Robotic Ventral Hernia Repair

Emanuele Lo Menzo

Samuel Szomstein

Raul Rosenthal

INDICATIONS/CONTRAINDICATIONS

Ventral hernias occur in 11-50% of laparotomies; however, only 350,000 ventral hernia repairs are performed every year in the United States. The application of robotic techniques to ventral hernia repair is relatively recent. The da Vinci robotic platform (Intuitive Surgical, Inc. Sunnyvale, CA) was approved by the U.S. Food and Drug Administration in the year 2000. Initially, the robot was embraced by specialties in which only single-quadrant operations were performed (urology, gynecology). Only recently have general surgeons developed an interest in the robotic platform, and expanded the indication from single-quadrant operations (cholecystectomy, hiatal hernias, and rectal procedures), to ventral, incisional, and even inguinal hernias.

In general, the indications for robotic ventral hernia repair (RVHR) are similar to the indications for laparoscopic ventral hernia repair (LVHR).

One of the major milestones in the evolution of the technique of ventral hernia repair was reached in the early 1990s when LeBlanc described the laparoscopic approach. Several randomized control trials have demonstrated the major advantages of LVHR over the traditional open counterpart. In fact, LVHR offers minimal soft tissue dissection determining decreased risk of infection and number of overall complications. Other proven advantages of the LVHR are the decreased length of hospital stay and the faster return to work. Furthermore, the possibility of wide mesh overlap of the hernia defect and more complete visualization of the abdominal wall has been linked to lower recurrence rates. Finally, LVHR appears particularly advantageous in obese patients. Although some surgeons have reported decreased postoperative pain, this claim remains a debatable point for both LVHR and RVHR.

However, the steep learning curve of laparoscopy and the often reported longer operating times have contributed to slow unanimous adoption of the laparoscopic technique. The major obstacle in the learning curve had to be attributed to the ability to perform extensive lysis of adhesions in a timely and effective manner and the challenge in manipulating large pieces of meshes in relatively small spaces.

Obviously, the longer operating room (OR) times in the LVHR also translate to higher costs, and hence another reason for the low acceptance of the laparoscopic technique. On the other hand, open repair of ventral hernia allows the freedom to address the skin redundancy and hernia sac, reducing postoperative seromas and, at times, improving the overall cosmesis of the repair.

Recently, to obviate some of the technical shortfalls of LVHR, the proponents of robotic surgery have more widely applied the use of the robotic platform in abdominal wall hernia surgery. The high-definition three-dimensional visualization, the dexterity of the multiple degrees of freedom of the robotic wrists, and the superior ergonomics have been advocated as postulated benefits of the latest application of robotic surgery in general surgery.

Very few contraindications to the use of laparoscopic or robotic technique exist. The contraindications can be divided as anesthesia related and hernia related.

Anesthesia-related contraindications
- Cardiac (i.e., severe coronary artery or valvular disease, congestive heart failure)
- Pulmonary (i.e., severe chronic obstructive pulmonary disease)
- Uncontrolled coagulopathy
- Hemodynamic instability
Hernia related
- Presence of enterocutaneous fistulae
- Mesh erosion
- Significant loss of domain
- History of open abdomen with skin graft closure or large areas of healing by secondary intention.

Although the adhesiolysis might be able to be laparoscopically accomplished, the devascularization of the primary blood supply to the skin graft or granulation tissue from the underlying viscera will lead to abdominal wall necrosis. In this case, the need to remove sizable anterior soft tissue coverage to avoid necrosis obviates the use of laparoscopy or robotic surgery.

The presence of a very large abdominal defect poses the problem of being able to obtain enough mesh overlap in the lateral abdominal wall, but at the same time maintaining room for instrument manipulation and laparoscopic visibility. Also, a relatively recent body of literature has underscored the importance of hernia defect reapproximation to improve abdominal wall function.

PREOPERATIVE PLANNING

A careful evaluation of the patient’s comorbidities and the hernia is paramount to achieve a safe and durable repair.

Some of the factors negatively affecting the outcome are as follows:

Obesity (body mass index ≥ 30 kg/m²)
Current tobacco smoking
Diabetes with glycosylated hemoglobin (HbA1C) ≥ 6.5%
Age over 75 years
Malnutrition
Coronary artery disease

The preoperative strategy specific to the type of repair should consider the following factors:

Previous emergency laparotomies
Immunosuppression—chronic steroid use
Multiple previous repairs
Location and size of the defect

For this reason, a thorough inspection of the previous abdominal incisions with particular emphasis on the history of previous hernia repairs and history of mesh infections is necessary. Every effort should be made to obtain previous operative reports, to understand the type and location of previous repairs and implanted meshes.

The physical examination should focus on location of the defect (central vs. lateral), proximity to bony confinements that might limit mesh overlap (subxiphoid, suprapubic, flank), presence of skin graft or granulation tissue that might become devitalized once the hernia is reduced, and assessment of potential loss of abdominal domain.

Preoperative imaging studies are helpful for defining the anatomy, especially in the setting of multiple previous repairs. In general, computed tomography scan with oral contrast is considered the gold standard to assess the characteristics of the hernia and guide in the preoperative strategy.

SURGERY

Most practices have moved away from full preoperative oral cathartic mechanical bowel preparation because of the increased chance of dehydration, electrolyte imbalance, and, occasionally, the increased intraoperative bowel dilatation. However, the patient receives a first-generation cephalosporin within 1 hour of the incision. All hair in the field should be clipped. A bladder catheter and a nasogastric tube are inserted to decompress the urinary bladder and the stomach, respectively. For hernias near the symphysis pubis, a three-way catheter can be used to facilitate bladder identification during the process of accessing the preperitoneal plane and exposure of Cooper’s ligaments.

Positioning

The patient is positioned supine on the OR table, ideally with both arms tucked (Fig. 67-1). This position will allow both the surgeon and the camera holder to comfortably work from the same side of the patient and protect important pressure points.

FIGURE 67-1 The patient is positioned supine on the operating room table with both arms tucked. The field is prepped widely. Iodine-impregnated drapes can be used.

Technique

Trocar Placement/Adhesiolysis

The access to the abdominal cavity should be away from the hernia defect, to avoid visceral injury and prevent sizable incision directly over the prosthetic mesh. Usually, the abdomen is accessed in the left subcostal area (Palmer’s point), or right subcostal area as an alternative, using an optical trocar. When severe adhesions in the upper quadrant are expected, an open Hasson technique is utilized. It is important to keep this first trocar site close to the costal margin and as lateral as possible. This placement will preserve the functionality of the trocar, while maintaining it lateral to the lateral edge of the mesh (Fig. 67-2). However, the insertion of the trocar lateral to the anterior axillary line or with an angle perpendicular to the table might result in insertion into the retroperitoneum, or in colonic injuries. Two additional accessory trocars are then placed as lateral as possible along the lateral abdominal wall. Additional trocars might be necessary on the contralateral side for visualization and fixation of the other side of the mesh. It is important to remember that the operating arms of the robotic platform require 8-mm trocars. Most of the authors who perform RVHR will proceed with the adhesiolysis laparoscopically. However, some of the proponents of RVHR argue that the enhanced 3D visibility and the robotic wrist articulation facilitate this part of the procedure as well. The hernia sac is usually left in place.

Hernia Defect Management

The defect is measured either by introducing a ruler in the abdominal cavity or by measuring the corresponding external landmarks (Fig. 67-3). Although the measurement of the defect using an external
landmark is faster and more practical, it results in overestimation of the defect itself, particularly in obese individuals, even after completed abdominal desufflation. The goal is to obtain an overlap of the mesh of 3-5 cm in all directions; multiple defects are collectively sized. Also, in cases in which primary fascia closure is planned, the size of the mesh should be based on the extent of the defect before its closure.

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