Robotic transabdominal retrorectus repair

Indications

For ventral hernias of the midline between 2 and 5 cm in width, I prefer to perform a robotic retrorectus repair with a 15-cm wide mesh. I use a technique with a single dock lateral transabdominal approach. This technique has been described previously by Chowbey et al. in 2003 and by Schroeder et al. in 2013 using conventional laparoscopic instruments. They concluded that the technique is safe and effective but is technically demanding, with ergonomic challenges for the surgeons. My personal algorithm is to perform this technique robotically for all ventral hernias, both primary and incisional, that are situated in zone M2-M3-M4. In lateral hernias (L1-L2-L3) and hernias limited to zone M1 (subxiphoidal) or M5 (suprapubic), I use a preperitoneal approach (robotic transabdominal preperitoneal, [rTAPP] ventral) ( Fig. 12.1 ).

The transabdominal lateral approach is in essence comparable with other retromuscular ventral hernia repair techniques like the mini or less-open sublay operation described by Reinpold et al. and extended totally extraperitoneal repair (eTEP) access approach described by Belyansky et al. All these techniques are similar in that they repair the ventral hernia using retromuscular mesh augmentation between the confines of the rectus sheath after closure of the anterior fascia on the midline and they leave open the posterior rectus fascia with a peritoneal bridge in between. In the lateral transabdominal approach the retromuscular plane is accessed by opening the ipsilateral posterior rectus fascia as described by Muysoms et al. ( Fig. 12.2 ).

In patients with a higher body mass index and a round abdominal contour, I favor a lateral transabdominal approach because there is ample space between the lateral trocars and the incision in the ipsilateral posterior rectus fascia ( Fig. 12.3 ). In lean patients and those with a concomitant rectus diastasis, I have currently adopted an eTEP-access approach with suprapubic docking.

Patient preparation

Most ventral hernias are diagnosed clinically and imaging is not needed. I will evaluate whether the hernia is reducible and if palpation is painful. If reducible, the size of the hernia defect can be estimated. I will also check for the presence of a concomitant rectus diastasis. If this is the case, the discussion is undertaken either to treat only the hernia or to also treat the diastasis. In some patients an ultrasound can be helpful to measure the dimensions of the hernia defect and to see if additional defects of the linea alba are present in addition to the symptomatic hernia. A computed tomography scan of the abdominal wall can be helpful in a patient with an incisional hernia to measure the size of the defect and the width of the rectus muscles and to assess for the presence of additional lateral defects ( Fig. 12.4 ).

No specific preparation is needed except that for general anesthesia. I ask the patients to void before transport to the operating room. No bladder catheters or nasogastric tubes are used. No perioperative antibiotic prophylaxis is given except for general indications like the presence of cardiac valve disease.