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48 Social Media and Education in Hernia Repair
379
will be slow to be accepted and used. I am a devotee but the
struggle for access is tiring.
Mentorship is the way to move forward. I think the company
have quality accessible surgeons who are willing to teach.
Should be regionalized with the epicenters mentoring in their
region. Then eventually have local guy at each hospital. Once
taught and through their learning curve, partners can teach each
other. Etc, etc. This can be done with industry (mesh, robot)
working with societies (SAGES, ACS, IHC, CRSA). I agree
with ********* that it needs to be done safely and MIS surgeons should be targeted first who will more quickly adopt this
MIS approach. No reason industry and societies can’t work
together for the greater good.
Seeing the failure and success stories of different products
will enable those in industry to make changes and improve.
Assessment of physician attitudes towards new technology
or materials, techniques, etc. through discussions on the
forum, rather than the formal surveys which are often
employed, could bring out broader opinions than those
offered in multiple choice, preselected answer choices. A
discussion about the pros and cons of a new technology or
product—more like a focus group—can generate both qualitative data and quantitative data. The distribution of opinions
(i.e., mostly positive or mostly negative) can be analyzed
across different regions, different hospital/patient population
types, physician age or experience level, etc. Additionally
one can gain insight into why a particular technology is not
being adopted in a certain location—i.e., hospital policy,
physician reluctance, lack of advertising or awareness, etc.—
without the time and money required for focus groups.
In addition to enabling collaboration with medical industry members, the IHC has enabled discussion of translational
research through consultation between surgeons and basic
scientists. In a recent post, members gave feedback to a bioengineer testing physical properties of meshes as to what
studies would be of the most help to their field:
I am a bioengineer at **************. We have developed a
new biomechanical test method for hernia grafts that we think is
more clinically-relevant than the conventional tests. In essence,
we test the grafts as sutured patch-shaped constructs (as opposed
to clamped specimens) to model in vivo loading. We found that
the graft-fixation method and test mode (ball-burst or planar-
biaxial) affect graft biomechanics. I now have a summer student
and I am planning to have him test a few more meshes to gener-
ate some comparative data that would be of potential interest to
hernia surgeons. I’d to get a feel from this group what meshes
(synthetic and biologic) would you want to know more about.
Thank you!—6/12/15, 13 comments
48.8 Conclusion
Social media is a rapidly growing means of networking and
communication amongst medical professionals, and has
potential as a forum for discussion, transmission of knowl-
edge, and continuing medical education. The International
Hernia Collaboration Facebook™ Group has revolutionized
the way surgeons collaborate globally. By embracing social
media as a collaborative forum designed to provide quality
improvement, surgeons are more effectively and transparently obtaining immediate global feedback that in turn is
improving both patient outcomes and the quality of care that
surgeons provide to their patients. We have witnessed the
beginning of the disruption and evolution of the current standards being used today to provide ongoing healthcare education and quality improvement. Dozens of new medical and
surgical Facebook™ groups and other social media collaboratives have since begun and continue to grow. Just scratching the surface, collaboration and education through user
generated social media sites is just the beginning of a paradigm shift in ongoing quality improvement efforts.
References
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update 2014. Pew Research Center: Internet, Science & Tech. 2015.
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Raphaeli T, Kelz RR. Social media is a necessary component of
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s12909-015-0435-x.
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education by enhancing interactivity: lessons from Iran. J Adv Med
Educ Prof. 2016;4(2):54–63.
Robotic Ventral Hernia Repair
Jeremy A. Warren and A.M. Carbonell
49.1 Introduction
The optimal surgical approach for the repair of ventral
incisional hernias remains a subject of considerable debate.
Use of a minimally invasive or open approach, combined
with a variety of mesh choices, positions in the abdominal
wall, and fixation constructs, produces numerous options for
repair and makes direct comparisons impossible. The RivesStoppa technique is widely considered the gold standard for
open VHR, and is our preferred open technique. This is performed by incising the posterior rectus sheath in order to
enter the retrorectus plane, dissecting the posterior rectus
fascia from the overlying muscle laterally until the semilunar
line is reached, followed by complete closure of the posterior
fascia, placement of mesh behind the rectus muscle over the
closed posterior fascia, and reapproximation of the anterior
fascia. Advantages of this approach include placement of
mesh in a well-vascularized, contained compartment separate from the viscera, and restoration of native functional
anatomy. However, wound morbidity remains problematic,
and mesh selection varies widely. While wound complications are significantly decreased with laparoscopy, this
approach requires intraperitoneal placement of mesh, and is
limited in its ability to restore the functional anatomy of the
abdominal wall. The long-term outcomes of intraperitoneal
mesh are poorly studied. Despite multiple available barrier
coatings designed to prevent adhesions, subsequent abdominal operations are necessary in up to 25 % of patients, and
the presence of intraperitoneal mesh increases the complexity of those operations and creates a higher risk of secondary
J.A. Warren (*)
University of South Caroline School of Medicine Greenville,
Greenville, SC, USA
e-mail: jwarrenmd@ghs.org
A.M. Carbonell
Department of Surgery, Greenville Health System, University of
South Carolina School of Medicine, Greenville, SC, USA
49
mesh complications. Reoperation is associated with longer
operative times, potential for secondary mesh infection, and
incidence of enterotomy or unplanned bowel resection in as
many as 20 % of cases [1–4]. Our technique for robotic retromuscular VHR (rRMVHR) utilizes the robotic platform to
replicate the open retromuscular hernia repair with a minimally invasive approach, conferring the benefits of both the
traditional Rives-Stoppa repair with those of laparoscopy,
while minimizing the negatives of each approach [5].
49.2 Overview of Current Literature
The use of the robot for ventral hernia repair was first
reported in 2003. Ballantyne reported two patients with
small defects repaired telerobotically using a standard intraperitoneal placement of mesh [6]. Using a porcine model,
Schluender also described the technique for intraperitoneal
mesh repair, focusing on intracorporeal suturing of the mesh
to the abdominal wall as a means of potentially reducing
postoperative pain associated with traditional tacking devices
and transfascial sutures used to secure mesh during laparoscopic VHR [7]. There has been very limited adoption of this
technique since these initial descriptions, however, with only
a handful of small case series published. The first series
reporting outcomes of rVHR included 11 patients repaired
with intraperitoneal mesh placement and exclusive intracorporeal suturing of the mesh [8]. Three complications
occurred (27 %), including a trocar site hernia, postoperative
ileus, and unrecognized enterotomy. In 2012, Allison et al.
reported a series of 13 patients with a similar technique, with
routine closure of the hernia defect intracorporeally followed
by intraperitoneal mesh placement [9]. One patient developed a recurrence, one had postoperative urinary retention,
and two had prolonged hospitalizations for pain control. The
largest series published to date reports a hybrid laparoscopicrobotic approach comparing 67 patients repaired using a
totally laparoscopic approach to 67 patients whose hernia
defect was closed robotically. In all cases, mesh was placed
W.W. Hope et al. (eds.), Textbook of Hernia, DOI 10.1007/978-3-319-43045-4_49
381© Springer International Publishing Switzerland 2017
382
J.A. Warren and A.M. Carbonell
intraperitoneally and secured with tacks, followed by either
transabdominal sutures in the laparoscopic non-closure
group, or with intracorporeally placed sutures to the
abdominal wall in the robotic group. Overall, there was no
difference between groups other than longer operative time
required for defect closure, though there was a trend toward
lower complications and recurrences when robotic defect
closure was performed [10]. Robotic preperitoneal repair
was performed in three patients reported by Sugiyama et al.
with no complications in short term follow-up [11]. Finally,
Abdallah et al. reported the first use of the robot to perform a
retromuscular hernia repair in five patients with small hernia
defects associated with diastasis rectus. This approach
involved a suprapubic docking position and transabdominal
trocar placement, with dissection of the posterior rectus
sheath from the overlying rectus muscle, similar to the RivesStoppa repair [12]. The report of this novel approach, which
allows replication of an open retromuscular VHR with a
minimally invasive approach, had a significant impact on the
development of our current technique.
49.3 Patient Selection
Though literature is currently sparse on robotic hernia repair,
the well-recognized benefits of minimally invasive surgery in
patients at high risk for wound complications, such as the
morbidly obese, smokers, and diabetics, are applicable to
rVHR. There are limitations to this approach, however.
Patients with poor skin and soft tissue integrity, such as those
with a prior skin graft, a widened scar from previous wound
complications, chronic wounds, or poor cosmesis will likely
still require an open repair. Defect size and the compliance of
the abdominal wall, best assessed by physical exam, are
important to determine if the defect can be closed robotically.
The largest total defect closed in our series was 20 cm, which
involved both a midline and lateral hernia defect; the largest
single defect closed was 15 cm. Defects larger than 8 cm
require a double-dock approach with bilateral transversus
abdominis release (TAR) as described below. For smaller
defects, typically less than 5 cm, a single-dock preperitoneal
approach is preferred, as there is less tension on the defect
closure and myofascial release is not usually required. Midsized defects, typically up to 8 cm, are approached with a
single-dock retromuscular technique. This avoids an unnecessary TAR for a small to moderate sized defect, but still affords
a myofascial release to more easily reapproximate the anterior
fascial defect. These are very general guidelines, and the ultimate decision on which approach will be used is typically
made in the operating room after initial abdominal insufflation, when the true extent of the hernia defect can be assessed.
49.4 Surgical Technique
As with any novel surgical technique, ours has evolved with
increased experience. Given the heterogeneous morphology
of hernias, one approach does not necessarily fit every hernia. Defect size, location, and patient body habitus all play a
role in the setup and execution of robotic hernia repair. Our
initial experience emulated the setup described by Abdallah,
docking the robot in the upper or lower midline to approach
hernias in the opposite extreme of the abdomen. In order to
apply this approach to infraumbilical defects, a lateral dock
was necessary. However, management of the dissected posterior sheath flaps, docking from both sides of the abdomen
separately, and working against the tension of pneumoperitoneum were barriers to broader applicability of the robot to
VHR. To address these differences in hernia characteristics
and the technical difficulties encountered, our technique has
progressed to include four separate approaches, each tailored
to the patient and hernia characteristics, and each adhering
to the same principles of the Rives-Stoppa retromuscular
hernia repair.
49.5 Double-Dock Approach
The patient is placed in a supine position with arms out. The
operative table is flexed slightly to open the angle between
the iliac crest and costal margin, and positioned at approximately 45° from anesthesia to allow the robot access to the
left side of the patient for docking (Fig. 49.1). Intraperitoneal
access is obtained using a 5 mm optical viewing trocar at the
right subcostal space. Pneumoperitoneum is established at
15 mmHg of carbon dioxide (CO2) and a long 12 mm optical
trocar is placed midway between the costal margin and iliac
crest as laterally as possible, typically along the mid-axillary
line. A balloon tipped trocar is useful to avoid retraction of
the trocar into the abdominal wall or subcutaneous space.
Two long 8 × 160 mm robotic trocars are placed at the costal
margin and over the iliac crest, the subcostal one typically
replacing the initial optical entry 5 mm trocar (Fig. 49.2a).
The longer 160 mm trocars are used regardless of the size of
the patient, as this provides additional clearance of the
robotic arms away from the patient, and allows greater flexibility for advancing the robotic instruments into the extremes
of the abdominal cavity. The robot is docked with the center
column of the patient cart aligned with the hip or upper thigh
(Fig. 49.2b, c). This allows more space between the robot
and the patient arm for the bedside assistant.
After completing any necessary adhesiolysis, the retromuscular dissection is initiated by incising the posterior rectus sheath about 5 mm lateral to the linea alba, typically
49 Robotic Ventral Hernia Repair
Fig. 49.1 Operative setup for rVHR. (a) Operative table turned 45° from anesthesia cart, with laparoscopic tower on the patients’ right, the robotic
patient cart on the patients’ left, and robotic vision cart at the feet. (b) Bed flexes to open angle between costal margin and iliac crest
383
beginning within the bounds of the hernia defect. The
retromuscular plane is developed laterally to the linea semilunaris and vertically at least 5 cm above and below the hernia defect (Fig. 49.3). The linea semilunaris can be identified
by the segmental neurovascular bundles that penetrate the
lateral posterior sheath to innervate the rectus muscle. They
course laterally between the internal oblique muscle anteriorly and the transversus abdominis muscle posteriorly, and
are a critical landmark when initiating the transversus
abdominis release. Additionally, the insertion of the obliques
onto the lateral rectus sheath can be visualized as a dense
fascial condensation lateral to the neurovascular bundles,
and will distract the rectus muscle downward when posterior
retraction is applied to the posterior sheath. Care should be
taken not to damage the linea semilunaris, as this could lead
to dissection of an interparietal plane between internal
oblique and transversus abdominis, internal oblique and
external oblique, or even a complete disconnection of the
oblique complex from the rectus sheath, resulting in a lateral
iatrogenic hernia.
The midline dissection superior and inferior to the defect
is critically important to create adequate space for mesh
overlap. The preperitoneal space above and below the hernia
defect along the midline must be developed for a distance of
at least 5 cm. The posterior sheath insertion onto the linea
alba is then divided in order to create a continuous space
from the contralateral retrorectus space to the ipsilateral retromuscular space, leaving the linea alba intact. While this
portion of the dissection typically begins on the patients’ left
side, it is easiest to complete from the right side after beginning the contralateral retromuscular dissection (Fig. 49.4).
A transversus abdominis myofascial release is performed
by dividing the transversus abdominis fascia and muscle
beginning just medial to the segmental neurovascular bun-
Fig. 49.2 Trocar placement and docking for rVHR. (a) Trocars placed
laterally. (b) Center column of robotic cart aligned over the patients’
hip. (c) Docked in standard fashion
dles, allowing continued lateral dissection in the preperitoneal or pretransversalis fascia plane (Fig. 49.5a, b). Dis sec tion
is continued to approximately the anterior- to mid-axillary
384
J.A. Warren and A.M. Carbonell
Fig. 49.3 Initiation of retromuscular dissection. (a) Posterior rectus
sheath incision just lateral to linea alba on the left. (b) Cross-sectional
schematic of same. (c) Retromuscular dissection extended to semilunar
Fig. 49.4 Dissection of the midline above the hernia defect. ra rectus
abdominis muscle, hd hernia defect, la linea alba, p peritoneum, ps posterior rectus sheath inserting onto the linea alba
line, and three additional trocars are placed into the dissected
space in the left abdomen in a mirror image to the right side
(Fig. 49.5c–e). A metric ruler is used to intracorporeally measure both the hernia defect height and width, and the extent
of the dissected space. The height of the dissected space will
correspond to the length of mesh required for repair. The left
half of the dissected space is measured and assumed to be
equal to half of the needed mesh width. This can be easily
accomplished by laying the ruler on the posterior sheath,
which is now lying over the viscera posteriorly, and passing
a spinal needle through the abdominal wall at the left lateral
edge of the hernia defect (Fig. 49.6).
line. (d) Cross-sectional schematic of same. ra rectus abdominis muscle, hd hernia defect, ps posterior rectus sheath, nv neurovascular
bundle
We prefer a mid-weight, large pore, polypropylene mesh
for repair. An appropriately sized mesh is selected, cut to our
measured dimensions, rolled along its vertical axis, secured
loosely with a single suture, and placed into the retromuscular space. This is secured just lateral to the nascent left-sided
trocars with suture or absorbable tacks (Fig. 49.7). The
patient is then repositioned and the robot docked on the
opposite side. Dissection is carried out on the right side in
the same fashion as the left to complete the bilateral retromuscular and transversus abdominis flaps. As the right retromuscular space is opened, the midline dissection above and
below the defect is easily completed (Fig. 49.4). Dissection
is carried out until the initially placed trocars are brought
into the retromuscular space. The posterior fascial defect is
then closed with a running self-fixating, slowly absorbable
2-0 suture, thereby closing the visceral sac (Fig. 49.8a, b).
The mesh is unrolled across the closed posterior sheath and
affixed to the right lateral abdominal wall just beyond the
initially placed trocars, again using suture or tacks (Fig. 49.8c,
d). The anterior fascial defect is closed using a self-fixating,
slowly absorbable #1 suture in a running fashion for completion of the hernia repair (Fig. 49.9). It is often helpful to
decrease the pneumoperitoneum to accommodate defect closure, particularly for larger defects. When possible, intermittent bites of the overlying hernia sac are included in the
closure, imbricating the hernia sac and thus obliterating the
dead space.
49 Robotic Ventral Hernia Repair
385
Fig. 49.5 Transversus abdominis myofascial release (TAR). (a) Initiation
of the transversus abdominis release (TAR) by incising the TA fascia and
muscle to enter the preperitoneal plane. (b) Extension of the TAR inferiorly along the aponeurotic portion of the TA. Cut edge of the TA denoted
by arrow. (c) Lateral extension of the TAR to the mid- axillary line.
49.6 Single-Dock Techniques
49.6.1 Single-Dock Retromuscular Repair
Smaller and mid-sized defects can often be approached
using a single-dock approach. The patient is positioned and
room set up in identical fashion. Rather than beginning the
retromuscular dissection on the contralateral side, the lateral
aspect of the right rectus sheath is incised to gain access to
the ipsilateral retrorectus space. Dissection is continued
from lateral to medial until the linea alba or lateral edge of
the hernia defect is encountered. The posterior sheath is
(d) Contralateral ports placed in mirror image fashion into the dissected
preperitoneal space. (e) Cross-sectional schematic of same. ra rectus
abdominis muscle, nv neurovascular bundle, ta transversus abdominis
muscle, p peritoneum, tf transversalis fascia, ps/p posterior flap comprising posterior rectus sheath medially and peritoneum laterally
incised to enter the preperitoneal space along the midline,
including dissection around and reduction of the midline
hernia sac. Once across the midline, the left posterior sheath
is incised in identical fashion as described above, and dissection completed to the left semilunar line. Here the
sequence differs slightly. The anterior fascial defect is
closed first, followed by placement of the mesh against the
anterior abdominal wall. Defect closure, intracorporeal
measurements, mesh sizing, and mesh fixation are all similar to that described above. Once the mesh is fixated, the
posterior sheath is closed to completely cover the mesh.
Figures 49.10 and 49.11 depict the single-dock retromuscular technique.
386
Fig. 49.6 Intracorporeal measurement of the hernia defect and dissected space for subsequent mesh placement. (a) Measurement of hernia width. (b) Measurement of hernia length and dissected vertical
space. The vertical dissection corresponds to the length of mesh
required. (c) Measurement of dissected transverse space. This is measured posteriorly along the dissected posterior flap and corresponds to
half the width of mesh required. hd hernia defect, ta transversus abdominis muscle, ps/p posterior flap comprising posterior rectus sheath
medially and peritoneum laterally
J.A. Warren and A.M. Carbonell
49.6.2 Single-Dock Preperitoneal Repair
Alternatively, repair can be completed without dissecting the
retromuscular compartment by simply separating the peritoneum over a space surrounding the defect. Closure, mesh
fixation, and peritoneal closure follow the same sequence as
the single-dock retromuscular approach described above.
This technique is depicted in Fig. 49.12, and is described in
more detail elsewhere in this text.
49.6.3 Single-Dock Epigastric and Suprapubic Repair
For hernias in the epigastric or suprapubic regions, the robot
can be docked in the opposite abdominal domain and
approached from a midline position. Three trocars across the
lower abdomen, with the addition of an assistant trocar, can
easily access the upper abdomen, typically within about
3 cm above the umbilicus. In this case, the patient is positioned on a split leg table in moderate reverse Trendelenberg
position. Conversely, for suprapubic defects, the robot
can be docked in the epigastrum with the patient in a
Trendelenberg position. In either case, the initial posterior
sheath incision is made transversely, opening from semilunar
line to semilunar line, with division of the posterior sheath
on each side to preserve the midline linea alba above and
Fig. 49.7 Mesh placement. (a) Mesh rolled along its vertical axis and
placed below the nascent trocars. (b) Mesh secured to the left lateral
abdominal wall. (c) Cross-sectional schematic of same. m mesh, ta
transversus abdominis muscle, ps/p posterior flap comprising posterior
rectus sheath medially and peritoneum laterally
below the hernia defect. If necessary, a transversus abdominis
release can still be performed from these positions. The
sequence of closure again follows that of the other singledock approaches, with defect closure, followed by mesh
placement and posterior sheath closure last. Repair of epigastric and suprapubic defects are depicted in Figs. 49.13
and 49.14, respectively.
49.7 Outcomes
To date, we have performed more than 80 true rRMVHRs, and
over 120 total cases, including preperitoneal and intraperitoneal mesh placements. We have performed two comparison
analyses evaluating the outcomes of RMVHR to both standard
laparoscopic repair and open RM repair. We compared our
robotic and laparoscopic cases between 2013 and 2015 contained in the Americas Hernia Society Quality Collaborative
(AHSQC), a prospective, hernia-specific database. A total of
49 Robotic Ventral Hernia Repair
387
Fig. 49.8 Closure of the posterior sheath and mesh deployment. (a)
Closure of the posterior sheath. (b) Cross-sectional schematic of same.
(c) Deployment of mesh across the closed posterior sheath. (d) Cross-
Fig. 49.9 Closure of anterior fascia/hernia defect. (a) Closure of the
hernia defect with imbricating bites of the overlying hernia sac. (b)
Cross-sectional schematic of same. af anterior fascia, hd hernia defect,
ra rectus abdominis muscle
sectional schematic of same. ta transversus abdominis muscle, ps posterior rectus sheath, ra rectus abdominis muscle, m mesh
156 patients, 53 robotic and 103 laparoscopic, were identified.
Patients had similar comorbidities and hernia characteristics.
The robotic approach resulted in longer operative time and
seroma formation compared to laparoscopy, but a much
greater fascial closure rate, 96 versus 50 %, and a shorter
median length of stay (LOS) at only 1 day, compared to 2 days
after LVHR. Anecdotally, this difference seems to be due to
less pain associated with rRMVHR, but we were unable to
demonstrate this upon retrospective analysis of narcotic
requirement during hospitalization. There was no difference in
surgical site infections between groups [5]. Tables 49.1 and
49.2 summarize these findings.
While this is a useful comparison evaluating the potential
benefits of two minimally invasive approaches to VHR,
these techniques are truly distinct. To more appropriately
compare techniques, we also analyzed our initial 21 rRMVHR compared to a matched cohort of 21 open RMVHR.
Cases were matched based on body mass index (BMI),
Center for Disease Control (CDC) wound classification, and
hernia width. Comorbidities were similar between groups
with the exception of chronic obstructive pulmonary disease
(COPD), which occurred more frequently in the open group
(Table 49.3). Again, a longer operative time was noted with
the robotic approach, and a greater number or seromas were
388
J.A. Warren and A.M. Carbonell
Fig. 49.10 Single-dock retromuscular approach for VHR. (a) Posterior
rectus sheath incised laterally. (b) Retromuscular dissection continues
to the linea alba and hernia defect medially, extending across the midline in the preperitoneal space. (c) Contralateral retromuscular dissection. (d) Completed flap consisting of the posterior rectus sheath
reported. No SSIs occurred in our initial robotic cases,
compared with 9.5 % in the open cohort (p = 0.488). The
impact on LOS was more significant. Hospital LOS decreased
from a mean of 4.2 days open to 2.3 days robotically
(p = 0.046). Interestingly, our rudimentary cost analysis,
comparing direct hospital costs only, was similar between
groups (Table 49.4). Further comparison is currently underway with encouraging early results [13].
49.8 Conclusion
The utility of robotics in ventral hernia repair remains a
contentious issue. However, by fully utilizing the benefits
of enhanced three-dimensional visualization and instru-
bilaterally, connected by the peritoneum in the midline. (e) Closure of
the hernia defect. (f) Mesh placed against the anterior abdominal wall.
(g) Closure of the posterior sheath. ra rectus abdominis muscle, ps posterior rectus sheath, hd hernia defect, la linea alba, p peritoneum, af
anterior fascia, m mesh
ment articulation afforded by the robotic platform, we are
able to duplicate the Rives-Stoppa VHR in a minimally
invasive fashion. The implication of our initial comparative
analyses is significant, as the ability to replicate an
open repair, with the benefits of complete abdominal wall
reconstruction, offsetting tension along the midline closure
through myofascial release, and extraperitoneal mesh
placement, combined with the wound morbidity of laparoscopic hernia repair, allows definitive hernia repair for
increasingly complex and high-risk patients with decreasing perioperative morbidity. The optimal patient selection
for this approach remains to be determined, and certainly
the cost of robotic surgery must be considered. However,
rRMVHR has the potential to dramatically improve the outcomes for VHR.
49 Robotic Ventral Hernia Repair
389
Fig. 49.11 Cross-sectional schematic of single-dock retromuscular
rVHR. (a) Posterior sheath incised laterally. (b) Dissection across the
midline, including reduction of the hernia sac, to the contralateral semi-
lunar line. (c) Closure of hernia defect. (d) Mesh placement against
anterior abdominal wall and closure of the posterior sheath
Fig. 49.12 Preperitoneal repair of small VHR. (a) Peritoneum dis-
sected away from the posterior sheath, beginning at least 5 cm from
hernia defect. (b) Preperitoneal dissection continues beyond the defect
at least 5 cm. (c) Placement of mesh against the anterior abdominal wall
after closure of the hernia defect. (d) Peritoneal flap closure. ps posterior rectus sheath, p peritoneum, hd hernia defect, m mesh