Fig. 1
Patient’s positioning and wide exposition of the abdominal wall
Operative Technique
Parastomal
The same operative steps as incisional laparoscopic hernia already described are carried out, but with some differences regarding extreme care in the presence of the exteriorized bowel well fixed in abdominal wall layers. Sometimes it is difficult to differentiate what is adhesion and what is the correct bowel to be left in place. Some bowel lesions could occur close to the ostomy, at this time.
Abdominal gas insufflation should follow the Palmer’s point needle entry, as described in other chapters [25, 26]. The blind insertion of a Veress needle must be preferred at this point, right subcostal, 2 cm below the costal margin, to create the pneumoperitoneum (Fig. 2). No specific technique has been shown to be superior in preventing vascular and visceral complications [27]. Optical trocars combine the advantages of the different entry techniques. An optical trocar provides a safe and feasible primary insertion method for laparoscopy in patients prone to access injuries. This is not always possible because of the size of the trocar and the robotic optics and a spare video set is necessary for that procedure. The optics’ camera is attached to the optical trocar to allow the view of every layer’s progress during this first insertion. This entrance should be at least 20 cm far from the stoma in a straight line with the surgeon’s position. Two other 8 mm robotic trocars are located at each side of the camera trocar, respecting the necessary distances from each other. Some situations require other new 5 or 10 mm punctures to complete adhesiolysis and/or dissection or suturing for safety and efficacy, depending on the case complexity. As a bowel opening can occur, the surgeon must be prepared to suture any bowel wall lesion immediately and if no contamination or small leakage is found, the procedure can continue as well.
Fig. 2
Pneumoperitoneum by the Veress needle
Adhesiolysis
The object is to get an open wide space from the border of the defect for a safety mesh fixation from 5 to 8 cm depending on its diameter. Parastomal hernia contents must be freely dissected, reallocated to the peritoneal cavity with meticulous care and patience, leaving the bowel that goes to the stoma isolated and intact. The robot assistance allows stability and safety at this dissection time, bostering the surgeon’s confidence. Sometimes it is very difficult to recognize the difference between small bowel seromuscular wall surface and the abdominal wall peritoneum (Fig. 3). During the console surgeon time, first assistant, by the patient side, is very important to push the external hernia bulge in and out as the dissection goes on. The hernia size is measured from all limits of the defect including the edge where the fixed bowel is hiding it. The mesh is big enough to cover the entire defect going at least 5–8 cm from any direction of these diameter limits. The distance increases with a larger defect, a minimum of 5–8 cm as necessary.
Fig. 3
Dissection of the stoma from the abdominal wall
Mesh Repair
The dissection leaves the bowel that goes to the surface like a pipe. This must be positioned against the lateral wall, with two opposite folds for good accommodation. There is no more content around the extremity of this pipe and any space must be attempted to be sutured with the help of the mechanical arm. Remember that the majority of the hernia contents goes to the anterior abdominal wall as a unique mass and we need to cover our reconstruction with a mesh between this mass and the wall. The abdominal wall is reinforced by mesh, holding the “pipe” in place behind it, leaving the bowel lateral and parietal, preventing recurrence and complications. This parietalization is comparable to the parietalization of the spermatic cord of the inguinal laparoscopic hernioplasty. The ostomy bowel remains against the lateral cranial abdominal wall, from proximal to distal finishing at the stoma. When the stoma is too low, under the arcuade line of the posterior rectus sheath, the peritoneal opening is facilitated and muscle fiber exposition is clearer and could allow placing the mesh in a retromuscular layer totally preperitoneal, covered by the lower abdomen peritoneal sac, which is better for fixation of the mesh and decreases postsurgery recovery time and pain (Fig. 4).
Fig. 4
Mesh placed in the parastomal repair
Lateral Defects
Lateral hernias comprehend a variety of diseases located far from the midline, usually in the lateral muscles. Different from the parastomal, these types of hernias do not have a bowel or colon passing through the defect. However, they tend to be hard to repair because of the lateral muscle hypotrophy [32] and difficult places to work on, such as subcostal or close to the iliac bone.
The abdominal gas insufflation as shown before follows Palmer’s point needle entry [25, 26]. The blind insertion of a Veress needle must be preferred at this point, left subcostal, 2 cm below the costal margin, to create the pneumoperitoneum. Care must be taken to avoid adhesions. The entrance of the camera port should be at least 20 cm away from the defect, as proposed by the da Vinci rules. The other trocars are placed following the same rule, forming a semicircle opposed to the defect. Some situations require an assistant port to help in the adhesiolysis and mesh placement . After completing that it is time to dock the robot and proceed with the surgery.
Adhesiolysis
The main objective of the minimally invasive hernia repair is to get the entire abdominal wall in which the defect is located free from adhesion. A wide space must be cleared to place a mesh at least 5–8 cm wider than the primary defect. At this time the robot confers stability and safety to the dissection; sometimes it is hard to reach the correct spot when working with standard laparoscopic instruments (Fig. 5).
Fig. 5
Dissection of lateral hernia
During the procedure the assistant, by the patient’s side, is very important, pushing the external hernia bulge in and out as the dissection goes on and correctly measuring the defect and mesh to put in. She can also prepare the mesh to be inserted and make marks in it to facilitate its handling inside the patient’s cavity. The hernia size is measured from all limits of the defect including the edge where the fixed bowel is hiding it. In the sequence it is time to repair the defect.
Mesh Repair
After the completion of the adhesiolysis a wide space is now seen by the surgeon. With the benefit of the robotic 3D view the lateral muscular planes can be well delineated, helping the surgeon achieve the correct closure of the hernia. Many studies show the benefits of the closure of the defect and in this particular case it can be done in a more proper way [33, 34] (Fig. 6a, b).
Fig. 6
(a, b) Closure of the lateral defect
A mesh is then inserted inside the peritoneal cavity and fixed with a minimal distance of 5–8 cm wider than the previous defect. Although tackers may be applied, using robotic technology, as discussed in the chapter, “Lower Abdomen Midline Defects,” the mesh can be fixed by sutures reducing the rate of complications [31]. The mesh used has to be composed in order not to have problems regarding adhesions or bowel injuries. Double crown fixation seems to be more stable and is the recommendation in these patients (Fig. 7).
