Fong_Robotic General Surgery, 1e

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SECTION 2 • Discipline-Based Practice - General Surgery

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FIGURE 7.2 Robotic TAPP. A, Peritoneal flap creation 5 cm lateral to the defect. B, Final preperitoneal space dissection with closed defect. C, Self-gripping mesh in place. D, Final aspect of closed peritoneal flap.

gentle to avoid tearing. During dissection of the perito neum off the hernia sac, separation of tissues without creating peritoneal defects may not always be possible. These peritoneal defects can be closed with absorbable sutures or patched with the pseudosac. These defects should be repaired because if left, an intraparietal hernia can occur resulting in acute incarceration or strangula tion of omentum or bowel. The hernia sac is reduced and the dissection continues laterally. It is important to dissect the preperitoneal plane widely, 5 cm in all direc tions from the defect, in order to allow for the placement of an adequately sized mesh. If the peritoneum becomes too thin, conversion to retromuscular mesh placement versus an intraperitoneal onlay mesh can be considered. After the preperitoneal space is widely dissected, the hernia defect is primarily closed with long-lasting absorb able barbed suture in a running fashion starting approxi mately 5 to 8 mm from the fascial edge. Desufflation of the abdomen to a pressure of 6 to 8 mm Hg and adequate relaxation by anesthesia will facilitate primary closure of

the defect under less tension. The subcutaneous tissue at the dome of the defect is incorporated within the primary closure, obliterating the anterior dead space in order to minimize risk of seroma formation. Once closed, the fas cial defect size is measured once it is important to select a mesh that has 5 cm overlap in all directions. The mesh is introduced via the 8-mm trocar and placed flat against the abdominal wall. Four cardinal sutures or tacks are placed to approximate the mesh against the abdominal wall and prevent mesh migration. Additional circumferential sutures or double crown tacks are placed to ensure flat placement of mesh against the anterior abdominal wall. A fibrin sealant can also be used. Following adequate fixation and hemostasis, the peri toneum is reapproximated to completely cover the mesh with running absorbable barbed suture or tacks. All port sites are removed under direct visualization, and pneu moperitoneum is released. A 10-mm or greater port site fascia is closed with absorbable suture.

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