Robotic totally extraperitoneal retrorectus repair

Introduction

The field of abdominal wall reconstruction has been rapidly evolving, particularly in recent years, with the popularization of several novel minimally invasive extraperitoneal approaches. Enhanced-view totally extraperitoneal (eTEP) access in combination with retromuscular repair has expanded what is feasible with minimally invasive surgical techniques. ^, The mainstay of traditional minimally invasive hernia repair has been intraperitoneal onlay mesh placement (IPOM) with penetrating fixation. ^, Although this technique continues to be a popular choice among surgeons worldwide, it is not without its inherent weaknesses. One drawback of IPOM is direct contact of the mesh to the intra-abdominal viscera. This can ultimately lead to complications such as intra-abdominal adhesions, mesh erosion, and, rarely, enterocutaneous fistulas. Many have adopted placing the mesh in the preperitoneal space to obviate this issue, which is a viable option especially with primary ventral hernias. This dissection becomes more challenging with incisional hernias, as the peritoneal layer can be quite thin and fragile. In addition to intraperitoneal mesh placement, the IPOM technique struggles to provide adequate mesh overlap in complex or atypical hernia defects such as subcostal, flank, and suprapubic hernias. Theoretically, the retromuscular space can be accessed anywhere on the abdominal wall via an eTEP approach, offering ultimate flexibility for dynamic port placement. With this approach, the surgeon is able to develop adequate space adjacent to the hernia defect for appropriate mesh coverage. In the retromuscular plane, the dissection can be carried out superiorly to the central tendon of the diaphragm, inferiorly to the pubis, and laterally to the psoas muscles if a transversus abdominis release (TAR) is utilized. Our goal in this chapter is to discuss the principles of eTEP robotic retromuscular repairs.

Patient preparation

As with any surgical patient, a thorough preoperative history and physical examination is mandatory. Risk factors such as diabetes, smoking history, and obesity should be documented. These should be mitigated prior to offering any surgical intervention. On examination, one should note prior incisions, location of hernia defects, and laxity of the abdominal wall musculature. Attention to surgical history is paramount, with focus on the locations of hernia defects and their characteristics, prior incisions, any palpable mesh from previous surgeries, and atrophic skin. Obtaining past operative reports if available is invaluable, particularly with patients who may have had multiple hernia repairs in the past. We routinely obtain preoperative computed tomography (CT) imaging to assess the patient anatomy. Some important details to consider include hernia defect size and contents, prior meshes, integrity of the remainder of the abdominal wall, and the width of the retrorectus space.

It is crucial to have a keen understanding of the abdominal wall anatomy prior to attempting these cases. The eTEP approach to ventral hernia repair relies on a relatively intact area of preperitoneal space for the cross-over maneuver via either the falciform or umbilical ligament. Thus, a large midline incision is a contraindication for the eTEP approach due to the danger of injuring intra-abdominal contents during cross-over; we recommend a transabdominal approach in such cases. Docking positions and their corresponding port placements are described in Table 13.1 along with their relative contraindications.

In addition to this, one should anticipate whether a retrorectus dissection, a Rives–Stoppa repair, will be adequate, or a TAR will be necessary. A rule of thumb is that a TAR is likely needed if the width of the hernia defect is greater than 50% of the width of the total retrorectus space at that level. It is important to realize that this is a generalization and does not account for other factors such as tissue compliance. If it is known that bilateral TAR is necessary, we do not believe that there are many or any technical advantages with eTEP access as compared to a traditional transabdominal approach.

Operative technique