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CHAPTER 7 • Robotic Extraperitoneal Repairs for Midline Hernias

defects greater than 7 or 8 cm or that requires compo nent separation or long “Swiss-cheese” defects are rela tive contraindications for the R-TAPP approach due to its challenging dissection. The initial indication proposed by the pioneers of the eTEP repair was primary ventral hernias associated with diastasis. There is no consensus in the literature regarding incisional hernias, body mass index (BMI), or defect size. Patients should undergo a CT scan of the abdomen and pelvis preoperatively for surgery planning. A minimal unilateral width of the rectus should be of 7.5 cm to allow proper working space for the robotic arms. Slimmer rectus may require transabdominal access ( Figure 7.1 ). A prior incision from xiphoid process to the pubic bone is a relative contraindication for eTEP. 18 Previous mesh in retromuscular or intra-abdominal posi tion; patients with contraindication for general anes thesia; and incarcerated or strangulated hernias, skin ulcerations, enterocutaneous fistulas, BMI higher than 35 kg/m 2 , and loss of domain are also contraindications to the procedure. 24,32-35 The patient is placed in the supine position. The abdom inal cavity is accessed via a Veress needle, Hasson technique, or optical entry, and pneumoperitoneum is obtained. It is important to place the three trocars as far from the defect as possible without sacrificing range of motion based on potential collision. A 12- or 8-mm trocar for the camera is placed as far lateral to the ipsi lateral edge of the defect. As a general rule the camera trocar should be a minimum of 15 cm away from the ipsilateral edge of the hernia as this allows for ideal visu alization, dissection, and instrumentation on the side SURGICAL TECHNIQUES Robotic TAPP

closest to the ports. The two additional trocars should be at least 8 mm from the camera port in order to reduce collisions. An 8-mm robotic trocar is placed in the lower lateral abdomen, and the initial 5-mm optical trocar is then replaced with an 8-mm trocar. Final configuration of the trocars for a da Vinci Xi robot are typically in a V configuration. Additional trocars on the contralat eral abdomen or an assist trocar is typically unneces sary; however, it can be inserted if the surgeon deems it necessary. Once ports are placed, the robot is docked directly over the lateral abdomen in line with the trocar sites. Optimal instrumentation consists of a grasper, monopo lar scissors, and a needle driver. A 30° up scope is used to begin the case and may need to be switched to a 0 ° or 30 ° down when progressing to the contralateral abdomen. First, the anterior abdominal wall is cleared of all adhesions to better delineate the full extent of the hernia defect as well as to identify any other sites of hernia tion. It is important to dissect carefully using monopolar energy as well as blunt dissection, as to avoid injury to the peritoneum, bowel, or omentum. An enterotomy can increase the risk of conversion to an open procedure, use of biologic mesh/primary closure, or the need for staged repair. Once adhesiolysis is complete, the peritoneal flap can be created ( Figure 7.2 ). Starting a minimum of 5 cm from the edge of the defect the peritoneum is incised using the scissors. Ideally this is made within the visible preperitoneal fat that underlies the rectus muscle. The preperitoneal plane is developed widely in a cephalad-to-caudad direction with a combination of blunt and sharp dissection. This is done by sweeping the blunt edge of the scissors to separate the peritoneum off the posterior sheath as well as using monopolar cautery carefully at areas of visi ble bleeding. The traction on the peritoneum should be

A FIGURE 7.1 CT scans of ideal indications for eTEP versus TAPP approaches for robotic repair. A, eTEP indication with 2-cm umbilical hernia defect associated with diastasis (5 cm in yellow) and wide bilateral rectus width (10 cm each side). B, Isolated small umbilical hernia defect (2 cm) without diastasis. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024 B