Robotic Transabdominal Preperitoneal Hernia Repair for Ventral Hernias

For most patients with small defects in the midline, supine positioning with the arms tucked is preferred, unless trocar access to the lateral abdomen is obscured by this position. In this situation, the arm is placed on a board set at 90 degrees from the trunk.

Any adjustments in patient position must be performed before docking of the robot.

Typically, Foley catheterization is not required unless the surgeon expects a prolonged case or the hernia defect extends to the lower abdomen.

An iodine-impregnated adhesive is applied to the widely prepared abdomen.

Although port positioning is similar to that for conventional laparoscopy, the mobility of the robotic arms must be taken into account ( Fig. 15.2 ). It is important to place the trocars as far from the defect as possible without sacrificing range of motion based on potential collision with the upper and lower extremities.

Gaining safe intra-abdominal access is the first step in minimally invasive surgery. This access can be difficult in a patient who has had multiple abdominal operations. Sites of previous operative interventions influence the strategy. Optical entry with a 5-mm trocar at Palmer point with or without initial Veress needle insufflation in the left upper quadrant is generally safe. A 12- or 8-mm trocar for the camera is placed as far lateral to the ipsilateral edge of the defect. This allows for visualization, dissection, and instrumentation on the side closest to the ports or proximal to the hernia defect. An 8-mm da Vinci trocar is placed in the lower lateral abdomen, and the initial 5-mm optical trocar is then replaced with an 8-mm da Vinci trocar. It is generally unnecessary to place trocars on the contralateral abdomen or to use an accessory trocar, but this may vary depending on surgeon comfort.

Once ports are placed and positioning is satisfactory, the robot is docked directly over the lateral abdomen and in line with the trocar sites ( Fig. 15.3 ). Instrumentation generally consists of a ProGrasp, monopolar scissors, and a suture cut needle driver ( Fig. 15.4 ). A 30-degree up scope is used to begin the case and may need to be adjusted to a 0- or 30-degree down scope when creating a large preperitoneal flap.

Adhesiolysis of the abdominal wall to isolate and define the hernia defect must be performed meticulously to avoid not only injury to intraperitoneal viscera but also injury to the peritoneum. The peritoneum is incised with scissors at a minimum of 5 cm from the hernia defect on the side of the abdomen ipsilateral to the trocar sites ( Fig. 15.5 ). The peritoneal incision is best made in proximity of the preperitoneal fat underlying the rectus muscle. In this area, the preperitoneal plane is easiest to access without disrupting the overlying posterior sheath.

In the event the posterior fascia is breached and the rectus abdominis muscle is visible, the defect is closed with absorbable suture. The preperitoneal plane is developed widely in a cephalad-to-caudad direction with a combination of meticulous blunt and sharp dissection. Cautery is judiciously applied so as to avoid thermal injury, which may result in peritoneal defects. The hernia sac is reduced, and further dissection continues distal to the defect ( Fig. 15.6 ). Wide preperitoneal dissection allows for two critical components of the procedure: the eventual placement of an adequately sized mesh based on the original size of the hernia defect and the creation of a well-mobilized peritoneal flap that can completely cover and reperitonealize the mesh.

If the preperitoneal space is inaccessible, the procedure is converted to placement of an intraperitoneal mesh after primary closure of the defect.