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22 Robotic Transversus Abdominus Release
357
incisions, and additional hernias. It is important to identify and document any evidence of pre-operative muscular dysfunction commonly seen in post-spinal or kidney surgery patients. If evident, patients should be made aware of the possibility of
worsening lateral dysfunction and/or bulging after surgery.
It is our practice to obtain axial imaging on all patients who may require a
rTAR.Our preference is CT abdomen and pelvis, and unless looking for other intraabdominal pathology, contrast is unnecessary. Imaging allows us to determine the
condition of the relevant abdominal wall components, to identify anatomical concerns regarding access to the intraperitoneal space, and to get a sense of the amount
of pre-operative weight loss to recommend to patients based on the perceived intraabdominal volume relative to the volume of the hernia sac. It also allows us to
identify potentially unrelated pathology that may warrant additional workup, and
possibly treatment prior to, or during, the time of surgery.
We generally do not operate on patients who are actively smoking unless there is
concern for imminent incarceration. Patients are advised to quit smoking at least 6weeks
prior to surgery and routinely undergo nicotine testing. Though there is little evidence
addressing the effect of marijuana use prior to surgery, we do recommend cessation of
all inhaled forms of marijuana for at least 6weeks pre- operatively. Patients with ongoing
or recent history of drug abuse undergo pre-operative testing the day of surgery.
Generally speaking, all patients who are considered overweight are advised to lose
weight prior to surgery. Obese patients are given a goal BMI of <30 to 32. Morbidly
obese patients who are unable to lose signicant weight pre-operatively, and who are
not severely symptomatic or have concerns for imminent incarceration are referred to
our weight management team and, when appropriate, bariatric surgery.
Patients with uncontrolled diabetes are referred to their primary care physician,
and in severe cases to an endocrinologist to assist in their glucose management.
Malnutrition is a risk factor for mortality and incisional hernia after major abdominal surgery. Measures should be taken to evaluate and treat at-risk patients prior to
undergoing a major reconstruction. Referral to a nutrition specialist should be considered in select patients [29, 30].
22.4 Technique
While there are several techniques which can be employed robotically to undertake a
robotic transversus abdominus release, this chapter will focus on a transabdominal
approach. It will also be very helpful for the surgeon embarking on the below techniques
to be very familiar with the performance of the open transversus abdominus releases.
22.4.1 Patient Preparation andPositioning
1. The patient is laid supine on the operating table. After induction of general
anesthesia, a urinary catheter is placed. The patient is positioned with the bed
slightly exed to increase the distance between the anterior superior iliac spine
358
D. Bernstein and G. R . Jacobsen
(ASIS) and the costal margin to allow for additional space for trocar place-
ment. Both arms are tucked, and padding is placed over the hands to protect
against contact with the robotic arms. In this regard, the bedside assistant plays
an important role in ensuring the patient is protected and not incurring any
injury during the procedure. It can also be helpful to drop the arms below the
level of the table to minimize contact between the robot and the extremities.
Care should be taken to support the elbows and the wrists appropriately. Straps
are placed across the hips and chest. We also make sure the face is padded with
either a Mayo stand placed directly above the face or with the use of a special-
ized face pad.
2. The patient is prepped and draped from the nipples to the upper thigh, and later-
ally beyond the midaxillary line.
3. Pre-operative antibiotics are administered, usually a rst generation cephalosporin.
22.4.2 Abdominal Access andAdhesiolysis
4. The method of abdominal access should be based on surgeon experience and
comfort. The access site is determined again by surgeon comfort and prior inci-
sions if present. With the use of the Si robotic platform, we prefer a left upper
quadrant (LUQ) 5mm optical trocar entry with a laparoscope. For the Xi plat-
form, we use the 8mm robotic camera with the corresponding optical trocar.
Preoperative CT imaging can be particularly helpful in the determination of the
initial access location, favoring areas that do not have bowel directly abutting the
access site. If the access site is to be used as the right or left arm access port,
consideration should be made to have this incision as lateral as the surgeon is
comfortable with. This is usually at or about the anterior axillary line. Safe
access is always the best access, so the site should be selected on this principle
with additional ports placed later for the robotic system.
5. Once abdominal access is achieved the intraperitoneal space is assessed and
adhesiolysis is performed to allow for additional trocar placement. The robotic
platform allows for an incredible advantage in regard to adhesiolysis when com-
pared to traditional laparoscopy and may even rival the open approach.
22.4.3 Trocar Placement
6. Additional trocars are placed equidistant from one another along the mid- and
anterior axillary lines triangulated towards the center of the hernia sac. Trocars
should be placed as lateral as possible while allowing for clearance of the
robotic arm to avoid contact with the patient or the edge of the operating table
(Fig.22.1).
7. When using the Xi platform, one must keep in mind that at least one 12–15mm
trocar must be placed to allow for mesh insertion, this can be done by nesting
an 8mm port into a large diameter trocar or by placing an accessory/assist port.
The latter provides the additional benet of quick and easy insertion and
22 Robotic Transversus Abdominus Release
Fig. 22.1 Trocars are
placed equidistant from
each other along the midand anterior axillary lines,
triangulated towards the
center of the hernia defect
removal of sutures, suctioning devices, assistant retraction, etc. The Si robot
requires a 12mm camera port which can be used for mesh placement, however
it is still our practice to place an assist port for the above listed benets.
22.4.4 Docking
359
8. rTARs are most commonly performed using a double-dock technique. There are
multiple docking orientations that can be used depending on the robotic plat-
form, the available operating room space, and surgeon preference. Our prefer-
ence when using the Si platform is for the robot to be positioned at a 90° angle
to the operating table. The contralateral dock can be accomplished by
maneuvering the robot, or by turning the patient. In either case, it is important to
discuss the docking plan with the operating room staff and anesthesia team to
allow for appropriate preparation.
A primary advantage of the Xi platform is the incorporation of a rotating
boom. This allows for re-docking without having to reposition the surgical cart.
When the Xi platform is available, we prefer a low-lateral dock whereby the
robot is positioned towards the foot of the bed lateral to, and in-line with the
patient. This allows for appropriate positioning while providing the bedside
assistant and operating technicians additional space to maneuver.
22.4.5 Retromuscular Dissection
9. Once trocar placement and docking are completed, additional adhesiolysis and
sac reduction are performed robotically.
10. There are several useful robotic instruments commonly used to facilitate retromuscular dissection and component separation. We prefer a Prograsp forceps
360
Fig. 22.2 The retromuscular dissection is initiated by incising the posterior sheath (white arrow)
just lateral to the linea alba (black arrows) and ~5 to 10cm superior to the hernia defect (not shown)
D. Bernstein and G. R . Jacobsen
and a monopolar curved scissors for the left and right arms, respectively.
Recently released is the Force Bipolar grasper which allows the surgeon to
modulate the grasping strength from once which it would be safe to grab bowel,
and a more aggressive grip useful for pulling on fascia or peritoneum. If available, this is the instrument of choice opposite the scissors.
11. The right sided retromuscular dissection is initiated by incising the posterior
rectus sheath approximately 5–10cm superior to the hernia defect and about
1cm lateral to the linea alba (Fig.22.2). In cases involving signicant diastasis
or an attenuated linea alba the surgeon may elect to initiate the dissection more
superiorly. This “top-down” approach is then continued inferiorly beyond the
caudal margin of the defect.
12. As the dissection proceeds inferiorly the arcuate line is encountered and incised
from its connection to the linea alba (Fig.22.3). Care should be taken to maintain a preperitoneal dissection plane in this region to avoid injury to the inferior
epigastric vessels which travel along the posterior aspect of the rectus muscle
in the pre-transversalis plane.
13. The retromuscular plane is then dissected out laterally using mostly blunt dissection until the medial edge of the linea semilunaris is encountered. Care
should be taken not to injure the neurovascular bundles as they are encountered as this may result in denervation and ischemia of the rectus muscle
(Fig.22.4).
22 Robotic Transversus Abdominus Release
Fig. 22.3 Incision of the medial attachments of the arcuate line (arrow) as they are encountered
in the “top-down” and “Bottom-up” (depicted here) dissection
361
Fig. 22.4 Completed
retromuscular dissection,
showing medial border of
the linea semilunaris
(white arrow) with
neurovascular bundles
(black arrows)
22.4.6 Transversus Abdominis Release
14. The transversus abdominis release is then performed. As described by Novitsky
et al. [16], the transversus abdominis (TA) muscle bers extend medially
beyond the linea semilunaris; this overlap is most pronounced in the upper third
of the abdomen. This key anatomic distinction allows for entry into the lateral
pre- peritoneal plane without disrupting the linea semilunaris or the neurovascular supply to the rectus muscle.
362
Fig. 22.5 Initiation of the TA release. The TA fascia is incised just medial to the NV bundles,
exposing the TA muscle (black arrow) beneath. White arrows depicting the medial border of the
posterior rectus sheath
D. Bernstein and G. R . Jacobsen
The dissection is initiated by incising the TA fascia just medial to the neurovascular bundles in the upper third of the abdomen (Fig.22.5). This will expose
the underlying TA muscle bers which are also incised, taking care not to violate the peritoneum beneath.
The pre-peritoneal plane can be developed as far lateral as the psoas muscle
to achieve midline closure. Once the preperitoneal plane is developed at this
level, it is often easier to extend the plane inferiorly by rst creating a lateral
pre-peritoneal tunnel, and then simply incising the medially connecting fascia.
This same concept is utilized on the contralateral side in the opposing direction
i.e. “bottom-up” dissection (Fig.22.6).
To ensure an adequate dissection has been performed the posterior sheath
should be seen to lay slack over the abdominal viscera.
22.4.7 Mesh Sizing andContralateral Trocar Insertion
15. Once the dissection on the right is completed, contralateral trocars are placed in
an opposing orientation. These trocars are inserted directly into the newly
created pre-peritoneal space. Some surgeons also prefer to insert the mesh at
this time.
ab
ab
22 Robotic Transversus Abdominus Release
Fig. 22.6 (a) Creation of a lateral pre-peritoneal tunnel prior to incising the adjacent TA fascia
and muscle. (b) After tunneling, the incision of TA fascia and muscle bers is easily achieved
363
Fig. 22.7 (a) The mesh width is determined by measuring the distance from the lateral edge of the
dissection plane to the midline. (b) Contralateral trocars are placed directly into the pre-peritoneal
plane
16. The cranio-caudal dimension of the hernia defect is measured to ensure adequate superior and inferior overlap. The width of the mesh is determined by
doubling the distance between the lateral border of dissection plane and the
patient’s midline (Fig.22.7).
22.4.8 Contralateral Dissection
17. After the robot is docked on the patient’s right side, contralateral dissection
proceeds according to the same basic principles. We prefer to use the “bottom up” approach for the left sided dissection however a “top-down” approach can
also be utilized. As the TAR dissection proceeds the original trocars are encountered and need to be retracted and then advanced into the pre-peritoneal plane.
We routinely suture the peritoneal defects closed, as well as any other defects
in the posterior lamella that may have occurred during the procedure (Fig.22.8).
364
Fig. 22.8 Contralateral trocars encountered during TAR dissection are re-positioned
D. Bernstein and G. R . Jacobsen
22.4.9 Fascial Closure
18. After completion of the TAR on the left, we attempt closure of the hernia defect,
as well as any signicant diastasis, using a 0-PDS barbed suture (Fig.22.9).
This is followed by closure of the posterior sheath using a 2-0 absorbable
barbed suture (Fig.22.10).
22.4.10 Mesh andDrain Placement
19. Once the posterior sheath is closed the mesh is positioned to lay at and even
over the posterior sheath. The mesh can be left as is or can be xated using a
tacking device, sutures, or glue, depending on surgeon preference (Fig.22.11).
20. Once the mesh is positioned, a drain is routinely placed to prevent uid accumulation and subsequent seroma formation. We prefer to use a single 19Fr
Blake Drain (Ethicon, Inc., Somerville, NJ). Once the drain is positioned and
secured to the skin, insufation is released, trocars are removed, and the procedure is concluded.
22.4.11 Post-Operative Care
The care pathways for robotic component separation at our institution are very similar if not identical to those involved in our open component separation pathway.
22 Robotic Transversus Abdominus Release
365
Fig. 22.9 Closure of the hernia defect
Fig. 22.10 Closure of the posterior sheath
366
Fig. 22.11 Mesh
placement above the closed
posterior sheet, Pictured
®
GORE
SYNECOR
Preperitoneal Biomaterial
D. Bernstein and G. R . Jacobsen
However, we have noted that setting expectations in the clinic preoperatively is an
essential component of any enhanced recovery pathway. For open component separations we have traditionally informed the patients that their stay will be between 3
and 5days on average. We have noted a signicant decrease in the length of stay for
our robotic group and inform them that we are currently averaging two to threedays.
As with any component separation it is critical to monitor patients for sign of
abdominal compartment syndrome. This is more likely in patients with massive loss
of domain, whom likely would not have been placed into the robotic pathway in the
rst place, but it is certainly possible with larger defects. These patients will develop
evidence of decreased end organ perfusion which is usually hallmarked by a decrease
in urine output and culminates in respiratory failure if not recognized. We do prefer
to remove any drain placed directly in contact with the mesh before discharge.
22.5 Conclusions
Over the last two decades the techniques employed in abdominal wall reconstruction have evolved at a rapid pace. Surgeons inclined to harness the power of laparoscopy immediately set upon the repair of larger and larger defects with the goal of
decreasing the overall morbidity of these repairs. The technique of the intraperitoneal onlay was perfected, and devices were developed to aid in mesh xation (tackers) and biomaterials evolved for intra-abdominal placement. The robot, while
available since the early part of the century, was largely ignored. The reasons are
unclear but were likely secondary to access and cost. While the laparoscopic repairs
did offer a satisfactory solution in most cases, many have looked to improve upon
the bridging nature of these repairs and provide a more reconstructive option.
The techniques of component separation have undergone their own evolution
and the transversus abdominus release emerged as a powerful adjunct to component