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34 Plastic Surgery Considerations for Abdominal Wall Reconstruction
259
The deep dermal sutures serve to evert the skin, which is known
to accelerate healing and result in a more favorable scar [55–
57]. A subcuticular layer of absorbable suture is then placed.
Tissue glue may be used as an impervious dressing after the
subcuticular layer [58, 59], or as a replacement for that subcuticular layer altogether [60, 61]. Similarly, staples may be used
to replace the subcuticular layer without loss of quality,
although they tend to be painful to the patient [62].
34.7 Negative Pressure Wound Therapy
34.7.1 Traditional Negative Pressure Wound
Therapy
Fig. 34.5 Central suspension sutures (CSS), placed between the
underlay mesh and the overlying fascia, are placed before fascial closure and tied afterwards, in order to ensure close apposition of the mesh
to the fascia
34.5 Tissue Expansion
Initially developed by Neumann [49], then popularized by
Radovan [50], tissue expansion is one of the most useful
rungs of the reconstructive ladder. Tissue expansion is capable of stimulating mitotic activity and collagen synthesis to
generate new tissue [51]. It also improves the vascularity of
the expanded tissue by stimulating angiogenesis [52].
Tissue expansion is usually used in abdominal wall reconstruction in cases where there is a deficit of skin and subcutaneous tissue [53]. This is often the case in thin patients, and
those with significant wounds, ulcerations, or skin grafts on
viscera. The reconstruction involves at least two stages: in
the first stage, an incision is made adjacent to the anticipated
skin defect and a subcutaneous plane is developed to place
the tissue expander. Expansion then is undertaken in the outpatient clinic environment until sufficient tissue is available,
and a second stage procedure is performed where the tissue
expander is removed, the tissue transposed to establish soft
tissue coverage, and the hernia repaired.
34.6 Skin Closure Techniques
and Technology
In abdominal wall reconstruction, especially in cases where
mesh is used, meticulous closure is essential to ensure adequate
healing of the incision and to prevent exposure/infection of the
mesh and potential loss of the entire reconstruction. A layered
closure is essential to offload tension off the skin [54]. Most
surgeons agree that the Scarpa’s layer should be closed with
absorbable sutures, followed by closure of the deep dermis.
In wounds that are too contaminated to close, or in cases of
postoperative dehiscence, the application of negative pressure wound therapy (NPWT) has the potential to accelerate
healing compared to standard dressings. It has been shown
that NPWT increases blood flow, enhances granulation tissue formation, and decreases bacterial counts in wounds
[63]. It has also been demonstrated that NPWT modulates
the cytokines in the wound to an anti-inflammatory profile
that is conducive to healing [64], and applies microstrain to
wound cells that culminates in enhanced cellular proliferation and angiogenesis [65]. Many surgeons use NPWT
mainly to salvage exposed mesh (particularly biologic mesh)
in cases of dehiscence. There is growing evidence, however,
that some synthetic meshes, namely macroporous, monofilament light, and mid-weight polypropylene meshes can also
be successfully salvaged in certain circumstances with
NPWT in cases of exposure and contamination [66].
34.7.2 Incisional Negative Pressure Wound Therapy
The application of NPWT over closed incisions is a novel
tool that has been added to the armamentarium of the surgeon performing abdominal wall reconstruction [67].
Incisional NPWT, applied for 5–7 days over high-risk
abdominal incisions, has been proven to reduce the risk of
wound healing complications from 63.6 to 22 %, and the risk
of dehiscence from 39 to 9 %, compared to standard dressings [68]. It has also been shown to reduce the risk of
surgical- site infection by two-thirds [69]. Similar results
have been demonstrated in high-risk patients undergoing
median sternotomies [15], groin vascular surgery incisions
[70], and fixation of lower extremity fractures [71]. One of
the common findings in most studies on incisional NPWT is
its ability to reduce seroma formation [72], which does not
appear to be related to a direct suction effect, but rather to
enhanced lymphatic clearance [73].
260
Fig. 34.6 In the string-ofpearls, French fry technique
the incision is closed
intermittently, and struts of
polyurethane foam are placed
in the open parts, then
connected with a foam
crossbar
I. Khansa et al.
34.7.3 Putting It All Together: The String-ofPearls Technique
As described above, the application of NPWT to both open
wounds and closed incisions offers distinct advantages. One
technique that we have employed in very high-risk patients,
termed the “String-of-Pearls, French Fry Technique,” takes
advantage of the benefits of open and incisional NPWT
(Fig. 34.6). At the completion of the hernia repair, the skin incision is closed intermittently. The closure consists of 2-0 polyglactin in the Scarpa’s fascia, followed by 3-0 poliglecaprone
in the deep dermis then either staples or a subcuticular running
4-0 poliglecaprone. Intermittent closure for 5 cm, interspersed
with open areas measuring 5 cm, is performed. The closed
parts of the incision are covered with a non- adherent dressing
such as Xeroform (Covidien, Mansfield, MA) or Adaptic
(Johnson & Johnson, New Brunswick, NJ). Struts of polyurethane foam are then cut and inserted into the open areas all the
way to the abdominal fascia, and connected over the closed
incisions with a foam “crossbar.” Adhesive is then applied, and
seal obtained at 125 mmHg of continuous suction.
The “String-of-Pearls, French Fry” technique allows partial closure of the wound, aggressive removal of effluent, and
a delayed primary closure of the open areas left within the
incision, which accelerates eventual wound healing. The
foam struts help improve blood flow to the open parts of the
wound. In essence, it facilitates the management of high-risk
incisions by achieving a controlled dehiscence.
34.8 Conclusion
Careful management of the skin and soft tissue of the abdominal wall is essential to achieving low complication rates,
and high patient satisfaction, after complex hernia repair.
The vascularity of the skin and soft tissue must remain a priority in the mind of the surgeon, from the beginning of the
operation when the perforators are encountered, to the conclusion of the operation when the skin is closed.
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Robotic Transabdominal Preperitoneal (rTAPP) Hernia Repair for Ventral Hernias
Conrad Ballecer and Alexandra Weir
35.1 Introduction
Robotic hernia repair is an emerging technique born from
well-established principles of both laparoscopic and open
ventral hernia repair. Its growing popularity in the United
States perhaps can be explained by enhanced 3D visualization, precision, and ergonomics. There are also inherent limitations of conventional laparoscopy which make it difficult
operating high on the anterior abdominal wall, many of which
may be overcome with the use of the robotic instrument.
There is a growing body of literature which promotes
keeping mesh out of the intraperitoneal cavity secondary to
bowel erosion and adhesions which may complicate subsequent abdominal operations [1, 2]. The robotic platform
enables exploitation of the individual layers of the abdominal
wall. Virtually any well-established surgical plane of the
abdominal wall can be exploited and dissected for the subsequent placement of mesh in a sublay position, effectively protected from the visceral cavity by the body’s own autologous
tissue. While this approach has been demonstrated with conventional laparoscopy, it remains technically challenging [3].
In this chapter, we introduce the robotic transabdominal
preperitoneal (rTAPP) approach for hernias of the anterior
abdominal wall.
35
the transversalis fascia, the hernia sac is reduced, and a mesh
is placed within this retroinguinal space. For hernias of the
anterior abdominal wall, preperitoneal mesh size is based on
the original size of the defect and adheres to the wellestablished principles of maintaining 5 cm overlap in all
directions.
This approach is best suited for smaller or medium size
hernias that do not require component separation and can
include hernias in atypical locations such as flank, suprapubic, retrosternal, and subxiphoid defects.
The authors feel that there are many advantages to placing mesh in a preperitoneal position:
1. Eliminates the requirement for placing coated intraperito-
neal mesh (IPOM).
2. Allows the mesh to incorporate on both faces, eliminat-
ing placement of full-thickness transfascial suture fixation which is associated with both acute and chronic pain
[4, 5].
3. Minimizes complications associated with leaving mesh in
an intraperitoneal position, i.e., adhesions and bowel
fistula.
35.1.2 Preoperative Considerations
Obtaining a thorough history and physical is mandatory to
35.1.1 Surgical Anatomy
It is critical to have a thorough understanding of the layers of
the abdominal wall in order to properly execute this technique. The technique of r-TAPP ventral hernia repair is borrowed from conventional laparoscopic TAPP for inguinal
hernias in which the peritoneum is incised and dissected off
C. Ballecer, M.D., M.S., F.A.C.S. • A. Weir, M.D. (*)
Department of Surgery, Maricopa Integrated Health System,
2601 East Roosevelt Street, Phoenix, AZ 85008, USA
e-mail: cballecer1@mac.com; Alexandra.Weir@mihs.org
© Springer International Publishing Switzerland 2017
W.W. Hope et al. (eds.), Textbook of Hernia, DOI 10.1007/978-3-319-43045-4_35
coordinate and execute an effective preoperative plan.
Specifically, certain comorbidities, such as diabetes, obesity,
smoking, prior hernia repairs, and prior history of abdominal
wall infection, may critically affect the approach as well as
the risk/benefit ratio for surgical intervention versus watchful waiting. The majority of primary umbilical hernias
detected on physical exam warrant no preoperative further
work-up.
CT scan of the abdomen and pelvis may be ordered for
atypical hernias or small to moderate incisional hernias in
order to correctly diagnose and delineate the size, position,
as well as the content of the hernia defect.
263
264
C. Ballecer and A. Weir
35.2 r-TAPP Hernia Repair for Umbilical or Small Mid-Abdominal Incisional Hernia Repair
35.2.1 Patient Positioning
Patients with small mid-abdominal midline defects are positioned supine with the arms tucked unless trocar access to
the lateral abdomen is obscured by the position of the tucked
arm. In this situation, the arm is abducted 90° from the trunk.
In patients with small torsos, it is helpful to position the
patient under the kidney rest at the level of the umbilicus
(Fig. 35.1). After obtaining safe intraperitoneal access, the
kidney rest is raised which increases the distance between
the costal margin and the anterior superior iliac spine. This
allows for port placement with adequate separation. Patient
positioning must be performed prior to docking of the robot.
Foley catheterization is not generally required unless the surgeon expects a prolonged case or the hernia defect extends to
the lower abdomen.
35.2.2 Port Positioning, Docking, and Instrumentation
The positioning of ports is similar to conventional laparoscopy (Fig. 35.2). It is important to place the trocars as far
from the defect as possible without sacrificing range of
motion based on potential collisions with the upper and
lower extremities.
The first step in any minimally invasive surgery is to gain
safe intra-abdominal access which may be difficult in the
multiply operated abdomen. Sites of previous operative
intervention will certainly influence the strategy. Optical
entry with a 5 mm trocar at Palmer’s point with or without
initial Veress needle insufflation in the left upper quadrant is
generally safe.
A 12 or 8 mm trocar for the camera is placed as far lateral
to the ipsilateral edge of the defect. As a general rule we
place the camera trocar a minimum of 15 cm away from the
ipsilateral edge of the hernia defect. This allows for visualization, dissection, and instrumentation on the side closest to
the ports. An 8 mm robotic trocar is placed in the lower lateral abdomen and the initial 5 mm optical trocar is then
replaced with an 8 mm trocar. Final configuration of the trocars for an SI robot is typically in a V configuration
(Fig. 35.2). Additional trocars on the contralateral abdomen
or an assist trocar is typically unnecessary, but this may vary
depending on surgeon comfort.
Once ports are placed and positioning is satisfactory, the
robot is docked directly over the lateral abdomen and in line
with the trocar sites (Fig. 35.3). Instrumentation consists of a
grasper, monopolar scissors, and a needle driver. A 30° up
scope is used to begin the case and may need to be switched
to a 0 or 30° down when progressing to the contralateral
abdomen.
35.2.3 Adhesiolysis and Developing
a Preperitoneal Plane
As with conventional laparoscopy, the anterior abdominal
wall is cleared of all adhesions to delineate the full extent
of the defect as well as uncover any other sites of herniation. This must be performed meticulously to avoid not
only injury to intraperitoneal viscera, but also to avoid
injury to the peritoneum which may complicate preperitoneal dissection. If bowel manipulation is required, a lower
grip strength grasper is utilized to avoid iatrogenic serosal
injury.
Starting a minimum of 5 cm from the edge of the defect
the peritoneum is incised using scissors (Fig. 35.4). This will
allow for the placement of mesh with a minimum of 5 cm
overlap on the side ipsilateral to the working ports. The ideal
Fig. 35.1 Kidney rest positioning
35 Robotic Transabdominal Preperitoneal (rTAPP) Hernia Repair for Ventral Hernias
Fig. 35.2 rTAPP port position
265
Fig. 35.3 rTAPP docking for midline abdominal wall hernias
location to start the incision is often made within the visible
preperitoneal fat that underlies the rectus muscle. The plane
for dissection is more easily entered in this manner without
causing disruption of the overlying posterior sheath. The preperitoneal plane is developed widely in a cephalad to caudad
direction with a combination of meticulous blunt and sharp
dissection. Sweeping with the blunt edge of the scissors is an
effective technique to separate the peritoneum off the posterior sheath. Cautery is judiciously applied so as to avoid thermal injury which may result in peritoneal defects. The hernia
sac is reduced and further dissection continues laterally
(Fig. 35.5). Wide preperitoneal dissection is performed to
allow for the placement of a large mesh based on the original
Fig. 35.4 Peritoneal incision
Fig. 35.5 Reducing the hernia sac
266
Fig. 35.6 (a) Preperitoneal dissection; (b) preperitoneal dissection
C. Ballecer and A. Weir
Fig. 35.7 (a) Primary defect closure; (b) primary defect closure
size of the defect (Fig. 35.6a, b). If the preperitoneal space is
deemed inaccessible, the procedure may be converted to
placement of an intraperitoneal coated mesh subsequent to
primary closure of the defect.
35.2.4 Primary Closure of Defect
After the preperitoneal space is widely dissected, the hernia
defect is primarily closed with absorbable barbed suture in a
running fashion (Fig. 35.7a, b). The subcutaneous tissue situated at the dome of the defect is incorporated within the primary closure, effectively obliterating the anterior dead space
in order to minimize the risk of seroma formation. Desufflation
of the abdominal cavity to a pressure of 6–8 mmHg may
facilitate primary closure.
35.2.5 Mesh Placement, Fixation,
and Reperitonealization
An appropriately sized uncoated mesh is introduced into
the abdominal cavity via the 8 mm trocar. The mesh is
placed flat against the abdominal wall and fixated with
either tacks or sutures placed at cardinal points
(Fig. 35.8a, b). A minimum of fixation points are used to
accomplish flat approximation of mesh against the
abdominal wall.
Following adequate fixation, the peritoneum is reapproximated to completely cover the mesh with either running suture or tacks (Fig. 35.9a, b). Peritoneal rents should
be repaired so as to not leave mesh exposed to the visceral
content. All port sites 10 mm or greater are closed with
absorbable suture.
35 Robotic Transabdominal Preperitoneal (rTAPP) Hernia Repair for Ventral Hernias
Fig. 35.8 (a) Mesh placement and fixation; (b) mesh placement and fixation
267
Fig. 35.9 (a) Tack reperitonealization of mesh; (b) suture reperitonealization of mesh
adequately sized mesh which extends well beyond the area
35.3 rTAPP Repair of Atypical Hernias
35.3.1 Introduction
Atypical hernias such as suprapubic and retrosternal hernias
are classically more difficult to repair due to anatomical constraints in dissection as well as limited points of fixation due
to bony prominences. Wide preperitoneal dissection is
required to gain adequate overlap of reinforcing mesh following defect closure. Suprapubic hernias require wide dissection of the retropubic space, bladder mobilization, and
entry into the space of Retzius.
35.4 rTAPP Repair of Suprapubic Hernias
of the parietal defect. This may require exposure of the
myopectineal orifice bilaterally in order to achieve 5 cm
overlap in all directions. Therefore, a thorough comprehension of the anatomy of these spaces is required to both minimize the potential for injury and execute a durable repair
which minimizes the risk of recurrence.
The patient is placed in supine lithotomy position with both
arms tucked. A three-way Foley is placed to distend the bladder
for proper identification. The camera port is placed at least
15 cm above the cephalad aspect of the suprapubic defect. Two
instrument ports are placed in line with the camera trocar
(Fig. 35.10). The patient is placed in a Trendelenburg position
and the robot is docked between the legs which enables complete evaluation and dissection of the right and left retropubic
spaces (Fig. 35.11).
35.4.1 Patient Positioning, Trocar Placement, and Docking
The repair of suprapubic hernias require a wide dissection
of the retropubic and Retzius space to accommodate an
35.4.2 Operative Steps
A preperitoneal plane is incised a minimum of 5 cm cephalad
to the superior aspect of the hernia defect. Dissection is carried
268
Fig. 35.10 Port position and docking for suprapubic hernias Fig. 35.11 Docking for suprapubic hernias
widely, encompassing at minimum both the right and left lateral umbilical ligaments in order to accommodate a large sheet
of overlapping mesh.
The hernia sac is encountered and reduced. The superior
dome of the bladder may occupy the hernia sac and therefore, careful dissection is performed to avoid bladder injury.
Proper identification of the bladder is facilitated by instilling
200–300 cc of saline into the bladder (Fig. 35.12). The retroinguinal space (space of Bogros) is developed bilaterally to
expose Cooper’s ligament. Posterior mobilization of the
bladder reveals the space of Retzius (Fig. 35.13). This space
can be dissected inferiorly to insure adequate overlap of
mesh inferior to the caudal aspect of the hernia defect. For
larger suprapubic hernias, the bilateral retropubic spaces are
exposed (Fig. 35.14a, b).
The hernia defect is primarily closed with running barbed
suture (Fig. 35.15). Partial desufflation of the abdominal
Fig. 35.12 Bladder distension
cavity may be required to facilitate defect closure. The space
of preperitoneal dissection is then measured and an adequately sized mesh is introduced into the preperitoneal space.
Absorbable tacks or sutures are placed to secure the mesh to
the abdominal wall. A series of interrupted sutures are used
to secure the mesh to Cooper’s ligament bilaterally, as well
as the symphysis pubis (Fig. 35.16). Upon completion of
mesh fixation, the mesh is reperitonealized with running
suture or tacks.
C. Ballecer and A. Weir
35.5 rTAPP Repair of Morgagni Hernias
35.5.1 Clinical Anatomy
As the rTAPP approach can be employed for hernias of the
lower abdomen, upper abdominal hernias are amenable to
the robotic preperitoneal technique. To illustrate this versa-
Fig. 35.13 Space of Retzius