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Robotic eTEP Retrorectus Rives-Stoppa Repair for Ventral Hernia

Rockson C. Liu, MD, FACS
Alta Bates Summit Medical Center

Transcription

CHAPTER 1

Hello, I am Rockson Liu. I'm a surgeon in Oakland, California, and I'm with a group called Epic Care and I'm currently operating at Alta Bates Summit Medical Center in Oakland. We have three Xi robots and we are a hernia epicenter with Intuitive. Today, We have a robotic eTEP retrorectus, or Rives-Stoppa repair of a ventral hernia. This is a 63-year-old female with a primary supraumbilical ventral hernia. The defect is about 5 cm wide by about 6 cm long. She also has a small umbilical hernia and a diastasis of about 6 cm. She has incarcerated colon in the hernia that is not reducible on physical exam. With the robotic eTEP approach, today you're going to see a left lateral port placement, which is my standard port placement for most midline ventral and incisional hernias. We're going to demonstrate the entry with the optical trocar and the ability to insufflate during an optical entry, and I'm going to show you how I place the ports. Prior to placing the ports, we're also going to perform an ultrasound to identify the linea semilunaris on the ipsilateral side and the contralateral linea alba and we're also going to perform a TAP block. Once the robot is docked, I'm going to separate the operation to three stages. The first stage is the left retrorectus dissection and identification of the left linea alba. Then the second stage is going to be crossover into the preperitoneal space through the posterior rectus sheath and take down of the hernia sac. And then the third stage is going to be dissection of the right retrorectus space by first dividing the posterior rectus sheath on the right side, entering the retrorectus space, and then separating the posterior rectus sheath from the rectus muscle. Following that, we're going to close any defects in the posterior layer and then reapproximate the linea alba to both fix the ventral hernia and also plicate the diastasis. Finally, we're going to place the mesh. Usually I use a medium-weight, macroporous polypropylene mesh. We're going to aim for at least 5 cm overlap in all directions. So this operation satisfies most of the modern day ventral hernia principles, which is closure of the fascial defect, wide mesh overlap, extraperitoneal mesh placement with an uncoated mesh - macroporous, medium-weight mesh. And then minimal fixation so that there is a minimal use of sutures and tacks - no use of tacks, so that patient will have less pain after surgery. So the first thing I do is perform an ultrasound to identify the linea semilunaris on the side I'm entering. Usually I enter on the patient's left side. I go into the left retrorectus space. It's much easier as a right-hand surgeon to work the laparoscope from right to left or from cranial to caudal. And also during the dissection, it's easier to go from cranial to caudal since my crossover usually occurs in the epigastrium where there's a lot of falciform fat and it's much easier to cross over. So I use a standard ultrasound probe that anesthesia uses for nerve blocks and vascular access. I use this transverse probe, and there is the ultrasound machine. Okay?

CHAPTER 2

So, the first thing I do is I get the rectus muscle. I find the rectus muscle first. That's the easiest structure to find, and so what I do is I scan transversely left to right. As I'm scanning, you'll see the rectus muscle right there, okay? There is the rectus muscle. Let's change the depth, go shallower. Okay, so as I scan there you can see the rectus muscle taper medially. So that's the linea alba on the patient's left side. And as I scan over, you can see diastasis and the patient's right rectus muscle starts showing up over there. Okay? There's some fat there. So that's the other linea alba. So you could see she has a significant diastasis. Okay? So here's the rectus muscle, and I'm going to scan laterally until I see it taper, and there she's got fairly thin rectus muscle so it's a little harder to clearly identify the linea semilunaris, but I think it's there. Right there, okay? So I'm going to make a marking. I'm going to center it. We center it there. And then here, I'm going to make a marking right at the midline. And I'm going to scan downwards caudally and see where the linea… So the linea semilunaris is actually over there. Okay. Let me scan back up. So in this patient, her anatomy is not as readily identifiable. Her rectus muscle is very thin and it's right there. Let's change the slide contrast. Yeah, okay. Just keep it right there. I think it's going to be right there, okay? Now slide the contrast up brighter again. Okay, good. So right about there, yeah. So I think her linea semilunaris goes this way. So again, I'm going to look at the rectus muscle, keep it centered, and it kind of - so it widens over there, so it keeps coming up. So there's her linear semilunaris. And her costal margin is right here. Okay? And so my entry point is usually about a centimeter medial to the linea semilunaris. All right, that's how I enter the retrorectus space. And right now I'm going to do a TAP block since I can visualize all the structures of the flank muscle. The flank. So, here is the transversus abdominis. the internal oblique, and the external oblique. So the TAP plane is right here between the transverse abdominis and the internal oblique. And this is a - this is a Pajunk needle. This is an Exparel solution containing 20 ml of Exparel, 30 ml of Marcaine, and how many ml of saline? 30 of saline. 30 of saline. So this is a syringe of saline. When you first enter the plane, you want to use saline to ensure that the injection is going into the TAP plane. The Exparel solution creates a lot of bubble artifact, and it's hard to ensure that you're in the correct plane. So once I find the plane I want to enter with the ultrasound probe - the firmer you press, the easier it is to identify the planes. Once I know exactly where my probe needs to be, I relax on the probe a little bit and go right next to the probe. Okay. And you want to see the probe come in. So there's my probe - there's my needle, okay? And I want to see the tip as it travels through the different layers And usually there's two pops. That's a little deep, okay, so go ahead and inject some saline. So you could see that white line almost splitting. Okay? All right, go ahead and inject the Exparel. So we're going to… Yes. So we're going to inject about 20 ml of Exparel into that plane. You can see, with the Exparel, you can't see the plane separate as well. Okay, all right. So that's 20 ml, and this probe is between the costal margin and the iliac crest right here. So now I'm going to go over to the other side and identify the contralateral linea alba, and mark that because sometimes during crossover, the exact location of the linea alba is not easy to identify. Everything is white. The diastatic linea alba looks just like posterior rectus sheath, and you can inadvertently cut into the diastatic linea alba rather than the posterior rectus sheath. So there I have the linear alba centered, and I'm drawing a line on the linea alba. And we can scan down, and you can see there's a hernia right there. We'll stay right above the hernia line. So there's her linea alba. Okay, so during the operation, during the procedure, my assistant can drop a needle right down through here to help me identify the linea alba. And now I'm going to do a TAP block on the contralateral side. Again, the costal margin is right here. Iliac crest is there. I'm going to put my probe right there, okay. And - go right by the probe. Let's see if I can find my needle. Make sure I'm right on it. I'm going to go a little bit more lateral. There's my needle. You see my needle's pushing on the - right there, okay? Just another little pop. Okay, go ahead and inject the saline. It's got some Exparel in there still. All right, so now I'm going to inject 20 ml of Exparel into the TAP. There we go. And this will provide anesthesia to T9 and lower. So around the umbilicus and lower. It's not going to cover the epigastric area, so - I will also need to inject some local up in the epigastric area. So if I can, sometimes I'll do a rectus block. Okay? I will do a rectus block on the right side, but not the left side because when I enter in the left side, I don't want the planes disrupted by the Exparel solution. So I will inject the Exparel later. So again, I find the - find the rectus muscle. I'm going to come in now with the needle and make sure I can see my needle. Okay, let's go ahead and inject some saline. So here I inject 10 ml of it. So I inject about 10 ml into that plane. Okay? All right, good, come on out. All right, so we're done with the ultrasound portion.

CHAPTER 3

So the next step - we're going to enter the left retrorectus space. So here is the patient's hernia, and I'm going to - she has colon within this hernia, and it's mostly reducible. The defect is about here. This is a primary ventral hernia. And the defect's width is almost 8 cm. Okay? With a big sac. So, again, costal margin here, linea semilunaris there. I'm going to enter about a centimeter medial to that, okay? I don't use any local anesthetic to start with just because - the port - has a hole. So, I like to use this port. It's got a little hole right there that allows me to insufflate while the scope is in the port. So there's a little seal there that prevents escape of CO2. May I have a Raytec? So make sure it's nice and dry so blood doesn't get into that hole. So I'm going to focus on the tip. And what I want to do is I want to dilate through the subcutaneous tissue until I come upon the anterior rectus sheath, which is white, and the rectus muscle. And you can see my tip is at the backside, on the dorsal side of the rectus muscle. Now I'm going to insufflate to 50 mmHg at high flow. So can I get insufflation, please? Yep. You see that… So, the system allows me to insufflate while the scope is in, all right? And when it's insufflating, you'll see that the posterior rectus sheath is going to start getting pushed away. And I take my time here. I let the CO2 really perform the dissection for me. This way I don't accidentally drive the port through the posterior layer into the abdominal cavity. We want to maintain CO2 in only the retrorectus space and keep it confined in there. Okay, so now I just slowly drive in. And my goal is to stay right on the posterior sheath if possible and lift up all the fibroareolar tissue. Okay, so I'm going to really take my time. And I'm going to use a sweeping motion from left to right. Okay? And I want to lift up all the areolar tissue. My goal is to get lateral enough so I can put my second port in. So there I just broke through - nice layer. She's got a nice wide retrorectus space, I predict. And one of the contraindications is a patient with a narrow retrorectus space. Usually when the retrorectus space is less than 6 cm, it becomes harder to work in the retrorectus space. Now my port is getting caught because there's a bevel, and so what I do is I will rotate the port 360 degrees until I drive that bevel past the anterior rectus sheath, and now it'll be easier for me to go further. Okay? So, here. And then once I hub the port, I can take out the obturator and perform some more dissection laparoscopically. Okay, so I try to keep this dissection as bloodless as possible. So, my next port should be 6-7 cm away. My three fingerbreadths is 6 cm, four is about 8, so if I can go around here, I think that will be good spacing. I'll take the local. And the local anesthetic on a spinal needle is best in this situation because sometimes there's a lot of tissue to traverse. And there you can see my needle. It's really important to get this port as lateral as possible because this is where the camera is going. This is your eyes. And so the more lateral you are, the - the more working space you're going to have, okay? So this - it's critical to get this port as lateral as you can. So I inject some local anesthetic into the entire layer that I'm going through from rectus all the way to subq. It's really important to take your time to come in with this port. Okay? Because you can inadvertently go too fast, too deep and through the posterior rectus sheath, so I'm taking my time. Watching my - looking for my tip on the screen and just slowly applying pressure. And I really want to do this and take my time because as you can see as I'm compressing and pushing, the rectus is touching the posterior rectus sheath, and as soon as - when you feel loss of resistance, your tip will probably already be through the posterior rectus sheath. So you really want to see the port come in. Okay? Another trick I use is… Let's increase the insufflation pressure, the set pressure, to 20. Okay. So by increasing the set pressure, it'll create a denser CO2 cushion within this space. So there, the pressure's going up. And this space is going to have a harder time collapsing. So you can see there. Now I'm really watching my port come in, okay? And you want to keep an eye on that tip the entire way. And once your port is in, you can take the obturator out. Okay? Let's go back down to 15, please. Okay. And then, let's clean the scope. And I'll take a Maryland. So at this point you can take the green cord for monopolar cautery, and I'll take the foot pedal, please. Attach it to a Maryland, and you can use a LigaSure if you want, or a harmonic. I have a simple Maryland. This sheath helps me prevent contact of the metal of the instrument to the metal of the port. Okay? So this helps me cover it because we're working in a fairly small space and frequently, if we're going through a robotic port, metal can be touching metal. Oaky? So, here. So what I'm going to do is use the Maryland to take some of the larger blood vessels and again, keep this space as hemostatic as possible, okay? Let's turn on the OR lights, please. Okay. And as I get down here… Let's clean the scope again. So I think I have enough space, but I'm just going to create a little bit more space. Again, always stay right on the posterior rectus sheath. If there any larger vessels, take it with a Maryland. Okay? Julie, can you push my sheath down on the Maryland? Yeah, good, okay. Good. And I just need enough space for my next port, okay? There's a little bit of a… Some blood vessels there. Good. Okay? So let's go ahead and put my next port. And I don't want to take too long to put the port in because as you can see, somehow CO2 is still getting into the peritoneal cavity. Okay? So here you could see my needle. That's going to be a good spot for me to bring in my next port. And I'm, again, spaced 6-7 cm away. Okay? So in this operation, we use three 8-mm robot ports. 8-mm incisions. Again, when you come in, you want to go slowly. Make sure you see. Oh, let's clean the scope again. Make sure you see the obturator come in the entire time. Okay. And because of the small space, usually we start with the remote center slightly outside where we want it. Okay. Next we're going to go and upsize the 5-mm port here. I moved the insufflation down to the lower port. All right, so I should be able to see the upper port.

Before I place the upper port, I'm going to just inject some more local anesthetic. This is where I can perform the rectus sheath block that I wasn't able to perform earlier because the Exparel would - let's see. All right, so there's my needle. You could see it right there. And we're just going to inject Exparel in here. And now we'll just bathe the tissue here with Exparel and hopefully provide anesthetic. Okay, so now I'm going to replace the five with a robot port. Okay? All right. So you can see, my ports are lined up along the linea semilunaris about a centimeter medial to linea semilunaris. There is a few blood vessels there. I can take that right now because it may be hard for me to reach it once I have the robot docked. Again, here the Maryland comes in very handy. It's really easy to just take these with monopolar cautery and make sure you don't get much bleeding. You also want to make sure that the area around the camera port is free. This way when you bring the robot scope in, you don't get smudging right away. Okay? So now we're ready to dock. So this patient is supine. We just tuck the arms, both arms. Or sorry, the left arm because I'm working on this side, and it's easier if the left arm's not in the way, but as you can see, the ports are fairly medial. So we're not going to have issues when I'm working on a dome with a pitch of the instrument hitting the arm. In rTAP and robotic iPALM operations, your ports are much more lateral. And when you pitch up, you're going to hit the patient's arms, so you'll want to sling it below the level of the bed. But in this case, we just leave it tucked normally. Since this is a higher hernia, I can leave the patient supine. If it's a lower incisional hernia, I usually put the patient in a Trendelenburg position so that the bladder and bowel fall out of the pelvis.

CHAPTER 4

All right, so we're ready to dock, so I'm going to switch over to the robotic scope. I'm going to undo the Stryker camera and just tuck it away. So we're going to set it to left renal, and for efficiency, I made sure all the cords are on the same side. Oh, another very important thing is to hook up a smoke evacuator, so this is a smoke evacuator, since it's a small space, we're using a lot of cautery, and if you don't have a smoke evacuator, it'll be difficult to see well. All right, hold on one second. I'm going to rotate the boom. So we're coming in from the patient's left side by the leg at an angle, and I'm going to rotate the boom as such, okay? And my assistant is going to drive the robot until the crosshair meets the camera port. Right there, perfect. Okay? And then her - good, right there. And what I did to rotate the boom was press this button behind - it's on arm 4 or 1. And I'm going to line up the target anatomy, which is right here, the hernia, with the camera port. Okay? And that's what the robot does when you do the software targeting. So, let's dock. So I like to meet the arm to the port rather than the bringing the port up because the port is barely in the retrorectus space, and if you moved the port too much, the port will come out of the retrorectus space, okay? The other thing I did with targeting is I made sure that the gray bar is not too small or too big once I dock. So you can see it's kind of right in the middle, all right? So we'll use 1, 2, and 3 today. So I'm going to put a... Scissor? Scissor in my right hand. Monopolar curved scissors with the green cord on it. And then, what do you have next? Camera in the middle. Camera, good. And this will be a 30-degree scope. Okay? And then force bipolar here. This is the dual grip instrument that is like a fenestrated bipolar in it's default mode, and when I step on the yellow pedal it becomes a prograsper. So the first thing I'm going to do is find my lower instrument, lower port. There it is. This is a blunt instrument. So when I move up towards the head, it's less likely to perforate the posterior sheath. I'm going to follow this arm up towards there. All right, so I can see my other port, which means I can come in now with my scissor. Okay? Here we go, now I'm going to burp all the ports. As long as I can see my two instruments in the same field of view, I can start. Okay? The other thing is I'm going to make sure that there's a fist's width between the arms. So this one, I'm going to move out a little bit. Okay? And make sure there's no collisions here. And I think we're good to go now, okay? I'm going to go to the surgery console.

CHAPTER 5

So this is the ipsilateral retrorectus space, the left retrorectus space. Now the next step is to clean out the retrorectus space so I can identify the entire linea alba along the entire length of linea alba that I need to dissect for crossover, so… So I'm working towards the linea alba, okay? And again, I like to keep things hemostatic in order to be able to see all the tissue planes properly, okay? So a little bit of cautery. And it's really important for your left hand to be pushing down well, to put the tissue on tension and to prevent the scissor from accidentally going through the linea alba, or the posterior rectus sheath. Vessels like this need to be divided since we need to crossover close to the linea alba. Okay? So again, I'm just going to keep cleaning until we get everything cleaned out. This is really important because if I start crossing over now and I accidentally get into the abdominal cavity, this space will start collapsing and going down towards the pelvis below the arcuate line will be harder. Okay? So right now I still have confined CO2. So performing this dissection is very easy as you can see since the CO2 is also providing a lot of retraction. Okay? So, again… So the linea alba - I don't always look for it, but if you do need to look for it, it's a seam right there. You can see the posterior rectus sheath meeting up with the anterior rectus sheath, or more specifically, the posterior lamella of the internal oblique meeting up with the anterior lamella. All right, so that's the linea alba. There's no doubt in my mind where the linea alba is when I am performing this operation. Because when you cross over, you do not want to accidentally cut the anterior rectus sheath and cause an iatrogenic hernia. So, as I dissect downwards, I need to move my instrument tip that way. Okay? Sometimes the force bipolar can feel a little long, but you can utilize the wrists and the joints to maneuver in this tight working space. So again, the left-hand push is very important to provide good exposure, good tension on tissue so that your cautery does not have to be activated for too long. So the inferior epigastric is right there. You can see she's got a branch there and a branch there. This is getting close to the linea semilunaris. We're going to want to preserve all the large neurovascular bundles. So there's one right there. So I'm going to move down towards the pelvis. I'm going to want at least probably 8 cm overlap below this defect.And the defect goes to about the umbilicus. So I'm going to want to get below the umbilicus, okay? So here you can see, I can be either in this plane or in this plane. It's usually best to kind of follow and hug the posterior rectus sheath as it gets to the arcuate line and attenuates. So I'm going to divide this since it's in my way. And you can see, I can either be in this plane, which is the retrorectus space, or in this plane, which is also the retrorectus space, but it's behind this retrorectus fat, all right? This is actually the same plane that I've been in, okay? Right here. You can see the difference between this plane and this plane. Okay? And here's the attenuated posterior rectus sheath. It's very thin, but it's there, notice that. And it's almost non-existent, but in robotic surgery, we can actually tease the layers apart, okay? And then I'm going to clean up here and below the arcuate line. So the arcuate line is somewhere around here. There's still a linea alba. You can see this attenuated posterior rectus sheath coming up to the linea alba, and if I cut into it, now I am in the preperitoneal space, okay? And then as I go across, I just cut through the other attenuated posterior rectus sheath, some people call it transversalis fascia. Now I'm in the contralateral retrorectus space, okay? I'm going to stop my dissection into the contralateral retrorectus space because that is actually going to be stage three, which I will perform later. So I'm going to continue with stage one, which is completing my ipsilateral retrorectus space dissection, okay? So there, I can see my linea alba very well. Okay? I'm going to go up and then, as I mentioned before, I want to cross over in the epigastrium if possible. Now the incisional hernia extends into the epigastrium, or the ventral hernia extends into the epigastrium, then I can cross over lower, but the falciform fat is a great companion in this operation because it allows you to cross over without getting into the peritoneal cavity. So I'm just going to get it again… So here my scissor is not going to allow me to go up like this. So I'm going to have my assistant burp the port out, all right? So Julie, can you? Arm 3? Yeah. Burp arm three out of the body. Good, okay. I can also use my force bipolar to perform a lot of this dissection since this is mostly for the areolar tissue. So, you know, I think I was a little inaccurate with the ultrasound assessment of where the linea semilunaris is. So my scissor actually came in very medially. I don't know if you recall from the video, the ultrasound, it was a little hard to identify the linea semilunaris. I kind of erred on being a little too medial rather than too lateral and then outside the linea semilunaris. So that's okay, my scissor will still be able to do what's needed. All right. So that's cleaning out the ipsilateral retrorectus space and identifying the entirely linea. Okay? This hernia doesn't go very high so I won't need to go all the way up to the xiphoid. At least I don't think so right now. So I'm going to stop my dissection here. And let's just get control of this bleeding. Okay, you can see some of my exploration there.

CHAPTER 6

So now I'm going to pick a spot to cross over. And a good spot is usually a centimeter away from the linea alba. So again, the seam of the linea alba is right there. I'm going to go about a centimeter away and during the initial entry into the preperitoneal space - so this is going to be a stage two which is crossing over into the preperitoneal space. I want to just incise the posterior rectus sheath without cautery, because I don't know what's on the other side of the post rectus sheath. It could be bowel. Now this is a primary ventral hernia so the possibilities are low that there's bowel on the inside, but you just never know, and you want to always be safe. And once I cut the posterior rectus sheath, I see fat, which is preperitoneal fat, which is great. That tells me that there's a tissue between me and the bowel. So now I can use cautery a little bit more - more often and still I have to be safe. I'm just going to cauterize more on the ventral side. See these little vessels? I'm going to just take those vessels and then cut the rest. Usually the vessels are more on the ventral side of the posterior rectus sheath, okay? And then once I get a wide window going, I can start taking down the preperitoneal fat And in the next step, I want to take the preperitoneal fat completely off of the linea alba, the diastatic linea alba here - you see that? So there's a little bit of fat on there. It's fine, but you really want to expose the white fibers of the linea alba. Okay, so here I can just use cautery to kind of zip up since there's nice preperitoneal fat, I'm not worried about bowel being stuck in there. Okay, and I'm going to zip up a little bit. Now I don't know how high my overlap is going to be, so I'm going to just stop here, and later, if I find that I need more cephalad overlap, I can always perform a little bit more dissection. So here's a little hernia. It's a little occult ventral hernia in the midline. She's got another one there. So this is a patient who I was planning to just perform a ventral hernia repair, but I may have to repair all these little occult hernias so that she doesn't get more hernias in the future. She's got a pretty wide diastasis, and you can see she's got little hernias here. So I'm most likely going to have to plicate all that. And again, take down all the fat, and this sweeping motion really helps. Once you get in the right plane, you can sweep everything off, all this areolar tissue should be swept off, that's - a lot of times we call it the transversalis. So here I can see some muscle showing up. That's the muscle, the transversus abdominis. It's not necessarily the muscle, the rectus muscle, okay? So I'm going to continue opening up my posterior rectus sheath, and again, staying about a centimeter away so that - that vessel right there, you want cauterize and not allow to bleed, okay? And again, I'm going to - if I'm not sure, I can always insert my scissor in here, push the peritoneum away, create a little bit of separation and then do this. Okay? With primary hernias usually there is a nice hernia sac, a nice peritoneum in the area of the hernia. So the risk of injury to bowel on the other side is low. In incisional hernias, you never know if there's a sac or not, so you always want to be very careful with this crossover. So again, I'm just incising the posterior rectus sheath about a centimeter away from the linea alba. This way there's no chance for injury of the linea alba. Another reason to do this is later on when I'm closing the defect and reapproximating the linea alba, the linea alba can disappear anterior to the rectus muscle. And if I have a veil of posterior rectus sheath like this, it'll be easier for me to identify the linea alba, and make sure I take robust bites with my suture, okay? So as long as this is going well, I will just continue like this. Sometimes in incisional hernias, this part gets challenging because you don't have much of a sac, or there's scar tissue, or there's potentially bowel right up against here, I will go and do easier stuff, but as long as it's going well, I would just open things broadly. It's always easier when you have a nice wide working space, and you achieve that by opening things up broadly in front of you and then move further away from yourself. There's a big vessel there, so I'm going to take that with bipolar. Make sure we don't get bleeding. So my linea alba is not as well identified, so - right there, so that I can move a little bit more medially. So we're getting to the area almost by the arcuate line. Okay? And even when I go past the arcuate line, I'm going to treat this posterior layer like a robust posterior rectus sheath. So I'm still not quite at the arcuate. A lot of patients don't have a discreet arcuate line, all right, so just - you see the plane you're supposed to be in, just stay in the same plane as you go down towards the arcuate line and you won't get into trouble. Right there - see, I'm going to stay right behind the posterior rectus sheath. Right there, stay right behind the posterior rectus sheath and complete my division of the posterior rectus sheath. There's a little bit of attenuated posterior rectus sheath. So, all right? So now I just completed the incision of the posterior rectus sheath. And I'm going to go back to where I was with the preperitoneal dissection. Again, go up and bring all this fat down. Okay? And - this really keeps you out of trouble. Sometimes there's planes that are a little bit deeper, and it's tempting to say no time, but really take all the fat down. This way when you come upon the hernia neck, the hernia sac, you can see it right there, it's much easier to identify the planes you need to dissect. Okay? So there's the hernia. Good-sized hernia. Okay? Hemostatic, all right? Hemostasis is the key to being able to perform this operation safely. And again, I'm bringing all the fat down. So this is a case where maybe I could stay completely extraperitoneal, but there's never anything wrong with going into the abdominal cavity if you're not sure what layer you're in, okay? The safest thing to do is open up the peritoneum, get into the abdominal cavity, let pneumo into the abdominal cavity, and see if the bowel will come off of it, okay? But if I can, I will stay completely extraperitoneal unless - we'll find out if that's possible in this case. Okay? So here are little hernias in her diastatic tissue, which I fully expected. The patient's BMI is about 32. Okay? So she's overweight. I guess that that would be considered obese. Certainly within a reasonable BMI range for hernia repair. So here, I'm going to try to keep this fat down. that I mentioned earlier, so keeping the fat down. And there maybe is another hernia there, or that could be part of the arcuate line. Keep the fat down, stay anterior to this fat. And I use a combination of a little bit of pushing, right? I don't push hard enough to break any blood vessels, but I push hard enough to try to separate planes. And then if I come upon a blood vessel, I'll just zap it very briefly. Okay? And here you can see the planes aren't quite as obvious, right? So, you know, if I'm not sure what's going on, I can always come back to this because a lot of times things become easier to identify when you come back to it. But in this case, you know, I think I'm okay going through. So, at some point the - we haven't come across the umbilicus. This may be the umbilical area. With the umbilical area there's a lot of stuff happening because the medial umbilical ligament, the median umbilical ligament, the contralateral medial umbilical ligament, and the ligamentum teres all come up to the umbilicus. And I think that's what's going on here. That's why you get this disorganized look. There's a lot of different fibers coming through. So I'm going to just slowly cut through these. I think this is the umbilicus right here. And you know, if you're not sure, have your assistant press on the belly button. So Julie, can you press on the belly button? Yeah. Let's see if this is the area of the belly button. I could be wrong. The belly button is right here. Let's see. Oh, it's actually right there. So this is below the belly button. Okay, thank you. So I'm going to try to, again, keep all the fat down if I can. Okay? So there's a lot of fat up there. I predict later - so there's the arcuate line - I'm going to end up going in here, and all this fat's going to need to come up, okay? And so that's how I know that I need to go right here. Okay? Now, it can be quite confusing with all these different fibers here. So I can always come back to this, all right? Let's work on - so there's the umbilicus, and there's her - the hernia that we're here to fix, okay? Now this could be colon. This could be peritoneum. It's hard to say what it is, right? I'm going to try to take the sac down, and you can see there's multiple layers that I can work with. I'm going to just open up, just incise this. This is kind of a- what I call the pseudosac or the anti-sac, and just cut into it and just see if there's one plane, one layer that wants to come down easily. Okay? And here, maybe over there, let's see. Yeah, maybe this layer, okay? So you can see, this is allowing me to take down the hernia sac, and that's probably peritoneum. On the other side is colon or fat. So here, I'm trying to create a distance between this tissue and the tissue around the hernia sac. Okay, there's another little hernia maybe. And of course, I'm always worried that there's bowel on the other side, so I don't use cautery if I can't create distance between this and the hernia sac. So, with this stuff, I can just divide with scissors. If I need to use cautery, I will lift away, quick burst of cautery. And that let's me use cautery. Okay? And here it looks like I got in a nice plane, and the entire hernia is going to come up. Okay? Here, definitely easy stuff. You know, if you're lucky, with primary hernias, you can find a nice plane to reduce your hernia sac, okay? And I'm going to go over here and see if I can get more of this dissected. It doesn't look like there's any colon close by, so I can use a little bit of cautery. And here, maybe colon will be close by. I'm going to lift away and use a little bit of cautery, okay? So, this structure has a lot of extra tissue, so let me just dissect outside of the hernia sac. And does this put me in the abdominal cavity? That may be - that's the abdominal cavity, okay? Which is okay, all right? As you can see, I'm in the abdominal cavity, but my working space is still there. And I frequently accidentally open up the peritoneum during eTEP because sometimes you just can't tell whether it's peritoneum or not. And it's not a big deal, okay? As long as everything on the other side is clear, and there's no evidence of bowel when we look through the tissue. Okay, so lots of little hernias that we have to reduce. So I try to reduce as much of this as possible. So again, this was the peritoneum, right? So this is - I want to stay on the other side of this layer, okay? Let's keep taking this stuff down. So yeah, the CT really just showed one hernia. Did not really pick up these little hernias. And in primary ventral umbilical hernias in obese patients, you almost always find additional small hernias in the diastatic linea alba. So always be prepared to fix more than you anticipate. So that's a little harder to bring down. So I'm going to go over here, just work on some easier stuff. So this is the umbilicus, and she did have a small umbilical hernia visible on CT. And I'm going to reduce this. And notice how, you know, I really keep things hemostatic. If I think there's going to be bleeding, I use a little bit of cautery. This is all fat, so there should not be any risk of injury to bowel. So there's the umbilicus reduced. This is probably some of the ligaments coming up. The medial umbilical ligament or the median umbilical ligament. Those can be divided and they actually need to be divided for me to join the periumbilical space with the space below and the space above. This is probably another ligament. So again, I'm going to cut the ligament, okay? And if you're not sure, I'm going to go, get some landmarks, so that looks like it's a preperitoneal space. And here I could see that this space joins up with that space, so I should cut this tissue, all right? I don't know exactly what it is, but it's probably one of the umbilical ligaments that looks like scar. Again, you know, if you always keep the fat down, you'll almost always stay in the right plane, okay? Again, you know, you can push, but when you push, you should not break blood vessels, right? You push to expose planes, expose blood vessels, and then you use your… Now this may be peritoneum on the other side. I'm not sure, so let me dissect it carefully, all right? So let's go back and take all the hernias down. And I like to work in stages like I mentioned. Stage one is the ipsilateral retrorectus space dissection and dissecting out the linea alba. Stage two is dissecting the preperitoneal space. So crossing over through the posterior rectus sheath into the preperitoneal space and taking down all the preperitoneal fat and the hernia sac, and then move over to stage three, which is dissecting contralateral retrorectus space. But if I have trouble identifying structures in the preperitoneal space in stage two, I will just start stage three if it's feasible. And I can - I know where the contralateral linea alba is and where the posterior rectus sheath starts. This is just taking out a bunch of little hernias here. So this doesn't look like peritoneum. I think the peritoneum is down here. This is just almost like transversalis material. Okay? So I'm going to scrape this down. You can see there's actually another layer here I could be - that I can take down. So right there, see that? This is actually bringing down the transversalis. So, if your peritoneum gets really thin, you can actually jump into another, and I knew that there was another layer because there were a lot of these squiggly vessels, and that usually signifies that there's another layer I can take down. Okay? And yeah, this is a skill that you learn in TAP ventral hernia repairs. When you're doing a preperitoneal dissection, you learn to take this stuff down to keep your peritoneum mobile bus, and that comes in handy in eTEP also when you have very little peritoneum, very thin peritoneum posteriorly. Okay? So this is a - and then bipolar is great for these little vessels because if I use monopolar, the rectus frequently jumps. So bipolar energy makes it easier to cauterize without the muscle jumping. So here I'm finishing my take down of the preperitoneal fat. So here you can see how the anatomy is much easier to discern as I did something different, came back to it. Okay? And here - let's leave that alone for now, okay? So that's a contralateral posterior rectus sheath, the linea alba is probably right there, okay? And I need to finish taking down this hernia sac. So that's tethering me right there, so I'm going to cut that right there. And there was still this hole right here that I have to remember to repair later. Right there. Right there, okay? So let's go and continue to take down this hernia sac. Let's see if we have any easy stuff to do. There's an art to taking down a hernia sac. And, with practice, and, you know, experience, you start seeing the planes that you need to divide. And a hernia sac has multiple layers usually. Usually, there's a layer that you can get into that will allow you to take down most of the hernia sac. And she has a really big sac. And you can see I've gone into a nice plane outside of the sac, okay? I'm just taking all the little subcutaneous attachments. Some are foamy, some are dense. And here, that's the peritoneum, I think. So I'm going to stay over here, I know I'm away from bowel, that's why I can use cautery. Okay? And I can see the sac going that way, right? So I know I can cut this. And sometimes there are a lot of vessels in the pseudosac, so you also want to make sure you be careful and not cut the larger vessels, which can retract and go out of your field of view. I'm going to continue to reduce this. You can see there's hernia sac with lots of air in it. I may have to pop a hole in the peritoneum just let some that CO2 out of the peritoneum so the hernia sac can reduce. I'm going to just pop it. A little incision into it, let's see if we can… Not big enough that I need to repair it, but big enough to let the CO2 out of it. Look at that thin layer. It just won't open. Open yet? No. Wow - oh, there we go. Deflating the balloon. Good, okay. So let's finish taking down the hernia sac. So now it becomes much easier. So my goal again is not to enter the contralateral retrorectus space yet. Just taking down the hernia sac. So, I want to be in the same plane as here. Here, I want be at the same plane as here. So to find that same plane, maybe I'll take down more of this right now, and then work my way from right to left, okay? So here you can see it's much easier for me to identify the plane I need to be in, right? So that ensures that I take down the hernia sac without violating the peritoneum. Now here, that may be peritoneum looking into the abdominal cavity, right? So I'm going to be up here, again, peeling down this areolar stuff, which is what most people call transversalis. Okay? And you can see there aren't a lot of squiggly blood vessels up there, which means I've taken down the transversalis, okay? And here, I'm just going to bring all the fat down. So here, the sac, the peritoneum, the preperitoneal fat, the transversalis fascia are all coming down off of the posterior rectus sheath. Okay? So at most, you need about this much dissection of the peritoneum off of the posterior rectus sheath so that you can enter the retrorectus space safely. I've gone a little further, which is not a big deal. So now I've finished stage two, okay? Actually, I haven't completely because there's some hernias here, so I could do more here and then go over to stage three, which is getting into the retrorectus space, or just go into retrorectus space and later decide how much to dissect here. Since I'm already looking at this area, I'm just going to do a little bit more here, okay? So again, back to the ipsilateral retrorectus space. I'm going to get up to the linea alba. All right, so the linea alba is right there. So your grasper, once it hits the linea alba, it can't go any further, all right? So that's one way to identify it. It's a wall that climbs straight up, And then I'm going to open this up and see if we can find more little occult hernias. And if there's no more occult hernias, then I just need to find a good landing zone for my mesh. Also, I can plicate the diastasis fairly high too. I usually don't plicate diastasis because it's essentially normal anatomy in most overweight or obese patients. And, also I think suturing to the diastatic tissue can lead to additional hernias in the future. So then you have to cover it with a bigger piece of mesh, and with a bigger piece of mesh comes more foreign material in the body and also higher risk for infectious issues since you're creating a much larger space. I'm just going to go a little higher, okay? So you can see the last hernia is about there. I'm going to have my mesh cover to about here, so that's going to be excellent mesh overlap.

CHAPTER 7

So, I don't crossover up here because working from right to left as a right-hander is challenging. You're not going to be as efficient and you're not going to be as smooth. So I like to go down to the arcuate line, okay? And here is the arcuate line. You can see a beautiful transition from posterior rectus sheath to attenuated stuff. I'm going to just take this vessel. [Drowned out by sound]. So now I'm going to put my left hand in there, bump up against the linea alba, open my jaws, and then just cut between my jaws. That will keep me about a centimeter away from the linea alba. So again, I'm going to bump up against the linea alba, open my jaws, and just cut. Okay? And you can see how this is a very efficient move when we bump up against the linea alba, open my jaws, and I can… A lot of times, I like to take out my grasper and reset because sometimes it gets into the wrong plane. So I'll maybe do this a little bit, take it out, and reset my plane. Hug the posterior rectus. So you can see here's a slight direction change in the linea alba. Right? Maybe? So let's see where the grasper wants to go. The grasper wants to go in here. And oh, actually, linea alba's right there, so we're still on the right track. Again, I'm leaving a veil of about a centimeter of posterior rectus sheath, all right? This will give me good tissue, good purchase, with my needle when I start to reapproximate the linea alba. So again, this is stage three. So I'm opening up the contralateral retrorectus space by incising the posterior rectus sheath 1 cm away from the linea alba. And it could be 2 cm, it can be 3 cm, but 1 cm seems to be a good - good place to incise the posterior rectus sheath. Just to mirror what I did on the other side, I'm going to enter the posterior rectus sheath on the patient's left side. I was about a centimeter away, so I might as well keep it a centimeter away here, for symmetry. And you want to make sure you know exactly where the linea alba is before you open it up. So here, it's a little stuck for some reason. I'm not sure that I can… This is probably where the… The… Yeah, it's a little stuck there. So I'll just go up a little laterally. Come back. Now, it looks like her linea alba's there, but for some reason there's a little bit of scar. So, no harm, I can go here, all right? Just to make sure that maybe for some reason her midline linea alba has come out here, so… That's probably the tendinous inscription of the rectus muscle that gives people the classic six-pack. The horizontal indentations. So again, then back to - cutting the posterior rectus sheath. about a centimeter from the linea alba. And you can see, I don't really use the cutting function of the scissor. I'm just using the scissor as a hot blade. I'm just using coag, okay? So, those two dissections are pretty much at the same level. So next, I'm going to take the posterior rectus sheath and separate it from the rectus muscle. And again, just like the ipsilateral side when I first entered, I want to hug the posterior rectus sheath. And these little vessels that are in the way - just divide it. I like to kind of cradle it and just use cautery, but you can also just go to it and just cauterize it too, that's fine. Okay? And, let's go 30 down. See into this space better. Again, I'm going to hug the posterior rectus sheath. Of course, you don't want to burn into here too much just in case there's bowel stuck up to the posterior rectus sheath, and here you can see the Exparel solution that I had injected. Hopefully, it's bathing the intercostal nerves. And this is a vessel that's small so it can be taken. But as you get more lateral, you'll start seeing larger neurovascular bundles that you definitely want to preserve, especially in a case like this where I don't need a huge overlap, so I don't need to go all the way to the linea semilunaris. So again, just cradle this. So again, my goal is to keep all the fibroareolar tissue up. If there's any bleeding, you can use bipolar. You can see how pneumo in this space helps you identify the areolar plane. Also gravity helps a lot, right? Again, I always want to stay right on the posterior rectus sheath. Try not to leave much fat on there. And sometimes you can push. Pushing sometimes compresses the tissue and gets you out of the plane. That's also - in some patients, you can just push and the whole thing opens up. Okay? So there's lots of Exparel here, Bathing these neurovascular bundles. There's a nerve right there. Okay? Now if there's a look of the - at the linea semilunaris, right about there. There's a seam right there. See that seam right there? That's where the internal lamella of the internal oblique and the posterior lamella of the internal oblique separate from the - or split from the aponeurosis of the internal oblique laterally. Okay? That's the demarcation of the linea semilunaris. If I were doing a TAR, I would definitely want to see that seam so that I don't accidentally cut into the anterior lamellae of the internal oblique, but in this case, we're not going to be doing a TAR. All right, so, I'm going to continue my dissection down past the arcuate line, and you can see I'm staying in the same plane here, which helps me with the dissection down here if I needed to do a bottoms up TAR, right? This is the posterior rectus sheath, but just attenuated. Okay? You can see this goes pretty far down. That attenuated posterior rectus sheath. So this plane, just like dissecting up high above the arcuate line. Okay? Let's take this vessel too. So that we get good, wide mesh overlap. Okay?

CHAPTER 8

So I've completed my dissection. See, that's the hernia sac. Okay? This is all hernia sac. And we're going to look up. And you can see the Swiss cheese defects. So this was the umbilicus. This was the main defect. A couple of Swiss cheese defects. One, two, three. So we'll say one, two, three, four, five, six. And then smaller hernias. Seven, eight, nine. at least nine little hernias, maybe another - another like few other ones, which I won't count, okay?

CHAPTER 9

So, right now I could either close the anterior fascia or the posterior fascia, or the posterior peritoneal defect. I'm going to close that first because I want to find it in case there's bleeding, and it gets obscured. So, now I'm going to have the scope cleaned. I'm going to get 3-0 V-Loc 180. Let's make it six inches. I take out my scissor, and give me a needle driver. Let's burp all the ports in, get the remote center into the correct spot, so let's burp all three ports in. Okay? In? Yeah, inward. Great, so on three. Okay. A little bit further. Okay, now press the port clutch, just to relax the tension. Good, okay now - push the scope in. Okay. Then the - good, and then the force bipolar. Okay, that's good. Okay, now we can clean the scope and take out the scissors. It's coming out. Where's that little hole I made? See that little hole I made. Wow, the hole already repaired itself. So I'm going to… Bipolar first? Yep. So the ruler is cut in half down the middle. That's your V-Loc. Okay. 3-0 six inch. Thank you. And then the needle driver. And the next step - I'm going to close that peritoneal hole that I created. Then we'll close the anterior fascia. So you can see the release that you get with a posterior rectus sheath incision. Look at the width of the rectus muscle now and the width of the posterior rectus sheath. Okay? So by just incising the posterior rectus sheath, you allow the rectus muscle to stretch medially, which allows you to close fairly large defects without much tension.

I'm going to go 30 down again. There's the apex of the hole. And I think I'm just going to go along this edge and this edge. Okay? And suturing on the floor is a little harder because you don't have gravity as counter tension. So I like to use shorter sutures when I'm suturing the floor. So six inch or nine inch, if possible. In the ceiling, I use much longer sutures. So here, there may be colon right there. so I'm going to be very careful and just take small bites on the right side of the screen. And you probably could use a 90-day suture also. This is a 180 day. So what is this needle that the 3-0 V-Loc comes in? That's the T20, I believe. T20, okay. Now while you're performing the dissection, if you start causing tears, and you're worried you may not be able to find the tears, repair it while you're looking at it. This way you don't miss a posterior defect, which may cause an internal hernia later. I don't lyse any adhesions that are inside if I'm not specifically worried about a band that causes small bowel obstruction in pass. Every time you lyse adhesion, adhesions reform. So I don't think the role of adhesiolysis is necessary. Again, you want to make sure you're not grabbing bowel underneath. If you're not sure, you know, maybe open up the peritoneum more so you can really see the tissue that you're suturing, and this should be the last bite. And I usually run it back twice just to lock it. Make sure it doesn't unravel. All right, next I will take a 0 V-Loc 180, 18 inch. Okay. So this I think was the hole I created earlier to let some of that CO2 out of the abdominal cavity. There we go. Needle ready. Okay. And I will give you a 3-0 back. And I'm giving you a... Go for it.

All right, so the next step is to close the anterior fascia. I'm going to go 30 up. Okay? I'm going to reapproximate the entire linear alba, all right? That's reconstructing the midline. And I like to go from caudal to cranial, or left to right, on the screen. As a right-hander, it works better for me that way. Okay? I start where the linea alba comes together right in the midline. So right about here. And you can see, we have plenty of distal or caudal overlap for the mesh. Okay? So you're starting left to right because of what you mentioned earlier? You're right-handed and it's easier? Yeah, and - sometimes I start from cephalad to caudal, but usually I go caudal to cephalad just because it's easier for me. It's easier for me to kind of - to push all the suture over to the caudal side with my left hand. Keep it out of the way as I'm suturing. That's another reason. Okay? Are you using a 3-0? This is an 0. It's an 0? Okay. And with a GS 21 needle. Okay? Okay. So I want a good bite of the linea alba on the contralateral side and then a good bite of the linea alba on the ipsilateral side, okay? And, you know, the linea alba is demarcated by this cut in the posterior rectus sheath. This is going to be just a little medial, of course, to that cut, since we left a 1-cm cuff, all right? And it can be hard to manage a 18-inch suture in the body, but, you know, we got lots of space. And what I do is I grab the suture close to where it came out of the fascia, pull it to the right side of the screen and then I can use my right hand to kind of push. Okay? Another way to do it is pull this way and use my right hand to push down. Okay? So a few different ways to manage the suture, but initially I like to pull the suture through, but not taut. Okay? I want to take out some of the slack. Or another option is to do this. So again, I'm going to grab the linea alba. Okay? You want good - about one centimeter, just pull a little bit through. Okay? Not all of it. This way I have enough to work with. And then I'm going to, again, go in - try to go in 90 degrees to tissue. I'm traveling about a little less than a centimeter, probably like 8 mm. Okay? And another good bite. So here you can see, I use up the length of my suture so I can just use my left hand, get a little bit more slack. Okay? And then I have a little bit more here. This way I'm not working with a very long length of suture the entire time. I never - I try not to - I try not to let go of the needle. So if I want to let go of the needle, I will park it and then use two hands to pull, okay? So, with these larger, wider defects you don't want to pull the suture tight and start reapproximating the linea alba as you go. You kind of want to just leave it like that for several reasons. One is, if you put in a lot of sutures first, you'll distribute the tension along the entire length of the defect, and it'll be like tightening a corset. It'll be much easier as you distribute the forces along all - multiple suture - areas. And another reason is, you'll start tearing at the last suture hole if you start pulling together these very wide defects. Once I start getting into the white area, I'm going to take a bite in the middle just to plicate it to decrease the dead space and also incorporate the hernia sac a little bit. So, and then another reason to not tighten as you go is you don't want to have to work with an 18-inch suture the entire time. If you pull through, it'll be 17.5 inch and then 17 inch and then 16.5, and that's just a lot of suture to constantly work with, all right? Here, I'm just working with a little bit of suture, which is much easier to handle. And then when I start running out of length, I can go and pull a little bit more. Okay? And when I pull, I try not to saw - pull too hard this way because it'll saw the tissue. I try to pull towards about six o'clock, and maybe brace the tissue a little bit with my left hand. Okay? So pull, brace a little bit, just till it's snug. We'll tighten it later. Okay? It's snug. Okay? You can see how you can start sawing through tissue if you pull too hard. Now this gives me a little bit more length, and I'm going to grab the linea alba. Okay? Julie, is her umbilicus tethered down or is it a coming out? It's down. Yeah, okay. So I don't need to grab the umbilical stalk since the stalk is probably still intact and attached to the linea alba. So here I'm running out of suture. So let's go and start tightening in this little bit. Okay? And again, try to pull towards about six o'clock. Brace with the left hand. And at this point, I'm going to have my assistant get another 0 V-Loc 180 ready. 18-inch again? 18 inch. Because I know I'm going to need it. This way there's no downtime. Again, pull towards and hold my belly button. And so, down there it's fairly tight. I don't have to tighten any more later. Okay? And you can see just this little bit of tightening gave me a lot more suture length to work with. Okay? And my needle is parked there for me to go. So I'm not wasting time looking for the needle. Then there's this little move - push down, helps you pull out the - the length of suture that you need. And I'm not going to grab the hernia sac since that's a small hernia. Let me know when you're ready. Okay, not quite yet. See if I can tighten a little bit more, get a little bit more suture. You want 15 still? For now. So good robust part of the linea alba. So people always ask about permanent versus absorbable sutures. I definitely think a 90-day suture is too short. That's why I use a 180 day. I don't use a permanent suture in most cases because I think, you know, beyond 180 days, the fascial defect should be pretty robust. The closure should be pretty robust. And the mesh is really doing all the work in preventing the recurrence. We've all been into abdomens where there's permanent stitches and you could see large holes at the suture line. And I think, you know, over the long-term, the permanent suture will continue to saw through the tissue, especially since most people gain weight as they age and create new hernias. So I think after 180 days, the suture has done its job to prevent an acute recurrence before, you know, a good remodeling of tissue happens. And after that, it's not needed. So I pretty much use the 180 day for most of my hernia repairs. So another thing that happens is if you start tightening as you go, is you can see the fascia starts disappearing. See how the anterior rectus sheath starts disappearing. It's over there. If I really pull this together, the rectus muscle, since it's one long muscle, will medialize while the anterior rectus sheath, which is not tethered to anything, will start retracting that way. So that's another reason to leave this untightened and bring in another stitch. So let's bring in another stitch. You can take out my needle driver. And the larger the defect, the more sutures I'll have in the belly. So learning how to manage the spaghetti is also important. I'll show you different tactics I use to manage and prevent entanglement of the sutures. So, the hernia defect's about 4 cm. So the abdominal was 4x5. But the width of the diastasis is about 5.5 cm. The length is, should be right there, 15 cm. Okay? So, the whole thing is about 5x15. Take the distance between the most cephalad hernia and the most caudal hernia. So, I'm going to have to start the suture somewhere. I don't want to start here because as I tighten those, I'll be able to close this area. So I'm going to just start here, a little way from the last stitch. With the first bite, I don't grab the midline. I find it harder to pull the suture together. In this patient, I'm definitely going to grab that hernia sac. So you can see I'm pulling down like this and I'm pushing away with my right hand. And just repeat this two or three times for the 18 inch until I see my loop. Then I push the suture off to the left side of the screen. This way it won't get in my way. And then grab the linea alba. So, you can see it going from left to right. I keep all my suture over there so that it doesn't get entangled. So with such a large sac, I'm going to grab probably two bites in here. If you don't… So I'm going to need my assistant to push down since I can't reach all the way up there. So, Julie, can you push down on the abdominal wall? And, it's a good one to capture on video. Let's go towards the feet and the patient's right side. The other side. Yeah, I'm going to - perfect, right there. Yeah, okay. You can relax for now and then I'm going to have you do it again soon. So, first I want to take bites of the linea alba. So I must be able to see the linea alba well. Okay? I can't see the linea alba, then I'm going to have to do something else to be able to visualize it. And sometimes that means putting extra ports. I've also put in a laparoscope in the contralateral side and laparoscopically watched myself suture, which is extremely painful and I don't recommend it. I would recommend maybe putting additional ports, so you're slightly off angle, but you'll be able to see it. All right, Julie, can I have you press in the same area again? So by plicating the sac in with your repair, you're going to take a large single sac, and turn it into multiple little sacs. So you turn one large seroma into multiple little seromas, which will be much better tolerated, it'll be less symptomatic cosmetically, it'll be less apparent. The patient will have dimples and irregular abdominal - irregular skin contours, but that will smooth out with time. So, I tell patients not to worry about the appearance of their abdominal wall because after about 4-6 months, it will smooth out. So here you can see the width of the defect is taking up my sutures nicely. So I don't have to deal with a lot of sutures. And then when I need it, I just pull more through. Push down again. Yeah, thank you. I'm not grabbing it too much of the skin, right? No. Yeah, it's good to have the bedside assistant check and make sure that you're not grabbing the dermis or pushing your needle through the skin. Try not to grab too much muscle, but sometimes you can't help but grab a little bit of muscle. So I'm running out of length, so I can park this for now. Actually, since it's staying in there, I'll just leave it like that. And then again, when I pull - and by using a little bit of force, I try to pull towards six o'clock, brace the tissue a little bit. That gives me a lot of length to work with again. Can you push from the upper abdomen? Go ahead - actually, it looks like I may be able to reach it. Good, thank you. That should be all the pushing that needs to be done. So here you can see this area is not really at risk for the linea alba disappearing. Okay? So, I can probably start tightening all the sutures and then come back to here to use the rest of the suture. So I'm going to go back here and start working on tightening, bringing things together. So, if at this point it gets difficult to tighten, you can lower the pneumoperitoneum. I also like to burp the three ports medially so that, you know, the three ports are fixed in place, and it's not going to let this ipsilateral abdominal wall slide medially. So by burping the port, you release the tension of the ports on the abdominal wall and let the abdominal wall slide more easily. This defect is not that great. It's not that big. So I don't think that'll be a problem, but if it does seem like the defect doesn't want to close without tension, then I will burp the port and hope it'll help the abdominal wall slide. If it's ipsilateral, the patient's left-sided hernia will slide medially. I'm going to catch up to that other suture, and it's going to be just right. And if I have any redundant sutures, it's actually perfect because I like to run the suture back a little bit. Let see if I can tighten it some more. And you can see, this is a nice way to just gently bring the gap together. You don't want to strangulate the tissue, so I'm not going to pull it too tight. Okay? Just until the linea alba is nicely reapproximated. So again, pull down and then press, then you press away. This way you can quickly pull a lot of suture through. I need one more suture here. All right, so I'm done with this suture in terms of moving cephalad. So, the key to not losing track of which suture belongs to which one is to park the needle after your last stitch. Okay? So I know on the right side is - this is a new stitch, this is the old stitch. And here I can tighten this a little bit more now too. Okay? And maybe I won't tighten it all the way yet. I'll just pull it just until it's fairly somewhat taut. Take out a lot of the slack, give me a lot of extra suture length to work with. Get the back of the linea alba. And we'll just continue to take this all the way up until I'm beyond the last hernia. I got to take a bite of the midline, which is okay. You don't have to take a bite of the midline every time. These moves can be quite efficient so you can close these quite quickly. So again, left hand pulls the needle out, right hand is ready to grab it and ready to go. One more throw and then I'll go and pull things tighter. Okay? I can go back and tighten the rest of these sutures. Again, pull towards six o'clock, brace the tissue a little bit. So, because I took a bite of the sac, sometimes there's a - you can pull a little harder just to make sure that the sac isn't hanging up the traveling suture. Okay? 18 inches is quite long. You can usually close a very long incision with it. So, sometimes, you know, with a really big hernia, it doesn't seem to last very long, but with the medium-sized hernias, it can last quite a long time.

So, here I'm starting to notice that my right hand is starting to reach, have some limitations. You can see I'm going to be very closely here. I'm going to have a hard time suturing here. Okay? And I'm going to have to suture to about here and I'm going to really have difficulty in this area. So, what I'm going to do is I'm going to perform image inversion so that I can use my left hand to suture. So if you looked at how… See my left hand can come in here and suture very easily, right? And my right hand really just needs, if all it does is pulls the needle and presents it to the left hand, then it's easy. Now, if I were ambidextrous, I could just start suturing with my left hand, but I'm not. But I could turn the image upside down, swap the instrument, and put my needle driver in my current left hand and my force bipolar in my current right hand, and swap it so that the needle driver after image inversion becomes my right hand. Okay? So we're going to do that right now. And image inversion can be done a couple of different ways. So, one way is to take the scope camera clutch, okay? And spin it. Okay? So now I have to reset my hand and then spin it again. Let's get further in. Spin it again. Okay? So now I'm looking… Now my instruments are backwards and I'm going to have my assistant take out the instruments and swap it. Ready? Okay. And then… And force bipolar? Uh huh. Okay? So now my assistant has swapped the instruments. On the touch screen, I'm going to go to the controls here, go to hand control, configure hand control assignments, go to manual. And then I'm using one and three as my needle driver and grasper, so I'm going to swap one and three and click save. Okay? The other thing I'm going to do is I'm gonna go to 30 down. And so now you can see… And then, it'll say instruments reassigned, press arms swap, so I'm going to kick this pedal, the arm swap pedal, and now the instruments… Oh, I need to look into that, okay. Now the instruments are reassigned, okay? So I'm going to look up, find my instruments. So now if I move my left hand, you see the left-hand instrument moving. If I move my right hand, my right-hand instrument is moving, but if you look down, you'll see three is the force bipolar, and one is Omega suture cut. Whereas earlier, it was opposite. So this hand, you know, I'm very limited. Okay? But the more important hand is the right hand, which is doing the suture, okay? So this should make it a little easier for me to suture, although it'll still be a little challenging, and, you know, with the lateral dock, you do occasionally get into situations like this, but image inversion really does help you be a little bit smoother with the suturing. So my left hand is a little bit limited, but my right hand can control very precise throws. And - so I'm just going to use my right hand. There's a little bit of a… Let's decrease pneumo. So my right hand right now is having a hard time moving up anteriorly, right? So I'm going to lower pneumo down to 10 and bring the ceiling down so that my right hand can more easily to reach up there. Okay? So we're going to lower pneumo right now. Okay, it's at 10. And I want to see this. Now, because I'm limited in range here, I'm going to have my assistant burp arm three out some more. Arm three is your force bipolar? Yes. Okay. Okay, good. Okay, maybe I can now see the linea alba a little bit better. Are one, and two, or three closed? Or do you want me to move to increase it? Okay, when I'm working towards the extremes, and the instruments are collapsed on each other, it can be very difficult to work. To make the instruments unstack on itself and be able to function at these extremes, you need to move the flex joints. Okay? So, to move the flex joints, you press the port clutch button, and then that disengages the entire arm, and then you move it or shift it towards the direction you're working. So in this case, it's going to be towards the head, so my assistant is going to perform that right now. By doing that, the instruments will unstack and it'll be easier to work in that direction. Okay? So let's see if it's a little easier now. Yeah, so it's a little… Yeah, now I have better range of motion. Okay? Now I continue to have issues with my right hand, or sorry my left hand. So, one option is to go with an instrument that has slightly shorter jaws like a Cartier or a fenestrated bipolar. But I'm going to continue to try to use this grasper and see if I can muddle my way to it, if not, I will change graspers. Circle the entire linea alba. It should be a little easier now, grabbing a little bit of the midline fascia. This is called the Venetian blind technique. So I've come to the end of that hernia. I'm not going to chase the diastasis all the way up because I got to chase it all the way up to the xiphoid, so what I'm going to do is start taking bites more medially and not take bites on the linea alba. And this will slowly taper the suture line so that there isn't a big step up externally. Okay? So this'll be my last bite. Okay? So then we'll go back and tighten the sutures. And if I travel too much or there's a gap, I can always come back with the same suture, and - and reapproximate the fascia. Now this can be disorienting, but if you just focus on suturing, it's really just like closing a laparotomy incision. Okay? So now I'm going to go back and just grab a little bit of the posterior rectus sheath. I'm going to grab full thickness. And just a little bit of the posterior rectus sheath. Here you can just go back about two throws, but you might go back a little bit more. I think it does help reinforce the closure and take a little bit more tension off the main suture line. So we're almost done with the closure, and the next step will be placing mesh. If I had been more efficient, I would have measured the space and asked my assistant to get the mesh and then start trimming the mesh, but I forgot to plan that step. So we'll measure it once I finish closing. Okay? So, this is probably enough. You know, there wasn't a lot of tissue on the diastasis, so I don't really need to go too far back. So we'll end here. Now let's go look at the other one. I never ran this one back. So I'm going to run this one back also. So running it back would be going in this direction since we're upside down. Again, just grab a little bit of the posterior rectus sheath, lift. Okay, that should be enough. Nice and tight linea alba reapproximation without tension. So now we're going to revert back to our non-inverted image. So I'm going to just put my scope back into the right side up position, and then I'm going to have my assistant swap out the instruments again. You can leave the mega suture needle out, just put in the force bipolar. Then I'm going to give you the two needles back. So I'm going to go back to my controls and configure hand control assignment, and then change one and three back to its original position and save. And then inside I'll be kicking the pedal swap again. Let's increase our pneumo back up to 15. So Julie can come in and get the suture. Can you redirect the port a little bit. So drop the hand. Let me help find you. Hold on one second. So this is a lesson that I always forget. Once you change the pneumo pressure, you should actually look at your ports and make sure they're still in before taking out an instrument, okay? So in this case, we had lowered pneumo down to 10. And when you lower the pneumo down, the abdominal wall slides down along the shaft of the instruments, and all of a sudden the port can be out. So to prevent this from happening before taking out an instrument, after a change in pressure, look at the port. Okay? Then clutch to take out the pressure. Good, okay.

CHAPTER 10

Let's measure the space while we're waiting for my assistant to scrub in to push the port back in. So, lengthwise, we're looking at 15. And Julie, can you move my flex joints back? She's going to press the port clutch and then just swing the… Kind of back to where it was. And that just helps me get back into the neutral positions, I can work towards the feet and towards the head. Beautiful. All right so, we're still there, and then we're going to - so that's a point where the ruler ends, so I'm going to move it down. So we're looking at almost almost 30 cm. We can say 30 cm, so we'll use a 30-cm long mesh. And then… Width-wise - so I basically take the ruler and go under my scope and bump up against the linea semilunaris. Okay? And so it's going to lay something like this. And then let's see, 15 is to there, and then we're going to add another… So it would be 19 from linea semilunaris to linea semilunaris. But as we desufflate… Sorry? Mike's in now. Okay. As we desufflate the abdomen, the space is going to narrow, and so I don't need a mesh that goes linea semilunaris to linea semilunaris right now at 50 mmHg. So I'm going to actually reduce it by about 2 cm. So we'll say it'll be a 17-cm wide mesh. Okay? So again, I'm going to go all the way up under my camera. Ruler's here. You know my - I remember that my scope came in pretty close to the linea semilunaris all right? So it shouldn’t - I shouldn't go very far under my chin. So 15. We'll add three, we'll make 18, okay? 18x30 will be the mesh. So let's open up the Bard soft mesh, 30x30. And Mike, I'm going to want you to come in here. My assistant has undocked the robot, and now he's trying to get that port back in. I think it's right here. And go ahead and take out the needles for me please, and the ruler. Yep. It's easier while the robot's undocked. Okay? Just to confirm, it's 18x30. 18x30, yes. And then the ruler. Excellent, okay. Mike, can you clean my scope? Yeah. So, one way to prevent loss of access to the abdominal cavity is to pull your scope back into the port. Make sure there's no tissue falling into your field of view. If there is, that means the port's outside the retrorectus space. Then you have your assistant burp it in before you take the scope out. So right now it looks like my port's in the retrorectus space, so my assistant can take it out and clean it. And you'll just lay that suture on the purple line down the center. And since this is a 30-cm piece of mesh, he's going to want a roll it really tight, so that it'll fit down the A port. If it will not go down the A port, you can always roll it in the other way, so it will be much slimmer, but a 30-cm piece of Bard soft mesh will fit down an A port. When he is ready to put the mesh in, one person will remove the port seal, and the other person will quickly push the mesh through the port. And sometimes the grasper will come off the mesh, but as long as the mesh has partly been introduced into the abdominal cavity, I'll be able to grab it and I'll pull from the inside while the assistant pushes the outside. So if your assistant takes his or her time to roll this nice and tight it'll be much easier and it'll prevent frustration and tearing of the mesh. He started with the cephalad side of the mesh and he's going to end with the caudal side of the mesh. So, when he introduces it into the abdominal cavity, he's going to have to grab it in the correct orientation, which will be on the side that his right hand is touching, and he's going to direct it from the upper port, where arm one is and direct it down towards the pelvis. And my grasper in arm three will be ready to retrieve it. Okay? He's going to cut it and leave a tail, about a one-inch tail, sticking out so I can see the suture. Okay? You can see he just takes a standard grasper. He's going to grab closer to the end.

CHAPTER 11

So I'm going to watch the port. I'm going to look for the mesh coming in, and my grasper's going to be ready to grab the mesh. So at this time, I'm going to experience loss of pneumo because they're going to take off the port seal. Oh, they didn't take out the port seal. Did you guys take out the port seal? No. Oh, wow, okay. So he rolled it really well, so it made it in without the port seal needing to be removed. So I'm going to press on the yellow pedal and activate the strong grip. This way it'd be easier for me to pull it through, although this mesh came in very easily. Okay? So I'm going to wait for my needle driver before I move the mesh too much. I don't want this mesh to unravel too much before I position it. So, remember this is the caudal side. So that purple mark tells me where the midline is. I'm going to rotate it. And then, I'm just going to pull and place the mesh down by - as low as I can go. It may be a little wide, lower down, which is okay. It'll make the mesh a little harder to unroll at this point, but… Looks like it's almost just right. So what I can do is now hold onto this suture, press on the mesh with my left hand, and as I pull up, my left hand's going to follow. Okay? If you take out these little creases, it'll make it easier to unroll the mesh. Okay? Let's just make sure the mesh is fitting the width of this defect well. It looks like it is. Maybe I can try and get up just a little bit here to center it. Before unraveling too much of it, I just want to make sure that it's in good position. Just a little lower. Good, okay. Okay? And I had expected this mesh to be about a centimeter away there and maybe about a centimeter away here. So it's still not quite right, so… Okay, so now it's about equally placed, maybe a little bit more this way. It'll all probably even out once I desufflate so we don't have to be too precise here. Okay? So now I'm going to unroll the whole thing. Almost perfect. A little short, so I need more - better coverage up here, so I'm going to just drag the mesh up a tad since I have excess overlap down low. Okay? And make sure the mesh is covering both sides well. My arm three is trapped. Yes. Oh, got it, okay. Okay, so let me now - pull this towards me now. I'm going to try to tuck the mesh under my ports if possible. Yeah, looks good. All right, let's decrease pneumo to eight. So I'm going to slowly decrease pneumoperitoneum just to make sure that the mesh doesn't shift too much when I desufflate. Okay, so this looks like it's in good position. As the space desufflates, the linea semilunar should get closer to this edge. As you can see, I got plenty of mesh overlap for this defect closure. Okay? And then don't go too far - because then I'm going to have you go lower So sometimes the edges get caught, so… Good. So you can see my mesh goes right up to there, so it's going to be a few centimeters beyond my last stitch. So if this stitch pulls through and a hernia tries to develop, I will have good mesh coverage, okay? And my mesh is tucked under my port. All right, let's go lower on the pneumo. Okay, to what? Let's go to four. All right. So as the mesh does this, you can... It's at four. kind of help it fold on itself. Okay? Good, all right. Go ahead and take out my needle driver. And let's go down to two. Needle driver coming out. Yeah, you're at two. You can see I'm going to have excellent coverage of my entire suture line, going well beyond 5 cm. Good. All right, we can remove the force bipolar and remove insufflation and completely desufflate the space. And that concludes the operation. So the robot is going to be undocked, and then we're going to close the skin with some 4-0 Monocryls and apply skin glue. The patient will get an abdominal binder to wear for about a month. This patient has elected to stay overnight in the hospital. So she'll probably stay tonight and then leave tomorrow. Any intra-abdominal gas will get reabsorbed. So it's not a - it's not an issue and does not need to be expelled. But the port seals can be taken off to let out any gas that's still in the retrorectus space.

CHAPTER 12

So I closed the - one, two, one, two, three.

CHAPTER 13

The case went fairly well, pretty routine robotic eTEP Rives-Stoppa repair of a large ventral hernia. As you saw, I performed an ultrasound first to identify the linea semilunaris, which is probably one of the most crucial steps at the beginning of the case because you don't want to end up lateral to the linea semilunaris during the entry. The optical trocar is also, I think, a really important product that makes the entry very easy. Without the optical trocar, with that small hole, when you enter it into the retrorectus space, you have to rely on just blunt dissection with that obturator tip, which can be quite challenging and I've made holes into the posterior rectus sheath and the peritoneum often without the ability to insufflate. So with the Applied Medical Kii Fios trocar, you have the ability to insufflate and let insufflation create that space for you in the retrorectus space so that you drive into a larger space without potential for injuries to posterior rectus sheath and peritoneum. If you're doing this case, and you do violate the posterior rectus sheath and peritoneum, and you start insufflating the abdominal cavity and you lose this space, I recommend placing a 5-mm port into the abdominal cavity to desufflate the abdominal cavity so that you can get the retrorectus space opened up again. If the violation of the posterior rectus sheath and peritoneum happens during the subsequent port placements, let's say the second port placement, you can always use a grasper to push up on the posterior sheath to create space for yourself without having to put in that extra port. As I mentioned, the ports should be spaced about 6-7 cm apart. You don't want it too close. So 6 cm is the minimum distance. And you don't want it too far apart. No more than 8 cm since while we work in the upper abdomen, lower abdomen, we need the instruments to be able to be parallel, and if they're too far apart, they're going to start running into each other more often. And then once the robot was docked, I demonstrated the plate dissection of the ipsilateral retrorectus space during the stage one portion of the operation. That is something that I think is also fairly important, although it's not absolutely necessary, you could crossover right away, but in teaching this operation, I find that a lot of people get lost if they try to cross over too early and they can't tell where the linea alba is and they can accidentally cut into linea alba. So I think it's really important to dissect that ipsilateral retrorectus space, identify the entire length of the linea alba so you never lose track of it. And then when you start stage two and cut into the posterior rectus sheath, you're not going to accidentally veer off anteriorly and cut the anterior rectus sheath and cause an iatrogenic hernia. And then with the stage two part of the dissection, remember to bring all the fat down. Hug the anterior rectus sheath or the diastatic linea alba. When you're using cautery against the diastatic linea alba, of course use it carefully, so you don't injure the linea alba and cause iatrogenic hernias. When you're getting close to the hernia sac, remember always assume, actually even while you're crossing over cutting the posterior rectus sheath, always assume that there's bowel on the other side. So, you don't want to use energy extensively at any point during this operation. They should be very short, brief bursts of cautery. I have my pole I set to classic and two with a maximum of wattage of 50. And that should reduce the amount of thermal spread when I use cautery. Other maneuvers that I do to avoid injury to bowel that's on the other side of the tissue is to create separation between the peritoneum and the posterior rectus sheath when I can. So that when I'm cauterizing the posterior rectus sheath, I don't injure the bowel. When I've taken down the hernia sac, if I haven't gone into the abdominal cavity to insufflate the abdominal cavity and have the hernia contents dropped down, I make sure that I don't use cautery when I'm taking down the hernia sac and I try to stay in that avascular plane so that I can use mostly just scissors and pushing to reduce the hernia sac. When it's an incisional hernia, I don't usually get a nice sac like that. So, I will frequently open up the peritoneum, look into the abdominal cavity, and see what's inside the sac. If it's just omentum, then I can more aggressively use cautery outside of the sac. If it's bowel, then I would either try to reduce the bowel or take the sac down with very little cautery. I also demonstrated that I don't jump into the contralateral retrorectus space early because I don't feel the need to. It does sometimes confuse the picture. If you had both the ipsilateral retrorectus space, the preperitoneal space, and the other retrorectus space open, and if the tissues get bloodied, then you can't tell where the contralateral linea alba is. So I like to take down the entire preperitoneal space and the hernia sac if possible, and then go down to the arcuate line and start working from left to right. And you saw that with the left to right dissection from the caudal to cranial dissection. The left hand's grasper made the dissection very efficient and safe because I can use a grasper to find the linea alba, and then I can cut between the grasper so that I don't damage the linea alba. For the posterior closure, I never reapproximate the posterior rectus sheath because it'll be under too much tension. We're not offloading the midline tension with securing the mesh as an open Rives-Stoppa repair. So, the midline tension is still present and not offloaded by the mesh. So if you close the posterior rectus sheath without a component separation, like a TAR, the posterior rectus sheath can fall apart, and you can get internal hernias. So, I don't close the posterior rectus sheath. I count on the peritoneum to bridge the gap between the posterior rectus sheath. And if there's any defects in the peritoneum during the hernia take down in the preperitoneal dissection, you definitely want to close them with Vicryls or V-Loc sutures. With the defect closure anteriorly, I almost always reapproximate the linea alba to reconstruct the linea alba, reconstruct the midline. And you can see with the veil in the posterior rectus sheath on the linea alba, it's very easy to identify the linea alba and get good solid bites of the linea alba. Each bite is about 8 mm to 10 mm, and the travel is about the same. I demonstrated the use of the corset technique, where I lay the sutures across the defect until the entire suture length is taken up and then I started tightening. That has the benefit of not having to deal with a very long suture the entire time. Distributing tension so that you don't have to pull too hard at any given point, which could tear the fascia. And then, you're also not going to lose track of the linea alba or the anterior rectus sheath because it's not going to retract anterior to the rectus muscle. And then I also demonstrated the use of image inversion, when your right hand is too close to the working point. So in this case, when I was suturing the epigastric area, my right hand was too close to the linea alba, and I was not going to be able to suture. So I used image inversion and took my left hand and turned it into my right hand, so I could suture more efficiently and more easily. This patient did not need a drain because with this smaller eTEP retrorectus space, I find that the drain is not necessary. If I had done a bilateral TAR, I would have left a drain in the patient and left it in until the output was about 30 cc a day. She's going to get an abdominal binder. And as I said, she's going to wear it for about a month. I find that most patients want to wear it for a month, and then between month one and month two, some patients prefer not to wear it, others will wear it for about two months. In terms of activities post-op, I really do restrict them to just walking, minimal weightlifting. The weight limit should be about 10-15 pounds. I ask them not to bend over too much, not to twist, not to reach up for about a month. And after a month, I'll reassess. In a patient like this where everything came together quite nicely, they have really good mesh overlap, at about a month, I'll just tell them to use pain as a guide, and they pretty much won't have any restrictions. If it was a larger defect, bilateral TARs, things came together under tension, poor tissue, not as much mesh overlap, then I would probably prolong the restriction past two months, maybe three months. Thank you for watching. I hope this was a very helpful video.