Robotic-Assisted Repair of a Left Lower Quadrant Spigelian-Type Hernia

A left lower quadrant partial-thickness Spigelian-type incisional hernia resulting from wound complications after deep inferior epigastric perforator (DIEP) flap harvest is repaired in a minimally-invasive, robotic-assisted, transabdominal preperitoneal (TAPP) fashion. Utilizing robotic assistance, a large preperitoneal flap is created, fascial closure is achieved using barbed suture, and the hernia defect is reinforced widely with medium-weight polypropylene mesh. In this patient, this approach also allows for areas that had previously had mesh placed to be avoided, and for repair of a fat-containing indirect left inguinal hernia. Similar approaches can address primary or lateral incisional hernias. This patient had an uncomplicated postoperative course without early wound morbidity.

Robotic hernia surgery; Spigelian hernia; flank hernia; DIEP flap hernia; minimally-invasive hernia surgery.

This patient had a left lower quadrant partial-thickness incisional Spigelian-type hernia following harvest of a deep inferior epigastric perforator (DIEP) flap from the left side of her abdomen and subsequent wound complications. Spigelian hernias are a type of primary partial-thickness hernia where abdominal contents bulge through a defect in the transversus abdominis and internal oblique aponeuroses, underneath an intact external oblique. The hernia in this case is more likely incisional in nature as a consequence of the patient’s prior DIEP flap and hernia repair. Abdominal donor site wound complications including bulging and hernia following harvest for autologous breast reconstruction can occur in up to 15% of patients. The procedure demonstrated in the video addresses a partial-thickness Spigelian-type incisional hernia following an abdominal flap harvest by creating a large preperitoneal pocket between the layers of the abdominal wall, allowing for closure of the muscular defect from inside of the abdominal cavity and reinforcement of the repair with mesh, which is excluded from the contents of the abdomen.

The patient is a 57-year-old woman with BMI 29 kg/m² who presented with a recurrent left lower quadrant partial-thickness incisional Spigelian-type hernia consistent with an L3W2 hernia utilizing the European Hernia Society (EHS) classification system. Her medical history includes breast cancer for which she underwent bilateral mastectomy with failed right-sided implant and subsequent right breast reconstruction with a DIEP flap harvested from her left abdomen. At this operation, a free flap consisting of skin and subcutaneous tissue and blood supply consisting of several perforating branches of the deep inferior epigastric artery were harvested, with the resultant external oblique fascial defect closed with permanent polyester and polypropylene sutures. In contrast to the transverse rectus abdominis myocutaneous (TRAM) flap, the rectus muscle is left in situ in a DIEP flap. Approximately 2 years after her DIEP, she underwent repair of left lower quadrant bulging with permanent synthetic mesh placed in an onlay position and concurrent abdominoplasty by her plastic surgeon. It is possible that she had a partial thickness hernia at this point that was not adequately treated with an onlay approach, but outside imaging from that time point is not available. She developed a mesh infection, and the majority of the mesh was removed with some fascial debridement being described in her outside operative reports. This series of events resulted in the recurrent incisional hernia for which she is currently being treated. Her symptoms include a left lower quadrant bulge and a sensation of stiffness in her midline abdomen. She does not have any evidence of ongoing infection and is not on any antibiotics. She has type 2 diabetes on metformin and a remote history of smoking. Her ASA class is III.

Abdominal examination demonstrates a transverse infraumbilical scar, with the mid-portion healed by secondary intention. On palpation, rigidity is present at the medial aspect of this incision, potentially from some remaining onlay mesh. There is an obvious 4–5-cm bulge in the left lower quadrant at the level of the anterior superior iliac spine (ASIS) outside the rectus complex, more notable with cough or Valsalva maneuver, though no fascial defect is able to be palpated. This constellation of findings is consistent with a Spigelian-type hernia, though in the context of this patient’s prior operations, it is more likely a partial-thickness lateral incisional hernia.

Due to the patient’s complex operative history, cross-sectional imaging was felt to be mandatory before proceeding with surgical intervention. On CT scan (Figure 1), there is evidence of a partial-thickness incisional hernia in the left lower quadrant lateral to the left rectus muscle, with disruption of the transversus abdominis (TA) and internal oblique, with an intact overlying external oblique. Particularly notable is the presence of bowel overlying the left internal oblique. Given the location and size of this hernia, it would be considered an L3W2 hernia using the EHS classification. Additionally, there is evidence of onlay mesh in the patient’s midline and a fat plug adjacent to the patient’s round ligament on the left side, suggestive of the presence of an indirect hernia component.

Figure 1. Axial view of a CT abdomen pelvis of this patient demonstrating a left lower quadrant partial-thickness incisional hernia. There is evidence of disassociation of the left internal oblique and transversus abdominis at the level of the semilunar line lateral to the rectus muscle with an intact overlying external oblique, consistent with a partial-thickness hernia.

The natural history of most hernias is to remain the same size or to enlarge. Hernias do not get smaller on their own. Hernias can vary greatly in the degree of symptoms that they cause, ranging from no symptoms or occasional discomfort to frequent pain, and can even lead to bowel obstruction and other complications. When hernias are observed nonoperatively over time, even hernias that initially cause minimal symptoms tend to become more symptomatic with regard to discomfort, and many individuals decide to pursue repair.

Alternative treatment options for this hernia would include nonoperative management with the expectation of persistent pain symptoms and gradual hernia enlargement as noted above, open repair through a flank/groin incision, or open retromuscular/preperitoneal repair through a midline (or lateral) incision with possible simultaneous or staged excision of any residual onlay mesh. While it would be possible to repair this hernia in a minimally-invasive fashion without robotic assistance, the use of the robot allows for somewhat easier creation of a preperitoneal pocket, improved visualization, and additional degrees of freedom to permit minimally-invasive suturing.

The goals of treatment for this patient are to address the pain that she is experiencing by repairing her hernia, for the hernia repair to be durable, and for the approach to minimize wound morbidity given her extensive history of wound complications following surgery. A minimally-invasive repair allows for the area that had prior mesh in place and prior mesh infection to be avoided.

In general, most patients who are candidates for a minimally-invasive hernia repair can benefit from these approaches compared to open procedures, as smaller incisions may lead to decreased pain, faster recovery, and lower risk for wound complications. A minimally-invasive approach might be contraindicated for patients who have had multiple intra-abdominal operations and are expected to have significant intra-abdominal adhesions, or who have had a recent bowel obstruction and require a complete lysis of adhesions. Patients who have already had a minimally-invasive hernia repair utilizing the preperitoneal or retromuscular planes are also more likely to be offered an open operation given that the plane is now a reoperative one. Additionally, patients who present acutely with a complicated hernia, such as an incarcerated hernia with concern for bowel ischemia, are typically not offered a minimally-invasive hernia repair in the acute setting.

In this case, the patient’s abdomen was entered safely in Hasson fashion at a location away from her hernia, and a total of three ports were placed so as to triangulate towards the hernia defect and avoid the areas where the patient had prior onlay mesh. As expected, the patient was seen to have a left lower quadrant, partial-thickness Spigelian-type incisional hernia measuring 6 x 7 cm. A TAPP approach was undertaken. Using the surgical robot, a large preperitoneal pocket was created and extended laterally into the retroperitoneum, medial to the midline, and inferiorly to the retropubic space. The hernia sac was reduced, and the left myopectineal orifice was dissected out, with reduction of an additional large plug of fat from the indirect space. The round ligament was isolated and divided to facilitate complete mesh overlap of the indirect space. After creating this pocket, the fascial defect was closed, reapproximating the internal oblique and the transversus abdominis muscle to the disrupted semilunar line while also plicating the external oblique fascia in an attempt to minimize postoperative bulging. A large piece of medium-weight, macroporous polypropylene mesh was fashioned in a triangular shape measuring 25x18x18 cm and then placed into the peritoneal pocket to overlap the hernia and myopectineal orifice and then fixed with Vicryl suture to the  anterior abdominal wall superomedially and superolaterally above the iliopubic tract. The bottom edge of the mesh was fixated with Tisseel fibrin sealant (Baxter), eschewing penetrating fixation to avoid injury to the major neurovascular structures found inferior to the iliopubic tract. The preperitoneal flap was then reapproximated to the abdominal wall with 2-0 V-Loc suture (Medtronic), covering the mesh in its entirety. Bilateral transversus abdominis plane (TAP) blocks were performed using Exparel liposomal bupivicaine suspension (Pacira Pharmaceuticals, Inc.) under direct laparoscopic vision with the intent of providing long-acting local anesthesia. The patient was observed overnight and discharged home on postoperative day 1 without complication. At one month follow-up, the patient was doing well without pain, wound complications, or evidence of hernia recurrence on physical exam. She will be seen again one year after surgery.

Donor site morbidity after autologous breast reconstruction with abdominal-based flaps is not uncommon, with rates of development of abdominal bulging or hernia of up to 15% depending on the technique utilized.¹ A recent multicenter study examining 661 patients undergoing DIEP free flap specifically noted a hernia rate of 1.7%, with rates of abdominal donor site wound dehiscence and surgical site infection of 17.2% and 11.2% respectively.² Surgeons that are treating such patients for long-term complications of hernia and abdominal bulging should be familiar with the autologous reconstructive technique used and should obtain prior operative reports to know whether any prophylactic mesh was used and in what plane of the abdominal wall. Additionally, if the patient did have issues with postoperative wound morbidity, knowing prior treatments including mesh excision and culture results is helpful in operative and perioperative planning. Current cross-sectional imaging is extremely helpful for operative planning and can also help to identify what plane(s) mesh may be in if it was used previously, as well as the presence of any nearby hernia defects that might affect the extent of repair. Using a minimally-invasive approach in this case allowed us to avoid planes that were involved in prior wound morbidity.

The use of the robotic platform to repair Spigelian-type and lateral incisional hernias has been reported in the literature in several small series.^3-6 The primary benefit of using the robotic platform over traditional laparoscopy in this context is that fascial closure is facilitated with substantially easier intracorporeal suturing. While there are not high-quality studies comparing traditional laparoscopic versus robotic-assisted minimally-invasive approaches for treatment of these hernias, the greater ability to reapproximate fascia robotically may lead to decreased sensation of postoperative bulging, which is a common occurrence in treatment of lateral hernias. Nonetheless, patients should be counseled preoperatively that they may still have some degree of post-repair bulging that cannot be corrected surgically.

From a technical standpoint, there are a number of principles that should be considered and highlighted with regard to a TAPP approach. Creation of the peritoneal flap should begin 5–7 cm away from the hernia being treated and should extend a minimum of 5 cm in all directions so that there will be adequate space for mesh coverage at the conclusion of the operation. If this is not done, it makes achieving adequate overlap significantly harder and may lead to undersized mesh being utilized. Laterally, it is important for dissection to stay directly on the peritoneal flap and to avoid veering into retroperitoneal fat, as injury to the lateral femoral cutaneous nerve may result. Given the close proximity of a Spigelian-type hernia to the myopectineal orifice, complete dissection and coverage of that space should occur to ensure adequate mesh overlap of the Spigelian-type hernia, to identify and treat any existing inguinal or femoral hernia, and to prevent a future inguinal or femoral hernia as a result of the dissection. As in minimally-invasive inguinal hernia repair, awareness of the presence of the iliac artery and vein is important to avoid catastrophic iatrogenic injury, and the inferior epigastric artery or its remnant can be used as a landmark to help aid in location of these structures. In women, the round ligament can be isolated and divided to facilitate mesh coverage of the indirect space, as was done in this case.

For reconstruction, fascial closure can be facilitated by progressively loading tension along the suture line by tightening each preceding suture throw after every new suture throw. For some defects, use of two sutures, one beginning on either end of the fascial defect, with alternating advancement and tightening, may be helpful as another method of loading tension on the closure. Decreasing the flexion of the patient on the bed and decreasing pressure of pneumoperitoneum may also help in closure of larger fascial defects. Care should be taken not to take excessively large bites of abdominal wall laterally, as the iliohypogastric, ilioinguinal, and lateral femoral cutaneous nerve of the thigh may be entrapped a fascial closure when reapproximating a disrupted semilunar line in the lower abdomen. In this case, we used a medium-weight polypropylene mesh with suture fixation, though other authors have reported using ProGrip (Medtronic), a self-fixating polyester mesh, in similar repairs. Medium-weight or heavy-weight meshes are likely most appropriate in the context of lateral incisional hernias in the interest of providing greater reinforcement to the lateral abdominal wall at the semilunar line. Excessive mesh fixation should be avoided, particularly laterally where nerves may run, but absorbable fixation to Cooper’s ligament, high laterally above the iliopubic tract, and potentially high medially on the mesh can help to ensure that the mesh remains in appropriate position during flap closure. Given that inferolateral penetrating fixation cannot be performed safely due to the presence of nerves and major vessels, we utilized Tisseel fibrin sealant (Baxter) in this case as a form of adhesive fixation. Peritoneal closure is a critical step in any operation where a large peritoneal flap is created to avoid the complication of an interstitial hernia and bowel exposure to uncoated mesh. Injury to the inferior epigastric artery should be avoided at this step if it is present. We typically use an absorbable barbed suture (2-0 V-Loc by Medtronic) for peritoneal flap closure and ensure that the mesh is completely covered by peritoneum. Additionally, exposure of the barbed portion of these sutures to the abdominal contents should be limited as much as possible, as exposed barbs can be a nidus for bowel obstruction. Any small holes in the peritoneum can be closed with absorbable suture, again to prevent bowel exposure to uncoated mesh. Of note, while TAP blocks were performed at the end of this case, it would also have been reasonable to perform them at the beginning of the operation with the intent of preventing centralization of pain. Though we are not aware of any high quality evidence comparing preoperative versus postoperative TAP blocks in this clinical context, there is substantial data that TAP blocks may reduce postoperative pain and opioid usage after laparoscopic inguinal hernia repair, which utilizes a very similar approach to the TAPP approach used in this case.⁷

While robust long-term outcomes for robotic-assisted repair of Spigelian-type and lateral incisional hernias are lacking, a robotic TAPP approach seemed ideal for this patient, with the abilities to avoid areas of her prior panniculectomy and onlay mesh from her failed anterior approach, to achieve fascial closure, to achieve wide mesh overlap while keeping mesh outside of the abdominal cavity, and to repair her concurrent inguinal hernia. As use of surgical robotic platforms increases overall and particularly within the world of hernia surgery, it is likely that we will continue to see boundaries be pushed to treat patients with increasingly complex hernias and surgical histories in a minimally-invasive fashion. With appropriate patient selection and technique, we expect that patients will continue to derive benefit from these advancements.

• Exparel - Pacira Pharmaceuticals, Inc.
• Tisseel - Baxter
• Bard Soft Mesh - BD
• Da Vinci Xi Robotic Surgical System - Intuitive

• SJZ: nothing to disclose
• EMP:
  • Speaking/Teaching Honoraria: Becton-Dickinson, Medtronic
  • Consultant: Boston Scientific, Actuated Medical, Cook Biotech, Neptune Medical, Surgimatrix, Noah Medical, Allergan, Intuitive Surgical, ERBE, Integra, Steris, Vicarious
  • Royalties: UpToDate (Wolters Kluwer), Springer

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.