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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_903_Библиотеки_им_академика_М_И_Перельмана.pdf
19 Robotic Transversus Abdominis Release: Tips andTricks
265
a
b
c
Fig. 19.12 Posterior sheath closure tips and tricks. (a) The cut edges are easily identied and lie
below the robotic instruments over the viscera. Closure proceeds using a self-xating absorbable
suture. (b) Any defects made during TAR, including initial trocar sites, are closed with absorbable
suture. (c) Posterior sheath closure begins (and ends) at the level where the peritoneum was left
intact (dashed triangle) above and below the hernia defect; dashed line linea alba, solid line closed
portion of posterior sheath, dotted lines cut edge of posterior sheath to be closed, ra rectus abdominis, ta transversus abdominis, ps posterior sheath
Fig. 19.13 Mesh
deployment tips and tricks.
(a) Mesh is located below
the robotic instruments and
camera. First, identify the
stay suture keeping the
mesh scrolled. (b) Unroll
the mesh across the closed
posterior sheath. (c) Mesh
should reach just beyond
the contralateral trocars to
the abdominal wall
a
266
J. A. Warren and A. M. Carbonell
Fig. 19.13 (continued)
Fig. 19.14 Defect closure
tips and tricks. (a)
Self-xating, absorbable
suture used for closure. In
order to control the loop of
the suture, make the initial
needle throw before
pulling the suture through.
To more rapidly advance
the suture, rst pull
downward with one hand
(b), and then sweep
laterally with the other (c)
b
c
a
b
19 Robotic Transversus Abdominis Release: Tips andTricks
267
Fig. 19.14 (continued)
c
• Make sure to clearly identify the fascia when closing.
• Begin the next throw before pulling the suture through to control the loop and
prevent tangling.
• Pull suture downward with one hand and sweep laterally with the second to prog-
ress suture more quickly.
• Include bites of the hernia sac to imbricate the tissue and decrease the dead
space.
• Decrease pneumoperitoneum.
Outcomes ofrTAR
To date, three studies have been published on this technique. The rst reported outcomes of robotic RM repair with or without TAR compared to standard laparoscopy
[3]. The operative time was signicantly longer for rVHR, and there was a signicantly higher rate of surgical site occurrences (SSO), primarily seroma, following
robotic repair. Despite the signicant difference in complexity and the extent of
musculofascial dissection with rVHR, the median length of stay was still reduced
compared to standard LVHR.In the largest report of robotic RM VHR to date, open
RM repair was compared to robot VHR using a propensity score matched cohort
from the AHSQC [2]. Robotic VHR resulted in a shorter median length of stay.
Fewer surgical site infections (SSI) were also noted, though this did not reach statistical signicance. Finally, the most recent published study compares open to
robotic TAR, again demonstrating a signicantly shorter length of stay. This study
similarly reported a decreased rate of SSI, but was not statistically signicant.
Table19.1 summarizes the current literature on rTAR.
268
Table 19.1 Summary of rTAR outcomes in the published literature
Author
(year)
Warren
(2016)
Carbonell
(2017)
Martin-delCampo
(2017)
rTAR robotic transversus abdominis release, SSI surgical site infection, LOS length of stay, LVHR
laparoscopic ventral hernia repair, ORVHR open retromuscular ventral hernia repair, OTAR open
transversus abdominis release
Comparison
n
group
53 LVHR
(n=103)
111 ORVHR
(n=222)
38 OTAR
(n=76)
rTAR SSI
(%)
2(3.7%) 1(1%) 1* 2*
9 (4%) 2 (2%) 2* 3*
0 (0%) 5 (6.6%) 1.3* 6*
Comparison
group SSI (%)
J. A. Warren and A. M. Carbonell
rTAR
LOS
(days)
Comparison
group LOS
(days)
Future ofrVHR
Robotic retromuscular VHR with or without TAR affords the ability to reestablish
the functional anatomy of the abdominal wall, reinforcing the closure with mesh in
an extraperitoneal sublay position. The optimal patient selection for this technique
or its variants has yet to be fully determined. The extensive dissection of a TAR is
clearly unnecessary for small hernias, and the promising early results may or may
not hold true for signicantly larger defects in high-risk patients. Ongoing clinical
trials hope to address this issue (clinicaltrials.gov, NCT03007758). Several varia-
tions on the above technique have also been used, including a single-dock method
that begins at the lateral aspect of the ipsilateral rectus sheath and then extends
across the midline [3], placing trocars in the upper or lower abdomen in a singledock approach [6, 8], or an extended totally extraperitoneal (eTEP) approach [9].
While early published results of rVHR are quite promising, continuous and critical
evaluation of this technology in hernia repair is needed to gain better understanding
of optimal patient selection, approach, and patient outcomes.
References
1. Rives J, Pire JC, Flament JB, Convers G. Treatment of large eventrations (apropos of 133
cases). Minerva Chir. 1977;32(11):749–56.
2. Carbonell AM, Warren JA, Prabhu AS, Ballecer CD, Janczyk RJ, Herrera J, Huang L-C,
Phillips S, Rosen MJ, Poulose BK.Reducing length of stay using a robotic-assisted approach
for retromuscular ventral hernia repair: a comparative analysis from the americas hernia soci-
ety quality collaborative. Ann Surg. 2018;267(2):210–7.
3. Warren JA, Cobb WS, Ewing JA, Carbonell AM.Standard laparoscopic versus robotic retro-
muscular ventral hernia repair. Surg Endosc. 2017;31(1):324–32.
4. Martin-del-Campo LA, Weltz AS, Belyansky I, Novitsky YW.Comparative analysis of peri-
operative outcomes of robotic versus open transversus abdominis release. Surg Endosc.
2018;32(2):840–5.
19 Robotic Transversus Abdominis Release: Tips andTricks
5. Sugiyama G, Chivukula S, Chung PJ, Alfonso A.Robot-assisted transabdominal preperitoneal
ventral hernia repair. JSLS. 2015;19(4):1–3.
6. Abdalla RZ, Garcia RB, Costa R, Luca C. Procedimento de Rives/Stoppa modicado
robô-assistido para correção de hérnias ventrais da linha média. ABCD Arq Bras Cir Dir.
2012;25(2):129–32.
7. Novitsky YW.Hernia surgery. Berlin: Springer; 2016.
8. Hope WW, Cobb WS, Adrales GL.Textbook of hernia. Berlin: Springer; 2017.
9. Belyansky I, Zahiri HR, Park A.Laparoscopic transversus abdominis release, a novel minimally
invasive approach to complex abdominal wall reconstruction. Surg Innov. 2016;23(2):134–41.
269
Ventral Abdominal Hernia Repair: MIS
Extraperitoneal Repair Techniques: eTEP
20
Rives, MILOS/EMILOS, andOnlay
MIS Repair
FlavioMalcherMartinsde Oliveira,
LeandroTottiCavazzola, AdamS.Weltz,
andIgorBelyansky
Introduction
Minimally invasive surgery (MIS) ventral hernia repairs were rst described by Le
Blanc in 1993 with the laparoscopic approach and an intraperitoneal onlay mesh
(IPOM) implant. The use of IPOM was never the gold standard in open ventral
hernia repairs because of the fear of placing uncoated mesh materials in direct contact with abdominal viscera [1]. The development of laparoscopic techniques
included several modications such as the use of new coated meshes, new xation
devices, and, perhaps most importantly, changes in surgical technique. These technical changes included the abandonment of the traditional onlay and retromuscular/
preperitoneal options. The intraperitoneal era had begun. Laparoscopic techniques
have proven themselves in the last 20years as safe and effective treatments for ventral hernias, despite increased rates of intra-abdominal complications [2].
The adoption of laparoscopic repairs plateaued at approximately 20% of all ventral hernia repairs, despite their noted benets. Several reasons have been postulated, such as increased cost (xation devices) and difcult learning curve.
Advances in MIS ventral hernia repair, such as the robotic platform, have
enhanced the ability to operate on the abdominal wall through fully articulated
F. M. M. de Oliveira (*)
Monteore Medical Center, Bronx, NY, USA
L. T. Cavazzola
Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
A. S. Weltz · I. Belyansky
Department of Surgery, Anne Arundel Medical Center, Annapolis, MD, USA
e-mail: ibelyansky@aahs.org; aweltz@aahs.org
© 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_20
271
272
F. M. M. de Oliveira et al.
instruments and improved optics and visualization. Surgeons quickly began performing MIS repairs without IPOM, returning to traditional techniques such as
onlay and sublay. After robotic surgery ushered this trend, several MIS surgeons
without robotic access began performing these techniques using traditional laparoscopic/endoscopic instruments. In this chapter, we will explore several of these
extraperitoneal techniques.
eTEP
Preoperative Planning andConsiderations
All potential minimally invasive abdominal wall reconstruction candidates must
undergo a comprehensive workup to ensure they are appropriately selected for surgery. This includes a comprehensive past medical and surgical history, physical
exam, and laboratory testing with emphasis placed on screening for absolute and
relative contraindications to the eTEP approach (Table20.1). An up-to-date computed tomography study of the abdomen and pelvis is recommended for effective
preoperative planning [3]. All major comorbidities must be addressed by means of
a multidisciplinary approach before proceeding to the operating room. Preoperative
antibiotics should be properly selected and dosed according to hospital protocol [3,
4]. We recommend routine administration of subcutaneous heparin for DVT pro-
phylaxis in our patient population, beginning prior to the induction of anesthesia
and administered throughout the typical duration of the procedure [5, 6].
Operating Room Setup andPatient Positioning
After induction of general anesthesia, all patients are positioned supine with arms
tucked to the side. A Foley catheter is placed to decompress the bladder. The operating table is exed with the legs extending downward at a minimum of 30° to afford
the surgeon greater instrument range of motion (Fig.20.1). Failure to sufciently
ex the operating table will result in hand collisions with the patient’s body during
dissection.
The enhanced-view totally extraperitoneal (eTEP) access approach was previously described for laparoscopic inguinal hernia repair by Daes in 2012 [7]. This
approach introduced the notion that the extraperitoneal domain is a limitless space
Table 20.1 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 intra-abdominal adhesions
Active mesh infection
20 Ventral Abdominal Hernia Repair: MIS Extraperitoneal Repair Techniques
Fig. 20.1 Positioning of
the patient for laparoscopic
eTEP.Patient is in
Trendelenburg position
with hips extended. Bed
exion is best avoided
273
once the conuence of arcuate line and semilunar line is taken down. This technique
relies on proper anatomic identication and dissection in the naturally occurring
retromuscular spaces. Typically, dissection is initiated in one of the retrorectus
spaces and then crossed 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 [7, 8].
Positioning of the surgeon, monitor, and trocars are dependent on the location of
the hernia defect and decision where to cross the midline. Monitors are placed at the
head of the bed with trocar sites on the lower abdomen when addressing an upper
midline hernia defect and inverted in instances of lower midline hernia defects.
Upper Midline Defect
Figure 20.2 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 the linea semilunaris in the vicinity of the #1 port.
Once the space of Retzius is developed, ports #2 and #3 are placed under direct
vision in the lower abdomen. The site of port #3 can also be used to pass the balloon
space-maker in a cephalad direction to develop the left retrorectus space. Thus, even
before any initiation of sharp dissection, the retromuscular space surrounding the
hernia defect is completely dissected bluntly with the balloon space-maker.
We prefer to perform the crossover below the level of the umbilicus, developing preperitoneal and retromuscular spaces that have not been previously violated.
A 30° scope is placed through port #3 after which we proceed with division of the
274
F. M. M. de Oliveira et al.
Fig. 20.2 Port positioning for upper midline defects. The balloon dissector is placed in port #1.
Ports #2 and #3 are positioned under direct vision. The arrows show the working instruments with
the camera vision demonstrated by the white triangle
medial contributions of the posterior rectus sheath to the linea alba bilaterally
from caudal to cephalad direction. 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 allow us to join the
right and the left retrorectus spaces together with the midline preperitoneal space
(Fig.20.3).
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.20.4). Any defects in the posterior layer can be xed with running
suture. 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.
20 Ventral Abdominal Hernia Repair: MIS Extraperitoneal Repair Techniques
Fig. 20.3 View of the
retrorectus space. After
crossing over and
dissection, the retrorectus
spaces on both sides are
combined into one large
retrorectus space. This
falciform ligament can be
seen below
Fig. 20.4 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
275
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.
Figure20.5 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.20.6). The right posterior rectus sheath is identied and its medial aspect incised and released in a cephalad to
caudal direction followed by blunt dissection in the right retrorectus space
(Fig.20.7). Port #4 is then placed under direct vision through the upper aspect of
right rectus abdominis muscle which is then used as the camera port. The retrorectus dissection is carried out in the caudal direction completing bilateral release
of the posterior rectus sheathes. When encountering the hernia sac, we try to