Robotic anterior component separation

Indications

Ventral hernia (VH) repair with onlay mesh placement after anterior component separation is a safe alternative to sublay mesh placement after posterior component separation in low-risk patients. Onlay open VH repair is still one of the most common surgeries for the repair of hernias worldwide. ^, It is technically easy, with a relatively short surgical time, is very reproducible, and has a shorter learning curve compared to other repair techniques (including laparoscopic surgery).

The possibility of surgical intervention in a minimally invasive way has the theoretical advantage of lowering the rates of surgical complications, with a shorter hospitalization time and early return to daily activities, as is expected in all endoscopic procedures.

Endoscopic surgery of the abdominal wall has its peculiarities, because intracorporeal closure of fascial defects is difficult due to the necessity to operate “on the roof” of the surgical field, and it is not broadly accepted nor performed because it demands advanced laparoscopic skills. Another consideration is the use of synthetic mesh in contact with the abdominal viscera. This is still a major point of discussion, even with the advance of technology on mesh protective layers. ^{, ,}

Most of the reports on minimally invasive robotic surgery use an intraperitoneal, preperitoneal, or retromuscular approach. The latter approach is growing in popularity but may be too challenging for many surgeons. The combination of the minimally invasive surgery (MIS) approach with a repair that can be performed safely by many surgeons—the onlay approach—may become a viable alternative.

In large or complex hernias, additional maneuvers are necessary to achieve linea alba medialization to re-establish a functional abdominal wall with an autologous tissue repair. The procedure involves dividing the relatively fixed external oblique aponeurosis, elevating the rectus abdominus muscle from its posterior rectus sheath, and then mobilizing the myofascial flap, consisting of the rectus, internal oblique, and transverse abdominus medially, as described originally by Ramirez in 1990. Although in the classical technique prosthetic material was not necessary, the procedure was updated to be used in more complex abdominal wall reconstruction with the use of mesh.

While anterior component separation with the subcutaneous onlay mesh was shown to be a very good option in open incisional hernia repairs, it is known to be associated with frequent complications due to the creation of lipocutaneous flaps, including flap ischemia, infection, seromas, and wound infections ranging from 25% to 57%. During a MIS approach for onlay repair, as robotic, the seromas and other complications from the subcutaneous flap dissection may occur, but once there is no incision to heal, the proper wound complications do not happen.