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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_874_Библиотеки_им_академика_М_И_Перельмана.pdf
336
d
n
SUL
Fig. 21.3 Port position for lateral docking technique
MCL
li
i
Midline
F. Malcher et al.
Trocar
Assistant
Camera
Trocar
SUL
MCL
closed with a running self-xating, slowly absorbable 2-0 suture. This will completely isolate de visceral sac form the retromuscular pocket created for the mesh.
After closing the posterior layer, than the mesh is unrolled across the closed posterior sheath and afxed to the right lateral abdominal wall (Fig.21.7).
At this point the pneumoperitoneum is decreased, and the anterior fascial defect
is closed using a self-xating, nonabsorbable number 1 suture in a running fashion,
trying to include intermittent bites of the overlying hernia sac imbricating the hernia
sac and thus obliterating the dead space (Fig.21.8).
21.2.5 Single Docking: Lateral Approach
Small hernias and even mid-sized defects can often be approached using a lateral
single-dock approach. It’s very important that the preoperative evaluation of the
patient showed that a large retrorectus space is available, so adequate overlap will
be achieved after dissection. Patient is positioned as described in Sect. 21.2.2.
Docking is achieved as describe in the previous section. The main difference
b
21 Robotic Retro-Rectus Repairs
a
337
Fig. 21.4 Retromuscular dissection in lateral double docking technique. (a). Begining of
dissection close to hernia defect. (b). End of lateral dissection close to semilunaris line, preserving
the neurovascular bundles
Fig. 21.5 Contralateral mirror positioning of the trocars
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Fig. 21.6 Contralateral mesh xation
F. Malcher et al.
Fig. 21.7 Posterior layer closure and xation of the mesh
21 Robotic Retro-Rectus Repairs
Fig. 21.8 Anterior layer closure
339
between this approach is the lateral aspect of the ipsilateral rectus sheath is incised
to gain access to the retrorectus space. Dissection is continued from lateral to
medial until the linea alba (or lateral edge of the hernia defect) is encountered.
Then the posterior sheath is incised to enter into the preperitoneal space along the
midline, including dissection around and reduction of the midline hernia sac. Once
across the midline, the contralateral posterior sheath is incised in it’s medial aspect,
and dissection completed to the semilunar line, creating a unique ap that is formed
by both posterior rectus sheat connected by peritoneum (including hernia sac) at
midline. The anterior fascial defect is closed rst. The retromuscular space that is
available after closure, followed by placement of the proper sized mesh. After xation of the mesh, the posterior sheath is closed to completely cover the mesh
(Fig.21.9).
21.3 e-TEP
21.3.1 Pre-Operative Planning andConsiderations
All potential minimally invasive abdominal wall reconstruction candidates must
undergo a comprehensive workup to ensure they are appropriately selected for surgery. There are absolute and relative contraindications to the eTEP approach for
hernioplasty (Table21.1). An up-to-date computed tomography study of the abdomen and pelvis is recommended for effective preoperative planning [5].
21.3.2 Operating Room Setup andPatient Positioning
After induction of general endotracheal anesthesia, all patients are positioned supine
with both arms tucked to their sides. Institutional protocols of antibiotics, venous
340
a
b
c
d
F. Malcher et al.
Fig. 21.9 Single docking—lateral approach. (a) Incision of posterior rectus sheat—lateral, close
to semilunar line. (b) Crossover the midline (includes) reduction of the hernia sac, reaching contralateral semilunar line. (c) Hernia defect closure. (d) Mesh placement against and closure of the
posterior sheath
21 Robotic Retro-Rectus Repairs
Table 21.1 Absolute and relative contraindications to eTEP approach
Relative Absolute
Previous incision extending from xiphoid process to the
pubic bone
Loss of domain Presence of stula
Dystrophic or ulcerated skin
Extensive intraabdominal adhesions
Active mesh infection
341
thrombosis prophylaxis are used [6–8]. A foley catheter is placed in order to decompress the bladder. The operating table is exed with the legs extend downward at a
minimum of 30° to afford the surgeon and assistant greater instrument range of
motion (Fig.21.1). Failure to sufciently ex the operating table will result in arm’s
hand collision with the patient’s body while dissecting and suturing the defects.
The enhanced-view totally extraperitoneal (eTEP) access approach was previously described for laparoscopic inguinal hernia repair by Daes in 2012 [9]. This
approach introduced the notion that the extraperitoneal domain is a limitless space
once the conuence of arcuate line and semilunar line are taken down, relying on
proper anatomic identication and dissection in the naturally occurring retromuscular spaces. Typically, dissection is initiated in one of the retrorectus spaces and then
crosses over to the contralateral side, thus joining the two spaces into one large
operative eld. Since Daes’ initial description, we have adopted this technique for
ventral and incisional hernia repair [10–12].
Docking is dependent on the system available (Si vs Xi), the location of the hernia defect and decision where to crossover. Lateral docking with the Si is possible
in patients with wide rectus sheet (>7to 8 cm) to a complete lateral approach.
Oblique docking may be accomplished for cases where the crossover would be done
laparoscopically, before the robotic docking.
21.3.3 Upper Midline Defect
Figure 21.10 demonstrates the port position for upper midline defects. The rst incision is made 2cm bellow a horizontal line drawn through umbilicus just medial to
the right linea semilunaris. The anterior rectus sheath is identied and incised
sharply. Single site balloon dissector is used to develop the right retrorectus space in
cephalad and caudal directions. It is critical to avoid over-ination which may rupture the linea semilunaris and consequently injure the rectus abdominis muscle. In
addition, special care should be given to appreciating the inferior epigastric vessels
that travel parallel and medial to linea semilunaris in the vicinity of the #1 port. The
telescope dissection without the use of the balloon is an option and allows a cost
reduction to the procedure. For robotics procedures, this may be a better option,
once the balloon uses a 10/12mm trocars and the robotic system uses 8mm trocars.
The use 5mm trocars to create the space may facilitate the change of those to 8mm
ones to be used for the robotic procedure. Once the space of Retzius is developed,
ports #2 and #3 are placed under direct vision in the lower abdomen. Thus, even
342
Fig. 21.10 Port
positioning for upper
midline defects. The
balloon dissector is placed
in port #1, green ellipse.
Ports #2 and #3 are marked
with blue circles. The
assistant port is located
higher, usually on the right
side of the patient
F. Malcher et al.
before any initiation of sharp dissection the retromuscular space surrounding the
hernia defect is completely dissected bluntly with the balloon space-maker.
The timing of docking may vary. One may prefer create a bigger preperitonial
space before docking to avoid difculties due the small working space for the
robotic instruments. We prefer to perform the crossover below the level of the umbilicus, developing preperitoneal and retromuscular spaces that have not been previously violated. In the middle we try to preserve the preperitoneal contributions to
the posterior layer which are made up of the falciform and umbilical ligaments. In
such a fashion the division of posterior rectus sheath and preservation of falciform
ligament and umbilical ligaments allows us to join the right and the left retrorectus
spaces together with the midline preperitoneal space (Fig.21.11).
Following the dissection in these planes we then anticipate to encounter the neck
of the hernia sac. In an incisional hernia, these layers surrounding the neck of the
sack can be thoroughly fused together and difcult to differentiate. 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 not often attempted. We frequently give consideration to sharply opening the peritoneal layer just proximal to the neck of the sac
to reduce visceral contents under direct visualization and perform limited adhesiolysis (Fig.21.12). Any defects in the posterior layer can be xed with 3-0 suture.
21 Robotic Retro-Rectus Repairs
Fig. 21.11 View of the retrorectus space. After crossing over and dissection, the retrorectus
spaces on both sides are combined into one large retrorectus space. The pre-peritoneal fat can be
seen below
343
Fig. 21.12 Sharp opening of the peritoneal layer proximal to the neck of the hernia sac, allowing
for reducing visceral contents under direct visualization and limited adhesiolysis
344
F. Malcher et al.
Once the hernia contents are reduced, retromuscular dissection commences with
release of the medial aspect of the posterior rectus sheath and concludes just below
the level of the xiphoid process.
Closure The edges of the PRS are sutured together in the midline with 2-0 absorb-
able or barbed suture starting near the xiphoid process running caudally. Starting at
the dome of the bladder the surgeon and assistant switch positions and suture is run
cranially, meeting in the middle where the two sutures are tied together. On the
anterior layer closure, the pneumoperitoneum is dropped to 8–10mm Hg to decrease
the tension placed on the anterior layer closure. The defect being closed is at the top
of the monitor and is sutured “upside down” with back handed needle driving. A 0
barbed suture is used for this closure due to technical ease of use afforded in this
situation. If a large subcutaneous sac is present, one or more bites of the sac are
included in the suture line for plication in order to reduce the likelihood of developing a postoperative seroma (Fig.21.13). With the previously performed posterior
CS, the defect edges should come together in a tension-free fashion. The defect is
closed with v-lock suture, completed with four or ve throws run in a backwards
fashion (Fig.21.13). Once both anterior and posterior fascial layers are closed, the
mesh is deployed in the retromuscular sublay position. The developed retromuscular space is measured for appropriate mesh size selection. Our preference is medium
weight macroporous polypropylene mesh which is deployed through our 12mm
trocar (Fig.21.14). There is no need for antiadhesion barriers as there now exists an
autologous barrier between the mesh and viscera; a signicant advantage of the
sublay position. Mesh placement in the retromuscular space has allowed for the
discontinuation of aggressive penetrating xation techniques with transfascial
Fig. 21.13 Closure of the anterior layer. A 0 barbed suture is used in a back-handed fashion with
an “upside down” view to take bites of the edges of the defect while including the sac (if a large
subcutaneous portion is present) in between to reduce the chance of postoperative seroma
21 Robotic Retro-Rectus Repairs
Fig. 21.14 Placement of a medium weight macroporous polypropylene mesh deployed through
the 12mm trocar. There is no need for antiadhesion barriers as there now exists an autologous barrier between the mesh and viscera
345
sutures, transitioning rst to brin glue and, more recently, to complete cessation of
mesh xation as our data illustrates penetrating xation is associated with higher
incidence of chronic pain without the added benet of lowered rates of recurrence.
Pneumoperitoneum is released under direct vision, assuring the mesh is lying at
and wrinkle-free between the posterior and anterior layers (Fig.21.14).
Formerly, we once placed drains just supercial to the mesh in all hernia repair
cases. We are now more selective with drain placement and do not utilize it for most
patients. To date we have not observed an increase in wound morbidity as a result.
21.3.4 Lower Midline Defects
For a right-handed surgeon, we found that lower midline defects are easier to
address by initiating the dissection in the upper portion of left retrorectus space.
Figure21.15 demonstrates the typical port position that we chose to use for this
approach. Balloon dissector is used at port position #1 to develop the left retrorectus
space, followed by direct visualization for placement of port #2 into the developed
space with an optional port #3. Blunt dissection in the left retrorectus space is performed in a caudal direction and the pubis is identied. As the upper midline has not
previously been violated above the level of umbilicus, the medial aspect of the left
posterior rectus sheath is incised and the preperitoneal space entered just supercial
to falciform ligament (Fig.21.16). The right posterior rectus sheath is identied and