-Rectus Repairs
21
FlavioMalcher, LeandroTottiCavazzola,
andIgorBelyansky
21.1 Introduction
Minimally invasive surgery (MIS) ventral repairs were rst described by Le Blanc
in 1993 with the laparoscopic approach with an intraperitoneal onlay mesh (IPOM)
implant. The use of IPOM was never a gold standard in open ventral repairs because
of the fear of using uncoated polypropylene and other materials directly in contact
with viscera [1]. For the development of laparoscopic techniques to the abdomen
wall, several modications were done, such as the use of new meshes with coated
barriers, new xation devices and mainly changes in surgical techniques, abandoning the traditional onlay and retromuscular/preperitonial options. The intraperitoneal era was inaugurated. Laparoscopic techniques have proven themselves in the
last 20years as safe and efcient in the cure of ventral hernias, despite the increased
incidence of adhesions and enterotomies following intraperitoneal surgeries [2].
Despite the advantage of important decrease in wound morbidity and the safeness of the laparoscopic ventral hernia repair, its adoption rate reached a plateau of
around 20%. Several reasons have been postulated as explanation for this, as
increased costs (IPOM and xation devices) and difcult learning curve (surgery
performed in the “roof" of the cavity with straight instruments) [3, 4].
The implementation of advances in MIS such as the robotic platform, shown us
enhanced skills to operate the abdomen wall, as articulated and strong instruments,
F. Malcher (*)
Abdominal Wall Program, Monteore Medical Center, Albert Einstein College of Medicine,
Bronx, NY, USA
L. T. Cavazzola
Robotic Surgery Program, General Surgery, Hospital de Clínicas de Porto Alegre,
Porto Alegre, RS, Brazil
I. Belyansky
Abdominal Wall Reconstruction Program, General Surgery, Anne Arundel Medical Center,
Annapolis, MD, USA
© Springer Nature Switzerland AG 2019
K. A. LeBlanc (ed.), Robotic Assisted Hernia Repair,
https://doi.org/10.1007/978-3-030-23025-8_21
331
332
F. Malcher et al.
better visualization and steady and 3D optics. It did not take long to surgeons start
to perform surgeries by MIS approach without IPOM, coming back to the traditional open techniques as onlay and sublay, avoiding IPOM and expensive xation
devices (using sutures instead). After robotics shown the way, several skilled surgeons without access to robotics, tried and developed MIS techniques without the
robot, using classic endoscopic instruments and resources [3].
While the optimal surgical approach for the repair of ventral incisional hernias
remains a subject of considerable debate [3]. In this chapter, we are going to explore
several of these techniques, all them designed to keep the mesh outside the peritoneal cavity, as intended in open surgery.
21.2 Robotic Rives: Retromuscular Repairs
Intraperitoneal anatomy is far more familiar for the average surgeon. That’s why
this approach is more frequently adopted by surgeons when they start using the
robot to do MIS abdominal wall reconstruction. There are a lot of options to
access the retromuscular space from inside abdominal cavity, and the choice will
be based mainly in the location and size of the defect. For example: for suprapubic
defects, a caudal single docking approach can be used. This approach will be discussed elsewhere in this book. On the opposite side, defects above the umbilicus
can be easily addressed by a cranial docking. For the vast majority of cases, a
double docking technique, coming from patient side will be preferable because
allows easy recognition of the anatomical landmarks and it’s suitable for defects
in almost all midline from the xiphoid through the pubic bone. This alternative has
the inconvenient that it’s obligatory the docking in the contralateral side, which
takes additional time. Alternatively, in patients with small defects and large retrorectus space (which can be addressed preoperatively by CT scans), a single lateral
docking can be used with good exposure and providing adequate overlap for a
large mesh after completion of the procedure. These alternatives will be discussed
along this chapter.
21.2.1 Patient Selection
There are some limitations for the robotic approach. Patients with poor skin and soft
tissue integrity (ex. prior skin graft), a widened scar from previous wound complications that will require surgical excision, chronic wounds, or poor hernia cosmesis
are not good candidates since they probably will need an open approach (or at least
an hybrid procedure).
There are no consensus about the best robotic technique to be used. Normally,
defects larger than 8cm will require a double-dock approach, even with bilateral
transversus abdominis release (TAR). Mid-sized defects, typically up to 8cm, are
approached with a single-dock retromuscular technique. For smaller defects (less
than 5 cm), a single-dock preperitoneal approach (ventral TAPP) is usually
21 Robotic Retro-Rectus Repairs
333
preferred by several surgeons, as there is less tension on the defect closure and myofascial release is not usually required and the procedure can be done quickly. This
technique will be described elsewhere in this book.
21.2.2 General Measures
All patients are positioned supine with both arms tucked, and a foley catheter is
inserted if the defect is infra-umbilical. Antibiotic dosing, body hair clipping, and
placement of sequential compression devices are used according to institutional
protocols. In the lateral docking options, it’s useful to ex the operation table, maintaining the legs extend downward at a minimum of 30° to afford the surgeon and
assistant greater instrument range of motion (Fig.21.1).
21.2.3 Single Docking: Cranial Approach
To deal with hernias located in the supra-umbilical position, the robot can be docked
in the cranial position (same as for foregut and bariatric surgery) and approached
from a midline position. A two arm conguration is used (one can add the use of an
auxiliary portal depending on the will of the surgeon). Camera trocar is inserted
Fig. 21.1 Positioning of the patient for robotic ventral repair. Trendelenburg position with hips
extended allows the wider space for ports in the abdominal wall
334
F. Malcher et al.
below the umbilicus, after insufation and abdominal access is achieved under surgeons preference. Long trocars are used to achieve extra room and avoid arms collision. For this approach, patient is positioned preferable on a split leg table, in
moderate reverse Trendelenburg position to allow more room to work upward the
abdomen. An initial posterior sheath incision is made transversely, opening from
one semilunar line to the other, with division of the posterior sheath on his medial
aspect each side to preserve the midline linea alba above and below the hernia
defect. After dissecting the defect, hernia repair starts with anterior defect closure,
followed by mesh placement and posterior sheath closure as the last part of the procedure (Fig.21.2).
21.2.4 Double Docking: Lateral Approach
Since this approach can handle most of midline hernia defects, despite their location
in the linea alba, it will be described in details. The patient is placed as showed in
Fig. 21.1, Pneumoperitoneum is established at surgeon’s preference, and a long
12mm optical trocar is placed midway between the costal margin and iliac crest.
This should be done as laterally as possible, to allow adequate distance between
trocars and defect. Two long robotic trocars are placed near costal margin close to
the iliac crest. The use of long trocars help to get additional clearance of the robotic
arms away from the patient. This also allows greater exibility for advancing the
robotic instruments into the extremes of the abdominal cavity. After placing the
trocars as described, the robot can be docked with the center column of the patient
side cart aligned with the hip or upper thigh, in order to allow more space between
the robot and the patient arm for the bedside assistant (Fig.21.3).
Adhesiolysis is performed either robotically or laparoscopically, and the retromuscular dissection is initiated by incising the posterior rectus sheath close to the
linea alba. The retromuscular plane is developed laterally to the linea semilunaris
and vertically at least 5cm above and below the hernia defect, so an adequate mesh
overlap will be achieved after defect closure (Fig.21.4).
At this point the surgeon decides if a transversus abdominis myofascial release
(TAR) is necessary. This will be addressed elsewhere in this book. After adequate
dissection is performed (either if a TAR is necessary or no), three additional trocars
are placed into the dissected space in the contralateral abdomen in a mirror image
(Fig.21.5).
A ruler is used to intracorporeally measure both the hernia defect height and
width, and the extent of the dissected space. The height of the dissected space will
correspond to the length of mesh required for repair. The half of the dissected space
is measured and assumed to be equal to half of the needed mesh width, because a
mirror dissection will be performed after redocking. After adequate sizing, the mesh
trolley
21 Robotic Retro-Rectus Repairs
Fig. 21.2 Trocar placement for single docking cranial
approach. (1). Camera, (2, 3). Robotic ports. (4).
Accessory port (not obligatory)
335
Slave
arm
3
2
4
1
is rolled and secured with a loosely tied suture. After being deployed in the retromuscular space, it’s sutured to the contralateral side (Fig.21.6).
Patient is then repositioned and the robot docked on the opposite side. When
using the Xi plataform, repositioning of the patient may not be necessary, once the
boom feature of Xi allows rotation of the arms. That feature facilitates enormously
the double doking process. Dissection is carried out in the same fashion to complete
the bilateral retromuscular (or transversus abdominis if necessary) aps. After adequate retromuscular dissection on the contralateral side, posterior fascial defect is