Robotic Ventral Hernia Repair
Technologic advances in surgery are often received with equal parts enthusiasm and skepticism. Perhaps no such advancement has created as much heated debate as the introduction of the robotic platform in general surgery. The limited clinical benefit and g
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Jeremy A. Warren and A.M. Carbonell
49.1 Introduction The optimal surgical approach for the repair of ventral incisional hernias remains a subject of considerable debate. Use of a minimally invasive or open approach, combined with a variety of mesh choices, positions in the abdominal wall, and fixation constructs, produces numerous options for repair and makes direct comparisons impossible. The RivesStoppa technique is widely considered the gold standard for open VHR, and is our preferred open technique. This is performed by incising the posterior rectus sheath in order to enter the retrorectus plane, dissecting the posterior rectus fascia from the overlying muscle laterally until the semilunar line is reached, followed by complete closure of the posterior fascia, placement of mesh behind the rectus muscle over the closed posterior fascia, and reapproximation of the anterior fascia. Advantages of this approach include placement of mesh in a well-vascularized, contained compartment separate from the viscera, and restoration of native functional anatomy. However, wound morbidity remains problematic, and mesh selection varies widely. While wound complications are significantly decreased with laparoscopy, this approach requires intraperitoneal placement of mesh, and is limited in its ability to restore the functional anatomy of the abdominal wall. The long-term outcomes of intraperitoneal mesh are poorly studied. Despite multiple available barrier coatings designed to prevent adhesions, subsequent abdominal operations are necessary in up to 25 % of patients, and the presence of intraperitoneal mesh increases the complexity of those operations and creates a higher risk of secondary
J.A. Warren (*) University of South Caroline School of Medicine Greenville, Greenville, SC, USA e-mail: [email protected] A.M. Carbonell Department of Surgery, Greenville Health System, University of South Carolina School of Medicine, Greenville, SC, USA
mesh complications. Reoperation is associated with longer operative times, potential for secondary mesh infection, and incidence of enterotomy or unplanned bowel resection in as many as 20 % of cases [1–4]. Our technique for robotic retromuscular VHR (rRMVHR) utilizes the robotic platform to replicate the open retromuscular hernia repair with a minimally invasive approach, conferring the benefits of both the traditional Rives-Stoppa repair with those of laparoscopy, while minimizing the negatives of each approach [5].
49.2 Overview of Current Literature The use of the robot for ventral hernia repair was first reported in 2003. Ballantyne reported two patients with small defects repaired telerobotically using a standard intraperitoneal placement of mesh [6]. Using a porcine model, Schluender also described the technique for intraperitoneal mesh repair, focusing on intracorporeal suturing of the mesh to the abdominal wall as a means of potentially reducing postoperative pain associated with traditional tacking devices and transfascial sutures used to secure mesh during laparoscopic V
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