Robotic transversus abdominis release (r-TAR) procedure

Introduction

Few techniques in surgery have evolved more over the course of the last two decades than those related to hernia and abdominal wall reconstructions. Advances in technology, coupled with a better understanding of the abdominal wall anatomy, have resulted in the popularization of advanced reconstruction techniques that aim to restore the functional abdominal wall. Abdominal reconstruction with posterior component separation via transversus abdominis release (TAR) was developed by Novitsky et al. to allow for retromuscular reinforcement with mesh while simultaneously overcoming limitations related to suboptimal myofascial medialization and/or neurovascular injury associated with other sublay techniques. The TAR operation allows for significant posterior and anterior rectus fascia medial advancements with broad lateral dissection for sublay mesh placement.

With the advent of robotics, videos of robotic retromuscular repair by Abdalla, Carbonell, and Ballecer emerged. It became rapidly clear that the application of robotic technology to complex retromuscular repairs was not only feasible but also conferred the tremendous advantage of minimal-access surgery to complex hernia patients. As our robotic expertise increased, we also have adopted minimally invasive approaches using the da Vinci robotic platform in TAR reconstructions. In this chapter, we discuss the indications for robotic TAR (r-TAR), highlight preoperative considerations, detail intraoperative techniques, and review recent literature related to outcomes following r-TAR.

Indications

Although most indications to perform an r-TAR are similar to an open TAR, there are some exceptions. Most patients with large midline hernias (typically >10–12-cm wide) who would benefit from abdominal wall reconstruction and sublay mesh repair are typically considered for r-TAR. Furthermore, given its ability to create a subcostal and subxiphoid plane, the r-TAR procedure is well-suited for large epigastric and subcostal hernias. Large lateral defects such as those from a previous open appendectomy, cholecystectomy, and old ostomy incisions, especially those with concomitant midline hernias, can also be approached via r-TAR.

Some situations, however, pose relative or absolute contraindications to r-TAR. Patients with a large amount of previous intraperitoneal mesh are typically treated via an open approach in our practice. Patients with significant overlying skin changes or very redundant/attenuated skin and soft tissues are often suboptimal candidates for r-TAR. In fact, any patient who requires significant soft tissue rearrangement, abdominoplasty, and/or panniculectomy is considered for an open approach. Finally, patients with a history of previous retrorectus repairs should be approached via robotic (or even open) TAR with caution.

Among the absolute contraindications to an r-TAR is the inability to tolerate a pneumoperitoneum, patients with so-called “hostile” abdomens with significant intraperitoneal adhesions and those insistent on existing scar revisions. Finally, we currently avoid robotic reconstructions in both clean-contaminated and contaminated scenarios.

Patient preparation

Operating room setup and patient positioning

The operating room should be large enough to fit the robotic operating system and boom, operating room table, scrub table, and anesthesia. The robotic boom is typically to the right of the patient bed.

The patient is placed on the operating table in the supine position with both arms tucked at their sides. For most patients, especially those with “short” torsos, flexion of the operating table at the hips can increase the length between the costal margin and the anterior superior iliac spine (ASIS) to facilitate adequate port placement ( Fig 14.1 ). A urinary catheter and an orogastric tube are placed. General endotracheal anesthesia is induced. The patient is then prepped from their nipples to their mid-thigh, and laterally to the posterior axillary line. We routinely attach an additional sterile quarter sheet to the cephalad aspect of the drapes in order to create more sterile space for the robotic arms and to minimize chances of accidental breaks in sterility during instrument exchanges ( Fig. 14.2 ). For the purpose of description of the steps of r-TAR, we will refer to various areas of the abdomen according to the clockface in ( Fig. 14.3 ).

Operative steps

The da Vinci Xi robot (Intuitive Surgical Inc, Sunnyvale, CA, USA) is our platform of choice for rTAR. The most frequently used instruments for this procedure are an angled robotic camera, monopolar scissors, a fenestrated bipolar grasper, and a Mega Suture Cut needle driver. More recently, we have begun to utilize Force bipolar with increasing frequency. Other instruments that should be available are robotic suction, a ProGrasp grasper, a vessel sealer device, and a needle driver. Basic laparoscopic instruments should also be readily available.

Step 1: Initial port placement and docking

We typically begin with placing our initial set of ports on the left side. The abdomen is entered via a 5-mm optical trocar in the patient’s left upper quadrant just lateral to the midclavicular line. After insufflation to 12–14 mm Hg, the remaining two ports are placed under direct visualization. As a rule for our Xi cases, each robotic port must be at minimum of 6 cm apart. We place our caudal most port next, roughly 1 cm medial and 2 cm cephalad to the ASIS. Care must be taken to avoid being too close to the ASIS as this can compromise the mobility of the port. An 8-mm bariatric length robotic trocar could be used here to reduce robot arm collisions with the lower extremities. For patients with significant upper abdominal hernias, this port should be shifted 1–2 cm laterally and cephalad. Importantly, if the lower port is placed too medially, the upper abdominal wall may become inaccessible due to external collisions of that robotic arm with the thighs. Finally, a middle port is placed in between the first two, essentially at the 2-, 3-, and 4 o’clock positions ( Fig. 14.4 ). It is important to confirm patient positioning prior to docking, particularly if a specialized operating table is not available. We typically start with about 8–10 degrees in Trendelenburg and go in the opposite direction prior to re-docking. Lateral tilt might be added according to hernia location and characteristics. The robot is then docked and a thorough assessment of possible external collisions is performed and cleared.