The essential steps of robotic hernia repair are analogous to that of conventional laparoscopic repair. Adhesiolysis of the abdominal wall to isolate the hernia defect must be performed meticulously. The dV platform facilitates adhesiolysis through its 3-D visualization, tremorless precision, and superior ergonomics. For direct bowel handling, the dV fenestrated bipolar grasper results in less trauma to serosal tissue. It is important to emphasize the loss of haptic feedback when performing robotic surgery. This drawback is overcome by the improved ability to see individual stretch fibers. Special attention is therefore required to prevent inadvertent bowel injury and excessive bleeding by way of atraumatic handling and judicious use of cautery. Clearing the entire abdominal wall of adhesions is mandatory to ensure complete evaluation. In dense adhesions the robotic harmonic scalpel may facilitate hemostasis.

Successful primary closure of the defect is facilitated by the use of the barbed V-loc suture (Medtronic). The ability primarily to close defects without component separation is based on the principles of Ramirez regarding width and location of the hernia defect. Of course this is based on open technique and not working against the forces of pneumoperitoneum . As a general rule, <10 cm wide defects are amenable to primary closure but also depend on body habits and age, being easier to close larger defects in the older population. Desufflating the abdominal cavity to 6–8 mm Hg pneumoperitoneum is often necessary. The suture is introduced into the intra-abdominal cavity through the 8 mm dV trocar. This is facilitated by skeeting the needle facilitating both introduction and removal.

A tissue-separating mesh is used when placed in the intraperitoneal onlay position. The size of the mesh upholds the principle of maintaining an at least 5 cm overlap in all directions. For larger defects primarily closed under certain tension, a wider mesh is utilized. The mesh is rolled and introduced through the 12 mm camera trocar site or assistant port if using a 12 mm.

There are myriad options and permutations of the technique to secure the mesh to the abdominal wall including reproducing the standard LVHR technique with a combination of tacks and sutures, or securing the mesh to the abdominal wall with circumferential suture fixation [19].

With the mesh positioned on the abdominal wall by using a scroll technique or the self-expanding mesh device (Echo mesh, Bard/Davol), a full-length nonabsorbable suture (00 or 0 prolene ethicon) is introduced into the intra-abdominal cavity through the trocar of the needle holder. The external end of the suture situated outside the trocar is secured with a hemostat. This technique avoids excessive suture in the intra-abdominal cavity thereby facilitating fixation. In a running fashion, the suture is then placed around the circumference of the mesh. This may be done with one or two sutures in the larger meshes >30 cm.

Upon completion of mesh fixation, the robot is undocked. Only 10/12 mm trocar fascial sites are closed with a suture passer.

The peritoneum is incised at least 5 cm proximal to the hernia defect. A preperitoneal plane is then developed widely with a combination of blunt and sharp techniques. Care is taken to avoid disrupting the posterior fascia. In the event the posterior fascia is breached and the rectus muscle is visible, it is subsequently closed with suture. The hernia sac is reduced and dissection continues distal to the hernia allowing for placement of an adequately sized mesh. Wide distal dissection allows for the creation of a large flap in which to reperitonealize the mesh completely.

The hernia defect is closed with 0 or 1 V-lock running barbed permanent or long- term absorbable suture (Covidien). Disinflation of the abdominal cavity may need to be employed to facilitate closure.