Fong_Robotic General Surgery, 1e

CHAPTER 7

Robotic Extraperitoneal Repairs for Midline Hernias Flavio Malcher, Diego L. Lima, and Conrad Ballecer

INTRODUCTION Ventral hernia repair (VHR) is one of the most per formed general surgery procedures, and the use of robotic approaches has been increasing. 1 More than two million laparotomies are performed annually in the United States, and an estimated 200,000 patients require incisional hernia repair each year. 2 Minimally invasive hernia repair ensures shorter length of stay, less post operative pain, lower surgical site infection rates and faster return to work. 3 The robotic platform is being increasingly used due to its enhanced 3D visualization, ergonomics, precision, and ability to operate high on the anterior abdominal wall as compared with standard lap aroscopy. These features allow for improved and natural intracorporeal suturing and fascial closure, extraperito neal placement of mesh, and more precise movements. 4 The robotic-assisted repair trends to be the natural pro gression of minimally invasive hernia surgery. 5,6 The literature has shown that placing mesh intra-ab dominally may increase adhesions with an increased likelihood of bowel fistula or erosions. 7,8 The robotic platform allows more precise and complex movements, enabling the surgeon to better explore different layers of the abdominal wall and allowing mesh placement in a sublay position, with no contact to the viscera. Different surgical techniques for VHR have been described through the years. Many authors have described the laparoscopic approach to VHR with the positioning of an intraperitoneal underlay mesh. 9,10 The transabdominal preperitoneal (TAPP) approach confers the possible advantage of minimal adhesion formation, even with the use of a noncoated mesh, since there is no direct contact between the mesh and the intra-abdomi nal structures. 11 Compared with laparoscopic repair, the robotic approach can facilitate the creation of peritoneal flaps and mesh fixation by suture. Furthermore, another advantage of the robotic approach is the ease to close the fascial defect, which traditionally has been the challeng ing task during a fully laparoscopic TAPP repair. 12 The Rives-Stoppa technique with the placement of mesh in the retromuscular space has been widely used for

open VHR. Its advantages are low rates of surgical-site infection and recurrence with restoration of the abdom inal wall functionality and avoiding any complication that would surface with an intraperitoneal mesh. 13-15 The enhanced-view extraperitoneal (eTEP) technique was first described by Dr. Jorge Daes for minimally inva sive inguinal hernia repairs. 16,17 The surgical steps of this technique are a fast and easy creation of extraperitoneal domain, flexible trocar setup, and a large operative field. The eTEP access for VHR was first described by a mul ticenter study by Belyansky et al. 18 Recently, the robot ic-assisted approach was reported with good short-term results. 19 Schroeder et al described the laparoscopic transab dominal technique for VHR using a lateral approach to the retromuscular plane by opening the posterior rectus sheath. 20 Although the procedure was safe and effective, the authors concluded that it was technically demanding to do it laparoscopically. With the advance of the robotic platform, surgeons have been able to per form the transabdominal retromuscular (TARM) tech nique. 21 Operative findings and outcomes from different approaches are summarized in Table 7.1 . In this chapter, we discuss different robotic surgical preperitoneal approaches for ventral hernia repair.

INDICATIONS AND PATIENT SELECTION Robotic eTEP, TAPP, and TARM have different indica tions. Computed tomography (CT) is needed to better evaluate complex or atypical ventral hernias. It can also help in identifying the location of previous meshes in recurrent hernias, evaluate alternative diagnosis such as abscess, seroma, hematoma, and endometrioma. Finally, the CT scan can help in the surgical planning and the best location to enter the abdomen without injuring any important structure. Primary small umbilical her nias can be evaluated by physical examination with no need for imaging. 31 Robotic TAPP (R-TAPP) is used for hernia defects with a defect width of less than 6 cm, in which component separation is not needed. The repair is limited to the size of the peritoneal flap. Larger fascial Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024

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