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CHAPTER 7 • Robotic Extraperitoneal Repairs for Midline Hernias

ROBOTIC-ENHANCED TOTALLY EXTRAPERITONEAL The eTEP Rives-Stoppa approach for ventral hernias was the combination of two surgical techniques: the eTEP first developed for challenging minimally invasive surgery inguinal hernia repairs with the Rives-Stoppa retromuscular mesh placement. The key steps of the eTEP Rives Stoppa technique are: l Development of the retrorectus space and placement of the ports l Crossover of the midline l Development of the midline preperitoneal space and connection of the bilateral retrorectus spaces l Closure of the defect and restoration of linea alba l Mesh placement and fixation The patient is placed in the supine position. The patient’s hips are placed over the operating table’s flex ion point. The bed is flexed, extending the working space between the subcostal margin and the anterior superior iliac spine (ASIS) to create more space for port placement. Next, upon preoperative review of cross-sec tional CT imaging, the width of the retrorectus space and the position of the semilunar line is measured and subsequently marked on the patient. A 5-mm Fios port (Applied Medical) is placed in the left upper quadrant (LUQ) just medial to the semilunar line. If there are prior scars or procedures at the patient’s left side, the same approach can be performed in the right side. The retro muscular space is identified under vision after travers ing the anterior sheath and rectus muscle, then the port is directed inferiorly at a 45° angle and insufflation is initiated. Blunt dissection is performed to allow space for the second port placement 7 to 8 cm below the LUQ port 1 cm medial to the semilunar to avoid any injury to the neurovascular bundles. A spinal needle is uti lized to ensure a safe tract into the retrorectus space,

and an 8-mm robotic port is placed under direct vision. Electrocautery with a hook or Maryland dissector is used to create space inferiorly for an additional 8-mm robotic port at the left lower quadrant, 7 to 8 cm infe riorly, 1 cm medial to the semilunar line again. The camera is switched to the inferior port to complete the dissection superiorly, providing good exposure prior to docking the robot, and the initial 5-mm optical trocar is exchanged for an 8-mm robotic port. The robot is docked from the right side of the patient. The dissection should start lateral to medial toward the linea alba performing a crossover at the epigastric area, taking advantage of the preperitoneal fat tissue of the falciform ligament of the liver, starting by transecting the left posterior rectus sheath 1 cm lateral to the linea alba, dissecting posteriorly to the linea alba, and reaching the right retrorectus space by opening the right posterior rectus sheath. The hernia sac should be identified, and its contents reduced into the abdominal cavity. After the dissection is complete, any opening on the peritoneum or posterior fascia is closed using running 3-0 barbed sutures. If the patient has a concomitant dias tasis, it should be plicated, including the hernia defect’s closure in cases with a concomitant hernia defect with a running 0 barbed slowly absorbable or nonabsorbable suture ( Figure 7.3 ). Mesh might be fixed in a few points with 0 Vicryl interrupted sutures to help position it; once the mesh lays flat in the retrorectus space, the abdomen should be deflated completing the procedure. Drains are not routinely used. ROBOTIC TRANSABDOMINAL RETRORECTUS MUSCLE REPAIR In this technique, the patient is placed in a supine posi tion, pneumoperitoneum is created, and three flank ports are positioned in the left flank at the midclavicu lar line between the 12th rib and the ASIS. The robot is

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A FIGURE 7.3 Robotic eTEP. A, Diastasis (green lines) plication with barbed suture. Left recuts (LR), right rectus (RR), preperitoneal fat (PF). B, Retromuscular mesh positioning under the plicated LA (blue line). Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2024 B PF RR RR