Robotic Ventral Hernia Repair



Robotic Ventral Hernia Repair


Emanuele Lo Menzo

Samuel Szomstein

Raul Rosenthal





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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May 5, 2019 | Posted by in GENERAL | Comments Off on Robotic Ventral Hernia Repair
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