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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_888_Библиотеки_им_академика_М_И_Перельмана
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Robotic Technique forIntraperitoneal
Onlay Mesh (IPOM)
JamesG.Bittner IV, MichaelP.Meara,
andNatashaL.Clingempeel
Overview
Laparoscopic ventral hernia repair (LVHR) with intraperitoneal onlay mesh (IPOM)
is an accepted technique for ventral/incisional hernia (VIH) repair. LVHR can
improve wound morbidity, shorten hospital length of stay (LOS), and lower the rate
of surgical site occurrence (SSO) compared to certain open approaches for smalland medium-sized VIH [1, 2]. However, at least 2% of patients report signicant
pain lasting more than 2–8 weeks postoperatively [3–6]. Most often, patients
describe the pain as localized to a specic dermatome, burning, and/or tugging/pulling at the site of transfascial sutures or tacks. Prolonged or severe postoperative pain
after LVHR represents a potential area for improvement, and robotic ventral hernia
repair (RVHR) with IPOM may help decrease the frequency and/or severity of this
sequalae [6, 7].
At the time of this writing, one robotic platform is approved for use in the United
States (da Vinci
lowing descriptions relate to three models (Si, X, and Xi). It is the opinion of the
authors that the robotic surgical platform offers advantages to traditional laparoscopic instrumentation including, but not limited to, additional degrees of motion,
three-dimensional imaging, a stable operating construct, and preferred ergonomics.
®
Surgical System, Intuitive Surgical, Sunnyvale, CA), so the fol-
14
J. G. Bittner IV (*)
Department of Surgery, Sentara RMH Medical Center, Harrisonburg, VA, USA
e-mail: michael.mear@osumc.edu
M. P. Meara
Division of General and Gastrointestinal Surgery, Department of Surgery, The Ohio State
University Wexner Medical Center, Columbus, OH, USA
e-mail: michael.mear@osumc.edu
N. L. Clingempeel
Division of Bariatric and Gastrointestinal Surgery, Department of Surgery, Virginia
Commonwealth University Medical Center, Richmond, VA, USA
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2019
S. S. Davis Jr. et al. (eds.), The SAGES Manual of Hernia Surgery,
https://doi.org/10.1007/978-3-319-78411-3_14
183
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J. G. Bittner et al.
Studies demonstrate the relative ease and precision of intracorporeal suturing when
securing mesh to the abdominal wall with the robotic surgical platform compared to
traditional laparoscopy [3, 8, 9].
There are several perceived benets of intracorporeal suturing compared to traditional transfascial suture xation of mesh to the abdominal wall. The method of
IPOM xation seems to play a role in the perception of postoperative pain when
comparing RVHR and LVHR.During RVHR, mesh is sutured in a continuous circumferential fashion to the posterior rectus sheath. This stands in contrast to LVHR
during which mesh is secured using transfascial sutures spaced at 2–5-cm intervals
and tacks (absorbable or permanent). Less acute pain after RVHR can have downstream benets including less use of narcotic pain medications, shorter hospital
LOS, fewer complications, and earlier return to physical activity compared to traditional LVHR [10–13].
Additional potential benets of RVHR include the relative ease of enterolysis
when considering surgeon ergonomics and fascial defect closure, minimizing the
need to bridge defects with mesh [14]. Recent studies demonstrate an increased
frequency of defect closure with RVHR compared to LVHR and less acute postoperative pain [10]. Closure of the fascial defect may portend a lower risk for SSO,
specically symptomatic seroma, and potentially hernia recurrence. This chapter
will detail the perioperative considerations and technical tips for RVHR with IPOM
for VIH repair.
Patient Selection
Patient selection is broken down into two phases. The rst phase is prehabilitation,
which connotes improving the overall medical condition of the patient with
VIH.The second phase is choosing the operative approach. Before selecting RVHR,
the operating surgeon must consider the medical and surgical history, hernia characteristics, as well as individual training and experience. When these two phases are
combined, the correct patient is matched to the correct operative approach, leading
to the best possible outcomes.
Preparing patients for VIH repair is critical to minimize risk for SSO and hernia
recurrence. Reviewing the medical history is critical before choosing RVHR with
IPOM. For example, patients with inammatory bowel disease (Crohn’s disease or
ulcerative colitis) may be a relative contraindication to IPOM with permanent synthetic
biomaterial. In general, patients should be smoke-free for at least 4weeks preoperatively to minimize the risk for surgical site infection (SSI). In addition, those patients
with body mass index (BMI) greater that 40kg/m
be counseled regarding medically supervised or surgical weight loss before VIH repair.
Surgeons have an opportunity to impact patients with morbid obesity by offering
appropriate counseling and referral to weight loss specialists and/or bariatric surgeons.
Operating on morbidly obese patients without rst discussing and requiring weight
loss misses a critical opportunity to improve the quality and quantity of life of patients
suffering from morbid obesity. Besides smoking cessation and weight loss, patients are
assessed for other risks associated with SSI including diabetes mellitus and history of
2
who wish to undergo RVHR should
14 Robotic Technique forIntraperitoneal Onlay Mesh (IPOM)
185
wound infection. Patients with hemoglobin A1c greater than 8% are referred to a primary care provider or endocrinologist for better blood glucose control before considering elective VIH repair. Those with a signicant history of SSI, especially when
infected or carrying methicillin-resistant Staphylococcus aureus (MRSA), may benet
from preoperative MRSA eradication and/or antibiotic treatment. The decision to eradicate MRSA and/or treat with preoperative antibiotics may be made in conjunction
with infectious disease specialists as needed. The operating surgeon should also consider the patients’ nutritional status before undertaking RVHR.Patients are at risk of
SSI and/or poor outcomes when nutritional status is poor. These individuals can be sent
for formal evaluation by a dietician and given preoperative dietary supplements to
improve protein intake and overall catabolic status.
The choice of operative approach depends on patient and surgeon factors. While
a complete algorithm for choosing an operative approach to VIH repair is beyond
the scope of this chapter, it is important to detail the specic indications for RVHR
with IPOM.Once the patient is prepared appropriately for operation, the next step
is to determine the type, size, and location of the VIH.Following a thorough history
and physical examination, the surgeon must decide if computed tomography (CT) is
indicated. The authors feel a preoperative CT is benecial in patients with large
primary ventral hernias as well as all incisional and recurrent hernias. CT also permits determination of defect type and size and may identify concurrent defects
missed on physical examination. The authors feel that with regard to hernia location
and size, RVHR with IPOM and defect closure is most appropriate for primary
ventral hernia located in the anterior abdominal wall and measuring less than 6cm
in diameter. Other indications may be off-midline defects such as small- or mediumsized Spigelian, ank, and parastomal hernias with the caveat that other more
advanced surgical techniques are not warranted or possible.
Operative Technique
The key to successful RVHR with IPOM includes appropriate patient selection and
understanding and exploiting the layers of the abdominal wall. Working high on the
anterior abdominal wall is feasible using laparoscopic instrumentation; however, it is
technically easier and ergonomically less challenging using a robotic surgical platform. Methods to approximate the fascia and secure the mesh, particularly suturing,
are less burdensome to the surgeon and potentially less painful to the patient. RVHR
with IPOM is most often performed in conjunction with primary closure of the
defect, though this is not mandatory. As experience with RVHR grows, an increasing
number of surgeons elect to close the fascial defect before IPOM.
Required Equipment andRoom Setup
The orientation of the operating table within the operating theater may vary depending on the model and mobility of robotic equipment as well as room size. Assuming
a square-shaped operating room, the operating table is placed in the middle of the
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J. G. Bittner et al.
Fig. 14.1 Room setup for robot-assisted ventral/incisional hernia repair with intraperitoneal mesh
using the da Vinci
®
Si robotic surgical platform
room. When using the Si or X model, all anesthesia personnel and equipment are
located at the patient’s head. Docking occurs from the patient’s side. The robotic
platform can be positioned perpendicular to the operating table from the patient’s
left or right side (side-docking). If the hernia defect is off midline, the robotic platform should be docked from the ipsilateral side. When using the Xi model, operating room and equipment setup and docking direction become less critical. The Xi
and its ability to side dock or parallel dock allows for anesthesia equipment and
providers to remain at the patient’s head, and the robotic platform is docked from
the patient’s left (preferred by the authors) or right side (Fig.14.1).
Patient Positioning
Patients are positioned supine on the operating table with bilateral lower extremity
sequential compression devices. The patient should be situated such that the midabdomen overlies a ex joint in the operating table. Clipping of hair can be performed
based on local practice routines. Some aspects of patient positioning are common to all
RVHR; however, certain key patient and hernia-related factors must be considered.
Patient factors impact positioning, so these issues should be addressed before
placing sterile drapes. In most cases, the patient’s arms are tucked with care to protect intravenous access and provide padding of pressure points. One tip is to avoid
14 Robotic Technique forIntraperitoneal Onlay Mesh (IPOM)
187
bulky anterior and medial padding of the arms, as this may limit access to the lateral
abdominal wall (or ank), a region commonly chosen for trocar placement. When
present, large pendulous breasts can be elevated cephalad and secured with wide
silk tape in a crisscross fashion so that breast tissue is not impacted (or injured) by
robotic arms. Very thin patients, especially those with medium-sized ventral hernias
requiring a lateral trocar position, can be positioned off-center on the operating
table with both arms tucked. This off-center positioning minimizes the risk for collision of the robotic arms against the operating table once docked. For patients with
a short torso (distance between the anterior superior iliac spine and costal margin)
and limited space to insert trocars along the anterior axillary line, it may be benecial to ex the operating table and elongate the torso slightly. Keep in mind that too
much exion of the operating table and elongation of the torso decreases intraperitoneal working space. In some patients, the leg ipsilateral to the operative site may
impede a robotic arm. By pushing both legs together away from the operative site,
a greater angle at the hips allows for more mobility of the inferior robotic arm.
Trocar Placement
Proper trocar placement is important for successful RVHR.Several factors inuence the type, number, and location of trocars placed. The type and size of trocars
may vary by robotic surgical platform, diameter of camera lens, and availability of
instruments. One strategy is to use the fewest number and smallest diameter trocars
that permit a safe, effective operation. At least three trocars are required for RVHR
with IPOM.Most often these trocars are placed along the anterior axillary line in a
staggered fashion, with the camera trocar most posterior. A general rule is to space
these trocars 6–8 cm from one another. A disposable laparoscopic trocar (assist
port) can be placed opposite the robotic trocars when necessary for passage of large
or heavyweight mesh, removal of foreign body mesh, or other assistance. Trocar
location may vary based on patient surgical history, body habitus, torso length, and
hernia size and location (Fig.14.2).
Docking
Docking position depends on the platform model, correct room setup, and hernia
characteristics. The Si and X platforms may need to be arranged in the operating
room on the side opposite the desired location for trocar placement. This simple
docking strategy is effective for midline ventral and incisional hernias, but defects
located in more challenging locations (ank, subxiphoid, suprapubic) may require
alternative docking strategies (Fig.14.2).
In certain situations, parallel docking or alternate-site docking may facilitate
repair of hernias in difcult anatomic positions. For subxiphoid ventral hernia,
RVHR can be performed with trocars placed in the hypogastrium (at or below the
arcuate line). In that case, docking the Si or X platform over the patient’s left or right
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Fig. 14.2 The most
common trocar positioning
for robot-assisted ventral/
incisional hernia repair
with intraperitoneal mesh
using the da Vinci
robotic surgical platform
®
Si
J. G. Bittner et al.
shoulder may facilitate in-line visualization and dissection as well as minimize
robotic arm collisions. Alternatively, the Xi platform can be side-docked without
limiting robotic arm movement. Suprapubic VIH defects can be approached through
trocars placed in the subcostal region. If trocars are placed in the subcostal area, the
Si and X platforms can be docked diagonally from the hip or between the patient’s
legs (low lithotomy position). Again, the Xi platform can be side-docked without
limitations. Flank hernia repair may require adjustments to patient position and
docking. Most often, the robotic surgical platform is side-docked on the side opposite the defect to allow for complete dissection of these challenging hernias. The use
of the patient clearance feature unique to the Xi platform allows for improved range
regardless of hernia location.
Dissection
After correct patient positioning, trocar placement, and docking, RVHR with IPOM
is dependent on careful enterolysis and reduction of hernia content. One tip to
reduce issues with dissection and eventual mesh placement is “ranging the robot,”
which entails inserting all instruments and moving both instruments as far cephalad
and caudad on the ipsilateral side of the camera as possible. The point of “ranging
the robot” is to assure that the surgeon will be able to use both instruments to secure
a sufciently large mesh to the anterior abdominal wall.
14 Robotic Technique forIntraperitoneal Onlay Mesh (IPOM)
189
Peritoneal structures such as the medial umbilical ligaments and falciform ligament as well as an intraperitoneal fat should be dissected free from the anterior
abdominal wall to facilitate localization of mesh. The use of cut current at low voltage is preferred compared to coagulation current for dissection of peritoneum from
fascia. The rationale for this recommendation is that cutting current results in vaporization of tissue making dissection easier and more precise, while coagulation current causes annealing of peritoneum to fascia making separation of tissue more
difcult. During dissection, care is taken to avoid disrupting the posterior fascia.
The operating surgeon may choose to dissect and reduce the hernia sac, though this
is not required. It is the opinion of the authors that any surgeon who attempts more
advanced approaches such as robotic transabdominal preperitoneal (TAPP) VIH
repair or posterior component separation must be procient with RVHR plus IPOM.
Defect Closure
Once enterolysis and dissection of peritoneal structures are complete, the next step
is defect closure. First, the surgeon inspects the linea alba for diastasis recti. It is the
opinion of the authors that diastasis recti should be addressed with VIH repair to
improve postoperative cosmesis, facilitate abdominal wall function, and lower the
risk of hernia recurrence.
Following inspection, the defect is measured to determine appropriate mesh size.
The choice of suture for plication of diastasis recti and defect closure may vary, but
the authors choose slowly absorbable barbed suture (#0 V-Loc™ 180 Wound Closure
Device, Medtronic Inc., Minneapolis, MN) on a GS-21 needle measuring 30–45cm.
Sutures are used according to manufacturer’s instructions for use. Often multiple
sutures are required to plicate the diastasis recti and close the fascial defect. Tips to
facilitate proper fascial approximation include decreasing the pneumoperitoneum to
8–10mmHg, ensuring adequate visualization of the anterior rectus sheath with each
stitch, and adhering to the short-stitch technique (Fig.14.3). When approximating
Fig. 14.3 Robot-assisted
ventral/incisional hernia
repair with fascial defect
closure using absorbable
suture (#0 V-Loc™ 180
Wound Closure Device,
Medtronic, Minneapolis,
MN) on a GS-21 needle.
The small-bite, short-stitch
technique allows for
dispersion of tension
across a larger cumulative
surface area
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J. G. Bittner et al.
diastasis recti, full-thickness stitches of abdominal wall to include anterior rectus
sheath are crucial to medialize the rectus abdominis muscles. To facilitate defect
closure (or diastasis recti plication), pull each self-locking suture through the fascia
after each stitch, rather than throw multiple stitches before pulling suture through the
fascia.
Mesh Placement andFixation
Following fascia approximation, the next step is mesh implantation. For IPOM, the
authors prefer a barrier-coated permanent synthetic mesh (medium- or heavyweight
polypropylene) for most defects. When using barrier-coated permanent synthetic
mesh, there are several keys to ensure the correct size, location, and xation.
Mesh size is determined by hernia defect length and width prior to defect closure. For example, a defect measuring 5cm wide by 10cm long would necessitate
a mesh 15cm wide by 20cm long to ensure adequate overlap. Next, mesh location
is centered about the defect by marking the center of the mesh with a permanent
marker, as well as the long axis of the biomaterial such that both are identiable
during manipulation and implantation. This assures the mesh is not fastened or
secured to the abdominal wall in a location that is off-center to the defect, a technical issue of utmost importance to prevent hernia recurrence. The mesh can be positioned on the anterior abdominal wall using traditional transfascial sutures or with
assistance from a mesh positioning device. Once positioned, monolament suture is
introduced to the peritoneal cavity through the same trocar as the robotic needle
driver. The suture is usually 45cm long, such that the tail of the suture extends out
the robotic trocar and is secured with a hemostat. A needle driver is then inserted for
suturing of mesh to the anterior abdominal wall and the hemostat removed. This
technique facilitates initial stitching of the mesh without excessive suture in the
eld of view. With this technique, it is necessary to remove the needle driver and
insert suture as needed until the mesh is secured to the abdominal wall. Alternatively,
multiple sutures can be placed in the peritoneal cavity at the outset and each suture
used to secure mesh to the anterior abdominal wall.
Finally, the mesh is secured to the anterior abdominal wall using one of several
xation strategies that include suture xation with multiple interrupted transfascial
stitches, circumferential fascial stitches, and/or tacks (absorbable or nonabsorbable). The authors choose circumferential fascial stitches without tacks to avoid
xation options that may be costlier, increase short-term postoperative pain, or
potentially increase hernia recurrence risk. If the mesh is larger than 10×15cm in
size, the authors use additional xation in the form of a midline running stitch that
secures the long axis of the mesh to the linea alba. This tightens the mesh against the
anterior abdominal wall and may decrease the space available for accumulation of
seroma (Fig.14.4).
At the completion of mesh implantation, it is important to inspect for gaps around
the perimeter of the mesh. If there are signicant gaps (≥2cm) between stitches,
additional stitches are warranted to minimize risk for herniation of omentum and/or
14 Robotic Technique forIntraperitoneal Onlay Mesh (IPOM)
Fig. 14.4 Intraperitoneal onlay mesh (Zenapro® Hybrid Hernia Repair Device, Cook Medical,
Bloomington, IN) secured with absorbable fascial sutures (#0 V-Loc™ 180 Wound Closure
Device, Medtronic, Minneapolis, MN) in a circumferential running fashion. An additional stitch
secures the IPOM to the linea alba in an effort to increase mesh-tissue interface and decrease space
for seroma formation
191
bowel, which can lead to incarceration and strangulation in the acute postoperative
period. Once the mesh is secured under tension to the anterior abdominal wall, the
robotic surgical platform is undocked. At this time, the authors recommend closure
of all fascial defects measuring greater than 1cm, which would include all 10–12mm trocar sites; however, there may be reasons to close 8-mm trocar sites, but this
decision is left to the discretion of the operating surgeon.
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