Robotic eTEP Retrorectus Rives-Stoppa Repair for Ventral Hernia

Minimally invasive repair for ventral and incisional hernias has rapidly improved over the last years, mostly due to the introduction of new robotic techniques. With the introduction of the robotic extended view totally extraperitoneal repair (eTEP), which combines the best aspects of laparoscopic and open surgery without the disadvantages of either, minimizing entry into the abdominal cavity is now possible. With robotic eTEP retrorectus hernia repair, the robotic ports are placed directly into the retrorectus space. Using the crossover technique, the retrorectus spaces are combined with a preperitoneal bridge of the peritoneum. The defects are closed robotically, and the mesh is placed within the retrorectus space. Here, we present the robotic eTEP retrorectus Rives-Stoppa repair of an upper midline primary ventral hernia in a 63-year-old female.

This is a 63-year-old female with hypertension, asthma, and bipolar disorder who has an upper midline primary ventral hernia. Her past surgical history is significant for tonsillectomy, tubal ligation, and an open appendectomy through a right lower quadrant incision for perforated appendicitis. She has not had any incisions through the hernia site. She is 5 foot 5 inches with a BMI of 32 kg/m². The hernia is partially incarcerated and causing significant pain to the patient. On physical exam, the patient has a large hernia sac containing bowel that is partially reducible but mostly incarcerated. 

A CT abdomen/pelvis without IV contrast is obtained prior to surgery for incisional hernia and larger ventral hernias, especially when the robotic extended totally extraperitoneal (eTEP) technique is planned. The CT images are reviewed not only to evaluate the morphology of the hernia, but also to detect occult hernias that may require more extensive surgery, to measure rectus muscle width to ensure that the retrorectus eTEP access is possible, and to determine if the transversus abdominis muscle release (TAR) component separation may be necessary. Knowing these variables further aids the surgeon in adjusting the operating room schedule appropriately.  

In this case, CT abdomen/pelvis without contrast shows a midline fascial defect that is 6 cm wide and 5 cm long and contains the transverse colon (Figure 1 & Figure 2). An occult small fat-containing umbilical hernia is also seen. The combined size of the defects is 6 cm x 8 cm. Additional incidental findings include several benign hepatic cysts and hepatic hemangiomas.

           Figure 1. Pre-operative CT scan - sagittal section                               Figure 2. Pre-operative CT scan - transverse section

There are multiple options for repairing this patient’s large ventral hernia and small umbilical hernia. Based on multiple studies, a mesh is recommended to reduce the recurrence rate in hernias greater than 2 cm.¹ Therefore, in this patient with a 6-cm wide hernia defect, a mesh is recommended. A permanent synthetic mesh will be the most economical and practical choice in this clean case. This mesh can be placed in multiple positions within the abdominal wall:  intraperitoneal, preperitoneal, retrorectus, and onlay.  

In the traditional laparoscopic approach, a coated mesh is usually placed in the intraperitoneal (underlay) position (IPOM). The benefits of a laparoscopic IPOM approach include small incisions and the ability to achieve good mesh overlap.^2, 3 The downsides include pain due to transfascial sutures and penetrating fixation tacks, difficulty in closing the fascial defect, and the need to place the mesh intraperitoneally against the bowel. ⁴ In the laparoscopic approach, the mesh is usually not placed extraperitoneally due to the technical challenge of developing the extraperitoneal space.  

With open surgery, the mesh can be placed in the intraperitoneal position, retromuscular position, or onlay position. The open approach is advantageous for several reasons: the ability to close most fascial defects, the ability to use cost-effective uncoated mesh, no expensive equipment is needed, and no specific expertise is necessary. The retromuscular approach is popular due to excellent mesh incorporation against the rectus muscle, the lack of adhesions in the retrorectus space, and low recurrence rates. The main disadvantage of open surgery is the large open incision that carries a higher surgical site infection (SSI) and surgical site occurrence (SSO) rate. 

The introduction of robotic eTEP ventral hernia repair promises to combine the best aspects of laparoscopic and open surgery without the compromises of either technique. With robotic eTEP retrorectus hernia repair, the robotic ports are placed directly into the retrorectus space. Using the crossover technique, the retrorectus spaces are combined with a preperitoneal bridge of the peritoneum. The defects are closed robotically, and the mesh is placed within the retrorectus space.

With the technical capabilities of the precise robotic instruments and the ability of the operating surgeons to perform the procedure in the comfort of a sitting position, large defects can be closed much more easily than laparoscopy, not dissimilar to open surgery, but with much smaller incisions.  Furthermore, eTEP utilizes the familiar retromuscular space to place a large piece of non-coated mesh for excellent overlap. In these situations, a medium-weight, macroporous polypropylene mesh (~50 g/m²) is preferred by us. These meshes have larger pores to reduce scar plate formation, but have sufficient ball burst strength for large-defect reinforcement. If more space is needed or tension needs to be released, a component separation can be performed via TAR in a minimally invasive fashion.  

Robotic eTEP retrorectus hernia repair has broad indications. It is a reproducible technique for most incisional hernias. The typical patient with midline or off-midline incisional hernias is the usual candidate for eTEP. Common contraindications for incisional hernia repair, not specific to eTEP, include active smoking status, poorly-controlled diabetes (i.e. HbA1C > 7.5), poor nutritional status, and BMI > 40 kg/m².^5, 6 Some contraindications used by us specific to robotic eTEP retrorectus repair include rectus width of less than 5 cm, patient height of less than 5 feet, and a previous violation of the retrorectus space (e.g., previous Rives-Stoppa repair).  Since eTEP involves cutting the posterior rectus sheath, which is a component separation of the abdominal wall, eTEP is avoided by us in patients who may have functional deficits with the division of the posterior rectus sheath. For example, athletes and laborers may notice a loss of abdominal core strength and function if the posterior rectus sheath is divided.

In summary, the ability to close large defects with excellent mesh overlap in the retrorectus space, the reproducibility of the technique, the flexibility to add a unilateral or bilateral TAR during the operation, the low length of stay, and the minimal wound complications make the robotic eTEP retrorectus hernia repair technique our procedure of choice for incisional hernia repair.  

Positioning

The patient is placed in the supine position. The arm on the side of port placement is tucked. This allows the surgeon and assistant to stand on the same side during the initial port placement. The other arm can be left untucked. The entrance through the left rectus muscle is preferred by us, which is the reason for the patient's left arm being tucked. Unlike other robotic hernia repair techniques, the bed does not need to be tilted or flexed.

Prep

The entire abdomen is shaved as needed, then prepped and draped in the usual sterile fashion. The prep should go well onto the flank in order to perform a bilateral transversus abdominis plane (TAP) block.

Prior to start

An ultrasound is performed on the abdominal wall after the abdomen is prepped. The ultrasound is used to identify the ipsilateral linea semilunaris to ensure the ports are placed just medial to the linea semilunaris. Once the linea semilunaris is identified by ultrasound, a line is drawn with the skin marker to mark this landmark externally for later identification during optical entry. The contralateral linea alba is also identified and marked. This mark is useful during crossover later. Frequently during the crossover, the linea alba is difficult to identify internally, which may result in accidental injury to the diastatic linea alba. If the surgeon misidentifies the diastatic linea alba as posterior rectus sheath during crossover and incises the diastatic linea alba, an unwanted iatrogenic hernia is created. By having the external marking over the contralateral linea alba, the bedside assistant can insert a needle through the line marking on the abdominal wall until the surgeon can see the needle internally, thereby providing the surgeon a visual of the linea alba location.

Once the ipsilateral linea semilunaris and the contralateral linea alba are identified and marked, a bilateral TAP block is performed. An echogenic needle and an Exparel solution consisting of 20 ml of Exparel, 30 ml of 0.25% Marcaine, and 30 ml of saline were used to perform the TAP block. 20 ml of this solution is injected in each TAP plane between the internal oblique and the transversus abdominis muscle lateral to the linea semilunaris.

Once the ultrasound and TAP blocks are done, the eTEP operation begins.

Port placement planning and philosophy

For most robotic eTEP incisional hernia repairs, we prefer to place the ports medial to the linea semilunaris, lined up in a vertical fashion. This is a very flexible universal port placement strategy since it allows access to the full midline abdominal wall from xiphoid to pubis. It is not uncommon to find additional incisional hernias or occult primary midline hernias not seen on CT scan. A port placement strategy that allows unplanned expansion of the dissection space is critical to address the occult hernias properly. The flexibility of this port placement also allows the surgeon to fix very long midline hernias without the need for additional ports or redocking the robot. Upper or lower abdominal port placement hampers the surgeon’s ability to reach certain areas of the midline, which results in the need for additional ports and redocking the robot or risk inadequate dissection with inadequate mesh overlap. Furthermore, robotic eTEP incisional hernia repair is a technically challenging operation with a steep learning curve. Using a consistent but flexible port placement strategy allows the surgeon to overcome the learning curve more rapidly.

Port placement

We prefer to enter in the left upper quadrant about 2 fingerbreadths below the costal margin and 1 cm medial to the linea semilunaris (as identified by ultrasound earlier). An 8-mm horizontal incision is made through the skin. A local anesthetic is not injected at this time, as the anesthetic can enter the port obturator and obscure visualization of the tissue. An Applied Medical Kii Fios trocar with a 0-degree 5-mm laparoscope is used to dilate through the tissue. The advantage of this specific port is the ability to insufflate while the scope and obturator are still in the port. Using a back-and-forth twisting motion, the port is slowly pushed through the subcutaneous tissue. Next, the white anterior fascia will be dilated and the rectus muscle, which is red, will be entered. When the tip of the obturator is noted to be in the retrorectus space, the dilation and pushing are temporarily stopped. High flow insufflation is initiated at 15 mmHg. The surgeon should be patient at this point and watch the CO₂ slowly expand the retrorectus space. The posterior rectus sheath will be slowly pushed away from the rectus muscle by the CO₂ insufflation. Once an adequate amount of space has been created by the CO₂ insufflation, the port and obturator are carefully pushed into the retrorectus space in the caudal direction. Next, a side-to-side sweeping motion to lift all of the fibroareolar tissue off the posterior rectus sheath is used. The goal is to keep the obturator in the plane directly on the posterior rectus sheath. This plane of dissection will prevent injury to the epigastric vessels and the major neurovascular bundles. Enough retrorectus space should be developed to allow placement of a second port 7 cm caudal to the first port. This second port should be an 8-mm robotic port. It is critical to insert this port as lateral as possible since the scope will be inserted through this port, and the surgeon will want the scope to be as far from the linea alba as possible. Once the second port is inserted, an instrument with energy can be used to develop the rest of the retrorectus space. A third port is inserted in the left lower quadrant, about 7 cm caudal to the camera port. Finally, the initial 5-mm port is upsized to a third robotic port.

Extreme care should be taken to avoid penetrating the posterior rectus sheath and peritoneum during initial entry or port insertion. If at any point the posterior rectus sheath and peritoneum are violated, CO₂ will escape into the abdominal cavity. When pressure equalizes, there may not be enough retrorectus working space to insert the ports. To re-establish adequate working space, a 5-mm port will need to be inserted into the contralateral abdominal cavity to desufflate the peritoneal cavity.  

The robot can now be docked. The robot should be driven towards the bed at a 45-degree angle to facilitate docking and leave room for the assistant to work between the patient and the robot. Automatic targeting with the DaVinci Xi robot can be performed at this point. However, manual targeting is preferred since eTEP is not a programmed setting in the robot. Manual docking involves manually rotating the boom until the green crosshairs on the camera port are lined up with the target anatomy (i.e. middle of the hernia). The boom is then lowered or raised to ensure the arms will have enough vertical play to retract or extend as needed during the operation. The left-hand instrument is usually a fenestrated bipolar or a forced bipolar grasper. The right-hand instrument is a monopolar curved scissor. A 30-degree scope is used.

Dissection

Stage 1 (Ipsilateral retrorectus dissection)

When the robotic surgery commences, the surgeon should continue to dissect the ipsilateral retrorectus space and clear the remaining fibroareolar tissue off the posterior rectus sheath. This will allow definitive identification of the linea alba to avoid injury of this important structure during the crossover. Moreover, the CO₂ is usually still contained at this point, which allows the surgeon to dissect the space with more ease. Additionally, the risk of injury to the inferior epigastric vessels will be lowered. The amount of the retrorectus space to develop is dictated by the size of the mesh that needs to be placed.  

Stage 2 (Crossover and dissection of the preperitoneal space)

Once the ipsilateral retrorectus space has been cleared, the crossover can begin. Crossover in the upper abdomen is preferred, where the falciform preperitoneal fat is usually abundant. The crossover begins by cutting the posterior rectus sheath about 1 cm away from the linea alba. The posterior rectus sheath should not be cut too close to the linea alba to avoid weakening or injury to the linea alba, which will result in an iatrogenic hernia.  

Cautery should not be used when initiating the crossover in case there is bowel on the other side of the posterior rectus sheath. Once preperitoneal fat is visible, cautery may be used more liberally, but judiciously. The posterior rectus sheath incision should be continued cephalad and caudally. The preperitoneal fat should be dissected off of the midline. When the hernia sac has been encountered, the entire hernia sac should be reduced. At this point, it is common to accidentally incise the hernia sac or peritoneum and enter the abdominal cavity. This should not be considered a failure. It gives the operating surgeon an opportunity to see within the abdominal cavity and determine the contents of the hernia sac. If extensive adhesions are noted, this is an opportunity to fully enter the abdominal cavity and lyse adhesions to make the sac take-down safer. Occasionally, the sac will reduce very easily, negating the need for extensive adhesiolysis. Once the preperitoneal space has been developed and the hernia sac has been reduced, the right retrorectus space is entered.

Stage 3 (Entry into the contralateral retrorectus space)

If possible, the contralateral retrorectus space is entered at the arcuate line. It is easier to identify the rectus muscle below the arcuate line where the posterior rectus sheath is very attenuated. If the entrance is not near the arcuate line and the exact location of the linea alba is not obvious, the bedside assistant is asked to insert a needle through the ultrasound-marked linea alba to facilitate identification of the linea alba intra-abdominally. This maneuver will help the surgeon to avoid inadvertently cutting medial to the linea alba and causing an iatrogenic midline hernia.  

Just like on the ipsilateral side, the posterior rectus sheath should be incised about 1 cm lateral to the linea alba. The amount of posterior rectus sheath divided should mirror the ipsilateral side.  Once the posterior rectus sheath has been divided, the posterior rectus sheath is separated from the rectus muscle. The retrorectus fibroareolar tissue again should be lifted off the posterior rectus sheath to avoid injury to the inferior epigastric vessels and neurovascular bundles.

Reconstruction

If there are any small defects larger than 5 mm in the peritoneum, they should be closed with figure-of-eight 3-0 Vicryl sutures. If the defects are large, a 3-0 absorbable barbed suture is used for the repair in a running fashion. Reapproximating the posterior rectus sheath without a component separation is not recommended as there will be too much tension. This tension can lead to postoperative suture line disruption and an intraparietal hernia.

There are multiple maneuvers, short of performing a component separation, useful for recruiting tissue to close a larger gap in the posterior. The first involves performing further peritoneal mobilization either cephalad over the falciform or caudally over the bladder into the retropubic space. One can also mobilize the peritoneum in the contralateral groin similar to the dissection performed in a TAPP inguinal hernia repair. These maneuvers are frequently used by authors since native tissue is used, component separation is not necessary, and little additional time is needed. If these simple maneuvers are not adequate, the hernia sac or pseudosac can be recruited from its native position to patch the defect.  This would be a free tissue transfer.  In the same vein, if authors anticipate a large posterior gap during the Stage 2 dissection, authors recruit the hernia sac and kept it tethered to the contralateral peritoneum or posterior rectus sheath. Other patches include using a robust omentum as a patch to prevent the mesh from contacting the bowel. A coated mesh can also be used as an inlay patch. This coated mesh, however, does not replace the usual retromuscular mesh used for hernia repair.

The anterior defect is repaired by reapproximating the linea alba with a 0 long absorbable barbed suture. For most defects larger than a few centimeters, a suturing technique similar to tying a corset with one or more 18-inch sutures is used by us. As shown in the video, we place sutures without tightening as they advance. Once most of the sutures have been used up, we return to the start of the suture line and begin pulling the suture tight to slowly close the defect. Distributing the tension along a long length of the defect makes it easier to close wider defects without breaking the suture or tearing tissue. After the defect is closed, the barbed suture is run back at least two throws to lock the suture.

Mesh

When the posterior and anterior defects are closed, the mesh is inserted. Medium-weight, macroporous polypropylene mesh is routinely used by us. The floor dimensions are measured with a single craniocaudal measurement in the midline and a single transverse measurement at the widest level. The mesh is then trimmed into an oval shape to those dimensions. If a TAR was not performed, the width of the mesh will usually be less than 20 cm. In this case, a 17-cm wide mesh is used. The mesh should fill the space from linea semilunaris to linea semilunaris. For most hernias, this width should give plenty of lateral mesh overlap. The mesh should overlap the craniocaudal direction by at least 5 cm for most hernias. In this case, the aggregate hernia defect measured 17 cm long, and the mesh was 28 cm long, which gave an overlap of about 5 cm in both the cranial and caudal directions.

The mesh is usually not sutured in place since the retrorectus space is a confined space and the mesh should not shift much. Furthermore, macroporous polypropylene mesh should integrate fairly rapidly in the retrorectus space. 

The drains are routinely used if a bilateral TAR has not been performed.

Conclusion of the operation

The retrorectus space is desufflated under direct visualization to ensure the mesh is not overly redundant. The robotic instruments are then removed, and the robot is undocked. The ports are removed. Since the mesh covers the port sites, the fascia does not need to be closed.  The skin is simply reapproximated with interrupted subcuticular 4-0 Monocryl sutures. Skin glue is applied. An abdominal binder is placed around the abdomen.

Minimally invasive ventral and incisional hernia repair has rapidly evolved over the last several years, mostly due to the introduction of new robotic techniques. By leveraging the advantages of laparoscopy and open surgery without the disadvantages associated with these traditional methods, robotic surgery provides the potential to further reduce recurrence and complication rates, reduce the length of stay, and speed recovery after surgery. Additional benefits include the ability to consistently close the fascial defect, utilize the retromuscular space in a minimally invasive fashion, provide excellent mesh overlap, and add component separation when needed without the need for a larger incision. With the introduction of the robotic eTEP retrorectus repair, the potential for minimizing entry into the abdominal cavity is now also possible.

In this case, a robotic eTEP retrorectus Rives-Stoppa repair is performed for the repair of an upper midline primary ventral hernia that was partially reducible but mostly incarcerated, and greater than 6 cm in a 63-year-old female with a history of hypertension, asthma, and bipolar disorder. Since a mesh is recommended to reduce recurrence in hernias greater than 2 cm, a 17-cm wide, 28-cm long, medium-weight, macroporous polypropylene mesh is used to cover the large defect and to overlap the cranial and caudal directions of the hernia by at least 5 cm. The procedure is completed without any complication. 

This patient stayed one night and was discharged on postoperative day 1. Most patients can be discharged on the same day or the next day depending on the size of the hernia. Patients are given an unrestricted diet and are encouraged to ambulate right away. With the TAP block and minimally invasive surgery, most patients take Tylenol, ibuprofen, and hydrocodone for postoperative pain. They are encouraged to wear the binder for one month. Patients are allowed to shower on postoperative day 2 and are asked to avoid strenuous activities for at least one month. Patients are usually seen two weeks after surgery. If patients are doing well, they are seen about two months, six months, and one year after surgery. After one year, follow-up is expected to be done annually indefinitely.

• Portable ultrasound device
• Applied Medical Kii Fios trocar with a 0-degree 5-mm laparoscope
• DaVinci Xi robot
• Medium-weight, microporous polypropylene mesh

• Intuitive Surgical – Consultant, Course instructor
• BD – Consultant, Advisory Panel
• Medtronic - Consultant

The patient referred to in this video article, Jacqueline Blueitt, has given her informed consent to be filmed and is aware that information and images will be published online. Ms. Blueitt has requested to be mentioned by name where appropriate. 

The authors would like to thank Ms. Jacqueline Blueitt for her contributions to the improvement of medical education.