Robotic Transabdominal Preperitoneal (rTAPP) Hernia Repair for Ventral Hernias
Robotic hernia repair is an emerging technique born from well-established principles of both laparoscopic and open ventral hernia repair. Its growing popularity in the United States perhaps can be explained by enhanced 3D visualization, precision, and erg
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Conrad Ballecer and Alexandra Weir
35.1 Introduction Robotic hernia repair is an emerging technique born from well-established principles of both laparoscopic and open ventral hernia repair. Its growing popularity in the United States perhaps can be explained by enhanced 3D visualization, precision, and ergonomics. There are also inherent limitations of conventional laparoscopy which make it difficult operating high on the anterior abdominal wall, many of which may be overcome with the use of the robotic instrument. There is a growing body of literature which promotes keeping mesh out of the intraperitoneal cavity secondary to bowel erosion and adhesions which may complicate subsequent abdominal operations [1, 2]. The robotic platform enables exploitation of the individual layers of the abdominal wall. Virtually any well-established surgical plane of the abdominal wall can be exploited and dissected for the subsequent placement of mesh in a sublay position, effectively protected from the visceral cavity by the body’s own autologous tissue. While this approach has been demonstrated with conventional laparoscopy, it remains technically challenging [3]. In this chapter, we introduce the robotic transabdominal preperitoneal (rTAPP) approach for hernias of the anterior abdominal wall.
35.1.1 Surgical Anatomy It is critical to have a thorough understanding of the layers of the abdominal wall in order to properly execute this technique. The technique of r-TAPP ventral hernia repair is borrowed from conventional laparoscopic TAPP for inguinal hernias in which the peritoneum is incised and dissected off C. Ballecer, M.D., M.S., F.A.C.S. • A. Weir, M.D. (*) Department of Surgery, Maricopa Integrated Health System, 2601 East Roosevelt Street, Phoenix, AZ 85008, USA e-mail: [email protected]; [email protected]
the transversalis fascia, the hernia sac is reduced, and a mesh is placed within this retroinguinal space. For hernias of the anterior abdominal wall, preperitoneal mesh size is based on the original size of the defect and adheres to the well- established principles of maintaining 5 cm overlap in all directions. This approach is best suited for smaller or medium size hernias that do not require component separation and can include hernias in atypical locations such as flank, suprapubic, retrosternal, and subxiphoid defects. The authors feel that there are many advantages to placing mesh in a preperitoneal position: 1. Eliminates the requirement for placing coated intraperitoneal mesh (IPOM). 2. Allows the mesh to incorporate on both faces, eliminating placement of full-thickness transfascial suture fixation which is associated with both acute and chronic pain [4, 5]. 3. Minimizes complications associated with leaving mesh in an intraperitoneal position, i.e., adhesions and bowel fistula.
35.1.2 Preoperative Considerations Obtaining a thorough history and physical is mandatory to coordinate and execute an effective preoperative plan. Specifically, certain comorbidities, such as diabetes, obesity, smoking
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