Most upper abdominal hernias can be approached using a single-dock technique. The patient is placed in a reverse Trendelenburg position on a split-leg table or low lithotomy. The bed is flexed slightly to allow greater clearance of the robotic arms above the patients’ pelvis and legs, particularly the center camera arm. Three trocars are placed across the lower abdomen, and a fourth assistant trocar is placed laterally. The robotic cart is placed parallel to the operative table for docking (Figs. 2 and 3a). Any necessary adhesiolysis is completed and the extent of the hernia defect assessed. Beginning at least 5 cm below the hernia defect, a transverse incision is made through the posterior rectus sheath to enter the retromuscular plane (Fig. 3b). The incision is extended from the semilunar line on one side, dividing the posterior sheath below its insertion on the linea alba to enter the preperitoneal space along the midline (Fig. 4a), and continuing to the retromuscular space contralaterally and ending at the opposite semilunar line. This creates three separate compartments that must be dissected: the right retromuscular space, the midline preperitoneal space, and the left retromuscular space. As each plane is developed cephalad, the only remaining partition is the posterior sheath as it inserts onto the linea alba. This is simply divided to create a contiguous space between these three compartments.

Dissection is continued until the inferior edge of the hernia sac is encountered. When possible, the hernia sac is separated from the subcutaneous tissue and completely reduced, leaving the hernia sac in continuity with the posterior sheath and peritoneal flap. Resection of the hernia sac can be technically challenging, and is not necessary in every case. The peritoneum can simply be incised and the dissection continued in each retromuscular space until the upper extent of the hernia is reached. At this point, the hernia sac is incised to re-enter the midline preperitoneal space above the defect, and dissection is continued at least 5 cm above the hernia in similar fashion as below (Figs. 3c, d and 4b). If there is inadequate space in the retromuscular compartment to accommodate superior mesh overlap, the transversus abdominis fascia and muscle can be divided along the posterior costal margin, entering the preperitoneal space. This plane can then be extended superiorly by stripping the peritoneum from the diaphragm to allow adequate superior mesh overlap. The retroxiphoid space is easily dissected at the midline to complete the dissection.

The hernia is measured intracorporeally using a metric ruler. The defect is then closed using a #1 absorbable self-fixating , barbed suture, including bites of the overlying hernia sac or soft tissue in order to imbricate and obliterate the dead space (Fig. 4c). The dissected space is measured to determine the appropriate mesh size. We prefer a large-pore, midweight polypropylene mesh, which is cut to occupy the entire retromuscular dissected space, and placed against the anterior abdominal wall. The mesh is secured with a few interrupted absorbable sutures. Minimal fixation is typically required, as the mesh should widely overlap the closed defect and be sized to match closely the dimensions of the dissected retromuscular space. Once the posterior sheath is closed, physiological intra-abdominal pressure will aid in maintaining the mesh in position. After the mesh is secured, the posterior sheath is closed transversely using a 2–0 absorbable self-fixating , barbed suture. Any peritoneal defects created during dissection of the hernia sac should be repaired with absorbable suture prior to closure of the posterior sheath (Fig. 4d). The single dock is represented schematically in Fig. 3, with accompanying operative images in Fig. 4.

The retromuscular approach is particularly useful for larger defects, as the release of the posterior rectus fascia facilitates medialization of the rectus muscles towards the midline. The addition of a transversus abdominis release is possible with this approach as well to allow greater medialization, wider overlap, or to address any more laterally oriented defects along the costal margin. The TAR is initiated by incising the transversus abdominis fascia and muscle just below the costal margin and medial to the perforating segmental neurovascular bundles. The preperitoneal plane is then developed laterally as far as necessary, and superiorly along the diaphragm as high as necessary to provide adequate mesh overlap. If a TAR is required, the lower transverse incision will typically need to be extended as well.

The single-dock approach is limited by the caudal extent of the hernia defect. To allow inferior overlap, dissection should begin at least 5 cm below the defect, and instruments are typically unable to reach the abdominal wall within 5–8 cm of the trocar insertion site. As a general rule, hernias that are less than 3–5 cm above the umbilicus are not suitable for a single-dock robotic repair. In these cases, a double-dock technique is used. The patient is positioned supine, arms out, and with the bed flexed slightly. Trocars are placed along the right lateral abdomen along the anterior to mid-axillary line between the costal margin and iliac crest. The robotic cart should be aligned over the patients’ hip, which allows the assistant access to the contralateral upper abdomen for later trocar placement and passage of suture and mesh (Fig. 5). After any necessary adhesiolysis and hernia reduction , the retromuscular dissection is initiated on the left side by incising the posterior sheath just lateral to the linea alba (Fig. 6a). Dissection is continued laterally to the semilunar line, superiorly to the costal margin, and inferiorly at least 5 cm below the hernia defect (Fig. 6b). Beginning just medial to the neurovascular bundles, the TA fascia and muscle are incised to enter the preperitoneal plane, which is extended laterally to approximately the mid-axillary line (Fig. 6c). At this point, three additional mirror image trocars are placed into the dissected preperitoneal space (Fig. 6d). The hernia defect and dissected space are measured in order to size the mesh appropriately. The mesh width is estimated at this point to be double the width of the dissected posterior sheath, and is best measured by passing a spinal needle through the left lateral edge of the hernia defect down to the ruler, which is placed on the posterior sheath inferiorly. The mesh is cut to size, rolled along its vertical axis, and secured to the left lateral abdominal wall with absorbable suture just beyond the left-sided trocars (Fig. 7).