Robotic transabdominal preperitoneal (rTAPP) ventral hernia repair

Preoperative considerations

It is critical to have a thorough understanding of the layers of the abdominal wall. The preperitoneal space can be surgically dissected from the overlying layers of the abdominal wall from the diaphragm to the myopectineal orifice and posterolaterally encompassing the retroperitoneum. While the peritoneum is not considered a layer of “strength,” the preperitoneal space is being increasingly utilized as a form of autologous coverage for the placement of uncoated prosthetic mesh excluded from the visceral compartment. In fact, this exclusion from the intraperitoneal content represents one of the major proposed advantages of preperitoneal hernia repairs.

For hernias of the anterior abdominal wall, mesh size is based on the original size of the defect and adheres to the well-established principles of maintaining a minimum of a 5-cm overlap in all directions.

The proposed advantages of the robotic transabdominal preperitoneal (rTAPP) approach to ventral hernias include the following:

• 1.

  Maintains the integrity of myofascial planes

• 2.

  Allows the mesh to incorporate on both parietal and visceral faces, effectively sandwiching the mesh within the patient’s abdominal wall and, thereby, minimizing the need for mechanical fixation associated with increased postoperative pain

• 3.

  Allows for placement of an uncoated, rather than a costlier coated, mesh

• 4.

  Minimizes complications associated with intraperitoneal mesh, which may result in dense serosal adhesions, bowel obstructions, and fistulations, thereby potentially reducing complexities and complications of future surgical intervention.

Indications

The robotic preperitoneal approach is quite versatile. It is generally applied for smaller midline hernias with a defect width of less than 5–6 cm. Atypical hernias such as subxiphoid, suprapubic, and flank defects are also amenable to the rTAPP approach. Certain small hernias, such as primary umbilical hernias, can be detected on a physical examination. However, more complex or atypical hernias require computed tomography (CT) of the abdomen and pelvis to better delineate the size, position, and content of the hernia. A CT scan can also aid in identifying the location of previously placed mesh as well as assist in surgical planning and determining a safe entry point into the intraperitoneal cavity. Relative contraindications for the rTAPP approach include, but are not limited to, larger fascial defects (greater than 6–7 cm), those defects requiring component separation to reconstitute the linea alba, and long “Swiss cheese” defects of the midline, which make preperitoneal dissection challenging.

Patient positioning and trocar placement

The patient is positioned supine on the operating table and general anesthesia is induced. Standard operative protocols are used, including antibiotic prophylaxis, hair clipping, and placement of sequential compression devices. Depending on the anticipated duration and targeted location of the surgery (especially suprapubic), a Foley catheter can be inserted. The patient’s arms are tucked and slight flexing of the bed may be beneficial for patients who have a short torso or have limited space to adequately insert the trocars ( Fig. 11.1 ).

Depending on surgeon preference, the abdomen can be accessed via a Veress needle, Hasson technique, or direct optical entry. Generally, we use a 5-mm optical trocar at Palmer’s point in the left upper quadrant ( Fig. 11.2 A). It is recommended that the camera trocar be placed at a minimum distance of 15 cm from the closest edge of the hernia defect. Placed in this manner, it allows visualization and dissection of the abdominal wall ipsilateral to the trocars, thereby allowing for adequate and symmetrical overlap by subsequently placed mesh ( Fig. 11.2 B). The two additional trocars should be at least 6–10 cm from the camera port in order to reduce arm collisions. An 8-mm bariatric-length robotic trocar is placed in the lower lateral abdomen, which reduces arm collisions with the lower extremities. The 5-mm optical trocar is then replaced with an 8-mm robotic trocar.

Once all ports are placed and positioning is satisfactory, the robot is docked directly over the lateral abdomen in line with the trocar sites ( Fig. 11.3 A). Optimal instrumentation consists of a grasper, monopolar scissors, and a needle driver ( Fig. 11.3 B). A 30-degree up scope is used to begin the case and may need to be switched to a 0-degree or 30-degree down scope when progressing to the contralateral abdomen.