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  • 1. Introduction
  • 2. Surgical Approach and Placement of Ports
  • 3. Robot Docking
  • 4. Exposure and Taking Down Attachments
  • 5. Creation of Peritoneal Flap and Reduction of Hernia Sac
  • 6. Primary Closure of Hernia Defect
  • 7. Mesh Placement
  • 8. Closure of Peritoneal Flap over Mesh
  • 9. Robot Undocking
  • 10. TAP Blocks
  • 11. Closure of Port Sites
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Robotic-Assisted Laparoscopic (rTAPP) Umbilical Hernia Repair with Intra-abdominal Preperitoneal Underlay Mesh (IPUM)

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Chloe A. Warehall, MD1; Divyansh Agarwal, MD, PhD1; Charu Paranjape, MD, FACS1,2
1Massachusetts General Hospital
2Newton-Wellesley Hospital

Main Text

An umbilical hernia occurs due to weakened umbilical fascia or at the site where the involuted umbilical vessels exited. Depending on the hernia contents—preperitoneal fat, omentum, or small intestine—symptoms may include a new bulge at the umbilical site, abdominal pain, tenderness to palpation, color changes to the surrounding skin, as well as obstructive symptoms such as nausea, emesis, and constipation. Given that umbilical hernias tend to have narrow necks compared to size of the sac, incarceration and strangulation are relatively common. Elective repair of symptomatic umbilical hernias is done to minimize these risks. Here we present the case of an 81-year-old male with a recurrent umbilical hernia who first presented secondary to obstructive symptoms caused by an incarcerated umbilical hernia. After reduction was successful, he underwent an elective robotic transabdominal (rTAPP) umbilical hernia repair with intra-abdominal preperitoneal underlay mesh (IPUM). This article and the associated video describe the pertinent history, evaluation, and operative steps of the procedure.

Umbilical hernia repair; rTAPP; IPUM.

An umbilical hernia is a subtype of a ventral hernia at or near the umbilicus, which is the parietal scar of the umbilical cord adherent to the fibrous umbilical ring comprised of embryological remnants, including the round, median umbilical, and two medial umbilical ligaments. Here the subcutaneous layers are relatively thin directly anterior to the umbilical fascia, with the peritoneum posterior to the umbilical ring.1 An umbilical hernia occurs secondary to weakness in the umbilical fascia or the site where the embryological umbilical vessels exited.2 Not uncommonly, preperitoneal fat, omentum, or small intestine can herniate through either the defect in the umbilical fascia, resulting in an incarcerated umbilical hernia.

Accounting for 6–14% of all abdominal wall hernias, umbilical hernias are the second most common type of hernia in adults. Approximately 90% of umbilical hernias in adults are acquired with higher risk in patients with increased intra-abdominal pressure, particularly those who are pregnant, obese, have chronic abdominal distension, or ascites.23  While many umbilical hernias are asymptomatic, patients with symptomatic hernias may experience a bulge at the umbilical region, which can be tender to palpation. When umbilical hernias become incarcerated, patients typically develop progressive abdominal pain, with or without associated skin color changes. When a loop of small intestine is incarcerated, patients may also experience obstructive symptoms such as nausea, emesis, or constipation.

If an umbilical hernia is reducible, symptoms usually resolve with reduction. However, umbilical hernias tend to have narrow necks compared to size of the sac, making incarceration and strangulation relatively common.2 Thus, elective repair of symptomatic umbilical hernias is routinely performed to minimize these risks. The defect closure can be achieved via open, laparoscopic, or robotic-laparoscopic assisted approaches, with or without mesh. Despite there being approximately 175,000 umbilical hernia repairs each year in the United States, the operative technique utilized is largely driven by surgeon preference, patient BMI, and hernia defect size.4

Recent publications have demonstrated no statistically significant differences in safety and early efficacy between robotic-assisted and laparoscopic operative techniques.5 In this case, we describe a robotic umbilical hernia repair with intra-abdominal preperitoneal underlay mesh (IPUM), an approach in which peritoneal flaps are created, the umbilical sac is dissected out, and mesh is placed posterior to the rectus abdominis with the peritoneum secured over the mesh. 

The patient in this case was an 81-year-old overweight male (BMI 26) who presented via referral from his primary care physician (PCP) after reporting several episodes of intermittent obstructive symptoms including abdominal pain, nausea, and emesis. He underwent a CT abdomen demonstrating a periumbilical ventral hernia with inflammatory changes, suggestive of possible fat or mesentery incarceration. His PCP was able to successfully reduce the hernia with improvement in his symptoms.

Notably, the patient presented twenty-two years prior with acute onset of pain associated with abdominal distension and diarrhea. His known umbilical hernia was found to be incarcerated and successfully reduced. Surgical repair was recommended, and the patient underwent primary repair of his umbilical hernia without prosthesis the next day. The patient had no evidence of recurrence on physical examination, but a small fat-containing umbilical hernia was appreciated on CT abdomen pelvis three months prior to the onset of his new obstructive symptoms.

His other past medical history included gastroesophageal reflux disease, hyperlipidemia, and a bicycle accident as a child, which had resulted in nondisplaced C1, minimally-displaced C2, 4th and 5th rib, and right clavicle fractures. Other than his umbilical hernia repair, the patient had a remote history of a right inguinal hernia repair fifty years ago.

Based on the patient’s symptoms and imaging findings, elective surgical repair was recommended. The patient expressed his desire to proceed with operative repair after understanding the benefits and risks of surgery, including bleeding, infection, recurrent hernia, and chronic pain.

The focused physical examination was performed with the patient in supine position with particular focus on the umbilical and periumbilical regions. Diastasis recti was appreciated. The abdomen was otherwise nondistended.

On palpation over the periumbilical region, a small hernia defect was appreciated when the patient was instructed to cough to simulate increased intra-abdominal pressure. The patient denied tenderness to palpation at this location. The hernia was subsequently reduced without difficulty.

The patient’s complete blood count was within normal limits. No additional imaging studies were necessary or obtained in this case aside from the CT abdomen exam noted above.

The patient was brought to the operating room and placed in supine position on the operating table. Midazolam was administered for sedation and induction of general anesthesia with fentanyl, propofol, and rocuronium was performed. One-time dose of 2 g Cefazolin was given for perioperative antimicrobial prophylaxis. The abdomen was then prepped and draped in the usual sterile fashion, and a hard stop timeout was performed.

The xiphisternum was palpated as a landmark for the midline, and a 12-mm epigastric incision was made. Access was obtained through an open Hasson technique with insertion of a 12-mm robotic port under direct vision. Camera inspection revealed that no iatrogenic injury was made upon trocar placement. Two additional 8-mm robotic ports were placed in the left mid abdomen and right mid abdomen under direct visualization in order to triangulate around the umbilical hernia. The fascial defect was measured to be approximately 4 cm; therefore, a 15-cm circular echo mesh was introduced into the abdomen to allow at least 4 cm on each side of the defect. The robot was then docked. The hernia was inspected and noted to have previous sutures intact along with adhesions and omentum entering the hernia. This was reduced, and the adhesions were lysed. 

Peritoneal flaps were then raised approximately 8 cm on each side of the defect with care being taken to avoid the abdominal wall muscles. The hernia sac was then separated from the skin of the abdominal wall and dissected free from the fascia. It was completely reduced inside the abdomen along with the peritoneal flap.

The hernia defect was closed with a continuous V-Loc nonabsorbable 0 stitch. The previously introduced mesh was then centered over the original hernia defect using an Endo Close device, and it was anchored in a circular fashion with absorbable tackers. It was continuously inspected during this process to ensure that the mesh lay flat. Satisfied with mesh placement, the peritoneal flap was placed over the mesh and secured with absorbable tackers, V-Loc, and 3-0 Vicryl sutures. 

The robot was undocked, and bilateral laparoscopic transversus abdominis plane (TAP) blocks were given. Robotic ports were removed under direct visualization. The fascia at the epigastric port was closed with a figure-of-eight 0 Vicryl suture. Skin at all port sites was closed with 4-0 Monocryl sutures. All surgical sites were washed, dried, and dressed with Steri-Strips. Lastly, the anesthetic was reversed, and the patient was extubated and transported to the PACU in stable condition having tolerated the procedure well. 

Several options are available to patients for umbilical hernia repair. Traditional open primary and prosthesis-based repairs are possible approaches, while laparoscopic and robotic mesh repairs are also becoming increasingly common. The choice of robotic transabdominal umbilical hernia repair with intraperitoneal underlay mesh was primarily driven by patient preference, possible improved postoperative outcomes, and surgeon experience. 

When comparing primary suture repairs versus mesh techniques, primary suture repair was associated with significantly higher (9.8% vs 2.4%) rates of recurrence with no significant differences in complication rates.3

Regarding laparoscopic techniques with mesh, there are fewer complications, shorter hospital stay, decreased hospital costs, as well as reduced morbidity compared to an open repair with mesh.67 Minimally-invasive surgery has a major technical advantage compared to an open approach because it enables complete visibility of the internal abdominal wall, allowing more accurate mesh fixation. However, the addition of robotic technology to conventional laparoscopy allows for more comprehensive three-dimensional visualization, six degrees of motion, and better ergonomics. All these factors allow improved intracorporeal suturing on the abdominal wall.6

With robotic advantages, a new focus is placed on utilizing an underlay technique in which the peritoneum is used as a barrier between the mesh and abdominal viscera. The aim of this technique is to avoid adhesive bowel obstructions, mesh erosion, or possible enterocutaneous fistula creation complications that have been associated when there is contact between mesh and the abdominal viscera.8 When comparing the overlay and underlay techniques, there is increased cost effectiveness and decreased complications appreciated with the latter.9 

Umbilical hernia repair is a common elective procedure for patients with symptomatic umbilical hernias. In this case, a robotic-assisted umbilical hernia repair with intra-abdominal preperitoneal underlay mesh was performed. Postoperatively, the patient was able to recover and be discharged home the same day. His pain was managed with non-opioid medications without issues. At his 3-week postoperative visit, he remained free of symptoms and pain without any evidence of recurrence. 

A robotic-assisted umbilical hernia repair should be considered as an elective option for patients with symptomatic umbilical hernias. There are no significant differences in safety and early efficacy between robotic-assisted and laparoscopic operative techniques.5 While there is a learning curve with robotic surgical procedures, the advantages of using a robot, such as enhanced visibility and six degrees of motion, allow for more accurate mesh fixation and increased use of underlay techniques, which have been shown to be more cost effective with reduced complications.910

No special equipment, tools, or implants used in the procedure.

No relevant disclosures of conflicts of interest.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

We thank the patient for giving us the permission to present this case in JOMI.

Citations

  1. Dokmak S, Aussilhou B, Belghiti J. Umbilical hernias and cirrhose. J Visc Surg. 2012 Oct;149(5 Suppl):e32-9. doi:10.1016/j.jviscsurg.2012.04.002.
  2. Coste AH, Jaafar S, Parmely JD. Umbilical hernia. [Updated 2023 Mar 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459312/.
  3. Shankar DA, Itani KMF, O’Brien WJ, Sanchez VM. Factors associated with long-term outcomes of umbilical hernia repair. JAMA Surg. 2017;152(5):461–466. doi:10.1001/jamasurg.2016.5052.
  4. Koebe S, Greenberg J, Huang LC, et al. Current practice patterns for initial umbilical hernia repair in the United States. Hernia. 2021 Jun;25(3):563-570. doi:10.1007/s10029-020-02164-z.
  5. Chen YJ, Huynh D, Nguyen S, et al. Outcomes of robot-assisted versus laparoscopic repair of small-sized ventral hernias. Surg Endosc. 2017 Mar;31(3):1275-1279. doi:10.1007/s00464-016-5106-4.
  6. Misiakos EP, Patapis P, Zavras N, Tzanetis P, Machairas A. Current trends in laparoscopic ventral hernia repair. JSLS. 2015 Jul-Sep;19(3):e2015.00048. doi:10.4293/JSLS.2015.00048.
  7. Colavita PD, Tsirline VB, Walters AL, et al. Laparoscopic versus open hernia repair: outcomes and sociodemographic utilization results from the nationwide inpatient sample. Surg Endosc. 2013;27:109–117. doi:10.1007/s00464-012-2432-z.
  8. Gokcal F, Morrison S, Kudsi OY. Short-term comparison between preperitoneal and intraperitoneal onlay mesh placement in robotic ventral hernia repair. Hernia. 2019 Oct;23(5):957-967. doi:10.1007/s10029-019-01946-4.
  9. Prasad P, Tantia O, Patle NM, Khanna S, Sen B. Laparoscopic ventral hernia repair: a comparative study of transabdominal preperitoneal versus intraperitoneal onlay mesh repair. J Laparoendosc Adv Surg Tech. 2011 Jul-Aug;21(6):477-83. doi:10.1089/lap.2010.0572.
  10. Kudsi OY, Gokcal F, Bou-Ayash N, et al. Learning curve in robotic transabdominal preperitoneal (rTAPP) ventral hernia repair: a cumulative sum (CUSUM) analysis. Hernia. 2021 Jun;25(3):755-764. doi:10.1007/s10029-020-02228-0.

Cite this article

Warehall C, Agarwal D, Paranjape C. Robotic-assisted laparoscopic (rtapp) umbilical hernia repair with intra-abdominal preperitoneal underlay mesh (ipum). J Med Insight. 2023;2023(407). doi:10.24296/jomi/407