• Perineal hernias have a rare presentation and high recurrence rate, up to 16%.

The pelvic defects comprise some hernia types, such as obturator,sciatic and peri­neal hernias. The rst are rare entities, mostly primary hernias [1]. The second, peri­neal hernias, are incisional hernias following protectomy or abdominal perineal resection (APE). They account for 1–7% of the incisional hernias with a rare inci­dence [2]. APE is the surgical treatment for patients with distal rectal cancer in whom an anterior resection with anastomosis (AR) cannot be performed, leaving them with a terminal colostomy. Even though it is a radical procedure, it has a high incidence of local recurrence due to the extended invasion those types of cancer have [3]. Therefore other techniques were created to try to get better oncologic results. This was how the extra elevator abdominal perineal excision (ELAPE) was created with a larger margin resection in the attempt to have better oncologic out­comes. However, with the increased resection, the incidence of perineal hernia became higher, leading to the discussion of prevention and possible treatments of this disease [4].

There are no classications regarding perineal or sciatic hernias, because they are rare and their main treatment is not well standardized nowadays. Regarding perineal hernias, the rst attempt to correct them was made by Yeoman etal. in 1939 [1]. Since then various types of procedures have been tried in the setting of this type of disease. Most of them are open procedures either done by the perineum with muscle ap rotations, primary closure, or from the abdomen with the placement of a prosthesis. Even though there are many procedures, the recurrence rate can be as high as 16% [7].

When minimally invasive surgery began, hernia surgeons saw the opportunity to treat incisional and primary hernias using that technology [10]. Video surgery has modied dissection and anatomy preparation of surgical diseases. This approach allied with the advantages of the repair coming from the abdomen led surgeons to try to use laparoscopy in the treatment of perineal hernias. In this way, many case reports showed techniques to repair those types of hernias, mostly utilizing a mesh placed in the defect without tension [11–13].

Before starting the procedure the patient has to be evaluated and prepared. First of all, a good history of symptoms and other comorbidities has to be taken from the patient. It is very important to have the oncologic status of the patient. After that a physical examination is done with the patient in different positions (Fig.1).

He is placed on the surgical table with both arms and legs closed. Sometimes the legs can be opened in order to dock the robotic cart between them. General anesthe­sia is applied with orotracheal intubation. After that, the patient receives prophylactic antibiotics, urinary catheter and the peripheral lines are placed. The patient is always secured on the table with xation straps and well protected with a chest protector and a head/eye protector. A heater device is used, placed on the chest of the client.

One of the most important parts of the dissection is the identication of the struc­tures to be separated. Because one of the major complications of the perineal hernia repair is bowel injury, the adhesiolysis becomes even more important. The perineal defects are often accompanied by strong, rm adhesions, mainly in the pelvic area, but the entire abdominal cavity can present them. The robotic instruments with wrist movements along with the 3D view can facilitate management of these adhesions, as the penetration of CO2between the conjuntive tissue,lowering the incidence of lesions and making the process faster. The instruments used are (Fig.5):