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Fig. 25.13 Measurement of the defect in both directions
Fig. 25.14 Measurement
of the lateral coverage of
the mesh (in this case,
6cm overlap)
A. Addo et al.
Fig. 25.15 Closure of the
defect
25 Robotic-Assisted Parastomal Hernia Repair: Sugarbaker Repair (With…
411
As noted above, the mesh selected should allow for a minimum of 5cm overlap
in all directions but if there is an associated incisional hernia, then a larger size will
be needed to repair this hernia at the same time. Three polyglactin sutures will be
placed onto the mesh prior to introduction into the abdomen to aid in positioning of
it. It is recommended that they be placed 8–10cm apart to allow an adequate orice
for the intestine to pass and avoid compression on the intestine. This material will
be inserted into the abdominal cavity via the 12mm trocar in the right upper quadrant (Fig. 25.16). Generally, it is not necessary to lateralize the intestine with suture
as the mesh will assure lateralization. As shown in Fig.25.17, two white sutures are
used and placed 10cm apart while a third purple suture is placed at the opposite end
of the mesh to position the middle of that portion of the mesh to center the hernia.
These two different colors help differentiate the sutures during manipulation of the
sutures.
Fig. 25.16 Mesh inserted
through 12mm trocar
Fig. 25.17 Preplaced
sutures to position the
mesh
412
A. Addo et al.
As single 2–3mm incision lateral to the stoma will be placed through which the
two white sutures will be pulled through the abdominal wall (Fig.25.18). This will
insure the adequacy of overlap while positioning the mesh to be sewn into the
abdominal with #2 permanent barbed sutures. A double armed suture will make this
easier as each limb can be used on one side of the intestine to xate that side of the
mesh material. It is preferred to start suturing on the lower portion of the mesh adjacent to the intestine with the rst limb (Fig.25.19). The second limb will be used to
sew the periphery of the mesh on that same side (Fig.25.20).
The second double armed suture will be started on the opposite (cephalad) side
of the intestine. The goal is to create a tube of mesh through which the intestine will
Fig. 25.18 Retrieval of
lateral positioning sutures
Fig. 25.19 Initial suture near intestine (note the tube created by the lateral sutures on gure
on the left)
25 Robotic-Assisted Parastomal Hernia Repair: Sugarbaker Repair (With…
Fig. 25.20 Suture
placement at the periphery
of the mesh
Fig. 25.21 Absorbable
suture of colon to mesh
413
pass. As before, the rst pass will be adjacent to the intestine and the second limb
will used to xate the periphery of the prosthetic material. After this has been completed, an absorbable 2-0 barbed suture will be used to sew the intestine to the mesh
to close off the potential space that exists between the intestine and the mesh
(Fig.25.21). At the completion of the suturing, the mesh will be fashioned as a tube
through which the intestine will pass through and the periphery of the mesh will be
sewn with the wide overlap (Fig.25.22).
414
Fig. 25.22 Completed
procedure
A. Addo et al.
25.9 Postoperative Management
The majority of patients will have the use of a transversus abdominis plane block.
This signicantly diminishes opioid use and decreases the length of stay. A regular
diet is begun the next day. In the past, we required the patient to have a bowel movement prior to discharge but no longer make this an absolute requirement. This technique has been applied to 22 patients with excellent results. To date only one
recurrence has been seen. This was a contracted, debilitated wheelchair bound
patient on chronic high dose steroid medication for severe osteoarthritis. It would
seem there are multiple possible reasons for recurrence in this patient.
25.10 Conclusion
Two options for repair of parastomal herniation have been presented in this chapter.
Of note, no description of the pure keyhole approach has been given because the
rate of recurrence is prohibitively high to recommend this procedure. We suggest
that the reader explore either of these two options as experience is gained in the
robotic incisional repair and the TAR repair.
References
1. Shah N, Craft R, Harold K.Parastomal hernia repair. Surg Clin North Am. 2013;93(5):1185–98.
2. O’Neill C, Borrazzo E, Hyman N. Parastomal hernia repair. J Gastrointest Surg.
2014;19(4):766–9.
3. Liu N, Hackney J, Gellhaus P, Monn F, Masterson T, Bihrle R, Gardner T, House M, Koch
M.Incidence and risk factors of parastomal hernia in patients undergoing radical cystectomy
and ileal conduit diversion. J Urol. 2014;191(2):1313–8.
25 Robotic-Assisted Parastomal Hernia Repair: Sugarbaker Repair (With…
4. Sugarbaker P.Peritoneal approach to prosthetic mesh repair of paraostomy hernias. Ann Surg.
1985;201(3):344–6.
5. Pauli E, Juza R, Winder J.How I do it: novel parastomal herniorrhaphy utilizing transversus
abdominis release. Hernia. 2016;20(4):547–52.
6. Belyansky I, Zahiri R, Sanford Z, Weltz A, Park A. Early operative outcomes of endo-
scopic (eTEP access) robotic-assisted retromusclar abdominal wall hernia repair. Hernia.
2018;22(5):837–47.
415
Robotic Ventral andIncisional Hernia
Repair: Management ofAdverse Events
AnthonyM.Gonzalez andRodolfoJ.Oviedo
Ventral and incisional hernia repair remains one of the most common, and sometimes challenging, procedures performed by general surgeons in the United States
and around the world. Despite this fact, there is little consensus on the best approach
to repair this type of hernia. Due to the rapid advancement of technology, the development of robotic surgery has been applied to simple and complex ventral and incisional hernia repair [1].
The robotic platform has been used for simple fascial closure and intraperitoneal
placement and xation of mesh, and more recently, for minimally invasive retrorectus dissection, closure of the linea alba and extraperitoneal placement of mesh.
The most advanced hernia specialists use this technology to release the abdominal
wall musculature to allow for primary closure of the midline, which in turn restores
and maintains the integrity of the abdominal wall, not only from an anatomic standpoint, but also with respect to its physiology.
As with any surgical procedure, adverse events or complications may occur. The
purpose of this chapter is to describe the most common post-operative occurrences
during and after robotic ventral and incisional hernia repair, and their appropriate
management.
26
A. M. Gonzalez (*)
Baptist Hospital of Miami, Miami, FL, USA
Florida International University College of Medicine, Miami, FL, USA
Bariatric Surgery Baptist Health South Florida, Miami, FL, USA
MIS/Bariatric Surgery Fellowship, BHSF, Miami, FL, USA
e-mail: AnthonyG@Baptisthealth.net
R. J. Oviedo
Florida State University College of Medicine, Tallahassee, FL, USA
Winchester Medical Center, Valley Health Metabolic and Bariatric Program,
Winchester, VA, USA
© Springer Nature Switzerland AG 2019
K. A. LeBlanc (ed.), Robotic Assisted Hernia Repair,
https://doi.org/10.1007/978-3-030-23025-8_26
417
418
A. M. Gonzalez and R. J. Oviedo
Intraoperative complications can occur during robotic primary ventral hernia
repair. However, it has been demonstrated that incisional hernia repair is associated
with more complications since lysis of adhesions is more likely [2]. This increases
the possibility of bowel injury either as single or multiple serosal tears, or as full
thickness defects with perforation. Therefore, bowel injury can occur during enterolysis or adhesiolysis during incisional hernia repair or manipulation of instruments
during ventral hernia repair. If recognized, the bowel should be immediately repaired
either via the robotic approach, or with conversion to an open procedure if not feasible. Most likely, however, a robotic repair of any enterotomy or serosal tear can be
appropriate due to the multiple benets offered by the robotic technology and with
adequate surgical skills.
Changes in plans regarding the approach to repair the hernia and with respect to
mesh selection may occur after an inadvertent bowel injury. These changes must be
carefully considered to prevent long-term issues like chronic mesh contamination or
infection.
Postoperative complications are more common than intra operative complications. Wound issues, though less likely after robotic or minimally invasive surgery,
can occur. Wound disruption can be seen due to pressure necrosis of the skin from
the trocar during surgery. This can be avoided by creating the correct size incision
to match the trocar size. After surgery, these issues are quite self-limiting and can be
dealt with using simple wound care.
A trocar site wound infection can occur, especially in an obese patient where
wound healing is not optimized due to excessive subcutaneous fat with poor blood
supply. This will be recognized 5–10days post operatively. Management is similar
to all surgical wound infections, beginning with opening the wound and instituting
antibiotic therapy, if indicated. These wounds are of low risk, since they are typically remote to the location of the hernia and mesh placement. Therefore, signicant
concern for mesh infection is not warranted.
Hematomas and seromas at the trocar site can also occur without an associated
infection. These can be observed with patience and will spontaneously resolve.
Seromas at the area of the hernia repair are more common, despite the introduction of robotic surgery and techniques for fascial closure. A 2017 study by the
Americas Hernia Society Quality Collaborative Analysis demonstrated higher rates
of surgical site occurrence (SSO) in the laparoscopic intraperitoneal onlay mesh
(IPOM) repair arm compared to the robotic arm, 14% vs 5%, respectively [3].
Gonzalez etal (not published) have educated many surgeons on the prevention of
seromas with a post-operative dressing that included Kerlix rolls over the hernia
repair with an abdominal binder. This applies pressure to the hernia sac, if the sac is
left in situ, or over the subcutaneous space, if the sac is resected, and diminishes the
formation of a seroma or hematoma at that location. Others have popularized the
incorporation of the hernia sac in the defect primary closure to diminish the formation of a seroma.
If seromas develop in the immediate postoperative period, application of the
above Gonzalez Hernia Binder technique can eliminate all that uid from the subcutaneous space through the still semipermeable mesh. If more than 2weeks have
26 Robotic Ventral andIncisional Hernia Repair: Management ofAdverse Events
419
expired since surgery, it is unlikely that this binder would help. Management of the
seroma would depend on whether it is symptomatic. If asymptomatic, no treatment
is needed. If the patient is symptomatic from the seroma, aspiration in the ofce
setting and application of the pressure binder is feasible. This may be repeated if
needed. For recurrent, symptomatic seromas involving a signicant granulation tissue cavity, surgical drainage of the uid and excision of the seroma cavity may be
needed. Drain placement after excision should be strongly considered.
Bleeding intraoperatively should be dealt with using basic surgical techniques
as described above. Postoperative hematomas can be subcutaneous in the area of
the hernia sac, especially if the sac was resected, or intraabdominal inlocation.
Subcutaneous hematomas can be observed, since needle aspiration increases the
risk of infection, as blood is a good milieu for bacterial growth. If they fail to
resolve in 3–6months and continue to be symptomatic, operative drainage and
excision can be performed similarly to seromas. Intraabdominal hematomas are
more likely to resolve and rarely require treatment. If super-infection of the hematoma occurs, percutaneous drainage using interventional radiology techniques is
possible.
If an intraabdominal hematoma becomes infected, contamination of the mesh is
possible. If the mesh becomes contaminated, treatment with long-term antibiotics is
the initial step. Many lightweight meshes available today will resist infection and
continue to incorporate themselves into the surrounding tissues [4]. If the infection
causes a systemic inammatory response and sepsis, or if it becomes chronic in
nature, the management would change to operative exploration and explantation of
the mesh. This can be attempted via laparoscopic or robotic approaches, but most
likely would have to be dealt with via an open procedure since the presence of
inammation and infection usually precludes a minimally invasive approach.
If exploration of the surgical site via an open approach is performed, the unincorporated mesh is explanted, while the peritoneal cavity (or the portion of it exposed
by the wound) and the abdominal wall are thoroughly lavaged. The hernia is repaired
via an open approach with monolament absorbable suture. Use of biological mesh
can be used to reinforce the repair and decrease the chance of recurrence of the
hernia [5].
Intra-abdominal adhesions can occur after any operation but have been proven to
occur less frequently with minimally invasive surgery. After robotic ventral hernia
repair, the likelihood of intraabdominal adhesions and resulting small bowel
obstruction depends on where the mesh has been implanted. It has been postulated
that the intraperitoneal onlay mesh (IPOM) technique has a higher likelihood of
intraabdominal adhesions due to mesh placement within the peritoneal cavity [6].
Despite the adhesive barrier provided on the mesh, the inammatory response by
the mesh itself will propagate adhesions [7].
When the mesh is placed in the extraperitoneal location the occurrence of
intraabdominal adhesions is less common [8]. When a small bowel obstruction
occurs, management is similar to all initial medical management of bowel obstruction with nasogastric tube placement and intravenous uids for resuscitation in the
setting of third-space volume losses. When these occur in the early post-operative
420
A. M. Gonzalez and R. J. Oviedo
period, resolution is more likely [9]. If the bowel obstruction fails to resolve with
medical management, operative exploration via laparoscopy or laparotomy is
indicated.
Pain after robotic ventral hernia repair is common. Studies have demonstrated
decreased pain with the robotic approach likely due to the elimination of tacks and
suture xation of the mesh [10]. This immediate postoperative pain is dealt with via
a multimodal pain approach as recommended by multiple societies [11]. Scheduled
acetaminophen and NSAIDS are used as a foundation for pain control, with judicious use of opiates as needed. The addition of an intraoperative nerve block, particularly in the preperitoneal plane with bupivacaine, may reduce the need for
opiates in the immediate post-operative period [12].
Long term pain for more than a few weeks or a month would be categorized as
chronic pain. This is less likely with the robotic approach, since transfacial sutures
are not used. The use of transfacial sutures is associated with more chronic pain
because nerve entrapment can occur with this technique [13]. Since the recommendation for mesh xation is implantation with a monolament absorbable suture, as
the suture absorbs in 6–9months, most pain associated with the xation of the mesh
should resolve. If chronic pain continues, attempts at nerve block in the ofce setting and nerve “destruction” can be managed by a pain specialist.
Hernia recurrence has been described as an important complication, which may
occur in the early postoperative period as well as a chronic adverse event months to
years later. As is expected, the patient’s habitus and body mass index (BMI) play a
crucial role, in addition to activity level and other factors such as diabetes mellitus
type 2, chronic steroid use, smoking, connective tissue diseases and overall immune
status, to name a few. Other factors include age, simultaneous bowel surgery, hernia
defect size, and method of hernia repair [14]. Regarding the hernia size and BMI,
Oviedo etal described the use of the robotic platform to repair large hernia defects
with intracorporeal suturing for primary closure and mesh implantation with the
IPOM technique, combined with an external oblique endoscopic component separa-
2
tion to decrease tension, with low recurrence rates in patients with BMI>30kg/m
.
Such a technique can be safely implemented in a community hospital setting with
proper team training [15, 16]. Moreover, Gonzalez etal have demonstrated the benet of the robotic approach to decrease hernia recurrence rates when repairing ventral hernias. Primary closure of the defect with intracorporeal suturing is facilitated
by the robotic instruments, which empower the surgeon’s dexterity when suturing.
This is followed by meticulous mesh implantation [17, 18].
With respect to the incidence of venous thromboembolism or deep venous
thrombosis (DVT) in addition to pulmonary embolism (PE), these possible complications are intricately related to the patient’s overall condition and risk factors such
as obesity, sedentary habits, propensity for venous stasis, among other well-known
factors that do not necessarily have to do with the presence of a hernia. Therefore,
specically for the eld of abdominal wall reconstruction and simple to complex
hernia repair, with or without minimally invasive techniques such as robotics, DVT
prophylaxis prior to surgery is not indicated unless the patient has a history of prior
DVT and/or PE. Otherwise, normal measures for DVT prophylaxis in the