The ports are positioned with the established principles of triangulation similar to conventional LVHR (Fig. 2). It is important to place the trocars as far from the defect as possible without sacrificing range of motion based on potential collisions with the upper and lower extremities.

As in any minimally invasive surgery, the first step is to gain safe intra-abdominal access which may be difficult in the reoperative abdomen. Sites of previous operative intervention will certainly influence the strategy. Optical entry with a 5 mm trocar at Palmer’s point with or without initial Veress needle insufflation in the left upper quadrant is generally safe.

A 12 or 8 mm trocar for the camera is placed as far lateral to the ipsilateral edge of the defect. As a general rule we place the camera trocar a minimum of 15 cm away from the ipsilateral edge of the hernia defect. This allows for visualization, dissection, and instrumentation on the side closest to the ports. An 8 mm robotic trocar is placed in the lower lateral abdomen and the initial 5 mm optical trocar is then replaced with an 8 mm trocar. Final configuration of the trocars for an SI robot are typically in a V configuration (Fig. 2). Additional trocars on the contralateral abdomen or an assist trocar are typically unnecessary, but this may vary depending on surgeon comfort.

Following port placement and satisfactory patient positioning, the robot is docked directly over the lateral abdomen and in line with the trocar sites (Fig. 3). Instrumentation includes a grasper, monopolar scissors, and a needle driver. A 30° up scope is used to begin the case and may need to be switched to a 0 or 30° down when progressing to the contralateral abdomen.

As with conventional laparoscopy, the anterior abdominal wall is meticulously cleared of all adhesions to delineate the full extent of the defect as well as uncover any other sites of herniation. Care must be taken to avoid not only injury to intraperitoneal viscera, but also to avoid injury to the peritoneum which may complicate preperitoneal dissection. If bowel manipulation is required, a lower grip strength grasper is utilized to avoid iatrogenic serosal injury.

Starting a minimum of 5 cm from the edge of the defect, the peritoneum is incised using scissors (Fig. 4). This will allow for the placement of mesh with a minimum of 5 cm overlap on the side ipsilateral to the working ports. Ideally, the incision is often made within the visible preperitoneal fat that underlies the rectus muscle. The plane of dissection is more readily entered in this manner without causing disruption of the overlying posterior sheath. The preperitoneal plane is developed widely in a cephalad to caudad direction with a combination of meticulous blunt and sharp dissection. Sweeping with the blunt edge of the scissors is an effective technique to separate the peritoneum from the posterior sheath. Cautery is sparingly applied to avoid thermal injury that may result in peritoneal defects. The hernia sac is reduced and further dissection continues laterally (Fig. 5). Wide preperitoneal dissection is performed to allow for the placement of a large mesh based on the original size of the defect (Fig. 6a, b). If the preperitoneal space is deemed inaccessible, the procedure may be converted to placement of an intraperitoneal coated mesh subsequent to primary closure of the defect.

After the preperitoneal space is widely dissected, the hernia defect is primarily closed with absorbable suture (Fig. 7a, b). In order to minimize operative time, the author prefers to use knotless barbed suture in a running fashion. The subcutaneous tissue situated at the dome of the defect is incorporated within the primary closure. This effectively obliterates the anterior dead space minimizing the risk of seroma formation. This technique also minimizes the risk of postoperative skin bulging. Desufflation of the abdominal cavity to a pressure of 6–8 mm Hg may facilitate primary closure and linea alba restoration.

An appropriately sized uncoated mesh is introduced into the abdominal cavity via the 8 mm trocar. The mesh is placed flat against the abdominal wall and fixated with either tacks or sutures placed at cardinal points (Fig. 8a, b). A minimum of fixation points is used to accomplish flush approximation of mesh against the abdominal wall.

Following adequate fixation, the peritoneum is reapproximated to cover the mesh completely with either running suture or tacks (Fig. 9a, b). Peritoneal rents should be repaired to prevent bare mesh exposure to the visceral content. The fasciae for all 10 mm or greater trocar sites are closed with absorbable suture under direct vision.