Intraperitoneal access is gained with a 5 mm optical viewing trocar at the tip of the 11th rib along the right costal margin. Once pneumoperitoneum is established, a 12 × 150 mm balloon tip trocar and 8 mm bariatric length robotic trocar are placed along the lateral right side along the midaxillary line. The initial 5 mm entry trocar is switched to a similar 8 mm bariatric length robotic trocar (Fig. 8.2).

A diagnostic laparoscopy is performed, and a lysis of adhesions is carried out similar to the laparoscopic technique, prior to docking the robot. If an area of around 2–3 cm is clear in front of the robotic trocars, the lysis of adhesions can be carried out with robotic assistance.

The robot is docked with the sidecart perpendicular to the patient bed. The center column is aligned with the patient’s anterior superior iliac spine (Figs. 8.3 and 8.4). This allows working room for the assistant at the bedside between the sidecart and the patient’s right arm. Adhesiolysis can be completed at this time.

The hernia defect is identified (Fig. 8.5) and measured intracorporeally using a ruler.

The Rives retromuscular repair commences by incising the posterior rectus sheath vertically, close to the edge of the hernia. The dissection is extended at least 5–7 cm above and below the hernia to allow for sufficient mesh overlap. The retrorectus dissection commences by peeling the posterior rectus sheath away from the posterior aspect of the rectus muscle (Fig. 8.6).

Care is taken to preserve the segmental innervation to the rectus muscle, which enters the retromuscular plane at its most lateral aspect. Identification of these nerves signifies the extent of the lateral dissection.

Once the lateral edge of the rectus sheath is reached, the transversus abdominis muscle is identified below the posterior sheath. The TAR is most easily begun in the upper abdomen, near the costal margin where the transversus abdominis muscle is more robust; however, the TAR can also be initiated in the lower abdomen (Fig. 8.7).

The division of the muscle is the extended inferiorly, where it becomes less muscular and more aponeurotic. This will divide the transversus abdominis muscle along its entire length. It is critical that the line of transection remain medial to the neurovascular bundles. Once the muscle is divided, the pre-transversalis fascia or preperitoneal plane will be exposed. Both the peritoneum and transversalis fascia are visible below the muscle. Lateral dissection can continue in either of these planes. The preperitoneal plane usually separates more easily, but the peritoneum can be extremely thin. The pre-transversalis plane is more difficult to develop but may be necessary if the peritoneum is too thin. A blunt dissection is performed from medial to lateral, peeling the peritoneum or transversalis fascia away from the cut transversus abdominis muscle (Fig. 8.8).