Robotic Transversus Abdominis Release (TAR)

CHAPTER 1

Hi there, my name is Eric Pauli. I'm a professor of surgery at the Penn State Milton S. Hershey Medical Center in Hershey, Pennsylvania. Thanks for joining us. I'm delighted to share today's case, which is a 56-year-old male patient who has a history of a large periumbilical region hernia that he came to see me for in clinic. He had previously had an umbilical hernia that was repaired with a piece of mesh in 2021. He did well after that repair, but unfortunately in 2023, he developed acute appendicitis and he underwent a laparoscopic appendectomy. It was a difficult operation. And in the process of doing that, his umbilical hernia mesh was divided. It was left in situ despite his pretty severe appendicitis. And as sometimes happens, it became infected as a result of the exposure during the surgery in an infected setting. Subsequently, he underwent an open excision of his previously placed mesh to clear the mesh infection. And not surprisingly, he developed a recurrent hernia at that area. When I met him in clinic, he had a large and enlarging symptomatic hernia, which on pre-op imaging, measured about eight-by-eight centimeters on the CT scan. Very tender, not able to completely reduce it in clinic as a consequence of the size, but also the amount of pain and discomfort that he was having. We had extensive discussions with him about how to approach this, and you'll hear some of those discussions in the operating room today with my fellow. The debate ranged from, should we do this as a total extraperitoneal operation? Should we do it as an intraperitoneal unilateral dock operation? Does this really need a transversus abdominis release to manage? Could we just do it open and do retrorectus alone? And I think this case demonstrates that there's no one ideal way to address these medium range hernias. There's a variety of options that are going to be at your disposal. And I think in general, whatever the surgeon does best is potentially a right solution here. What the patient and I talked about was a few things. Number one was that he understood that this needed mesh, but with a history of a previous mesh infection, we wanted to keep the mesh out of the abdominal cavity. And in my particular way of thinking about this, I like to use reduced weight meshes when somebody has had a previous history of an infection. So for both of us, that means no heavyweight mesh and not in the peritoneal cavity. We elected to do this as a bilateral dock robotic transversus abdominis release to allow us to not only close the defect, to reduce all the content that we felt was going to be incarcerated clinically and to do that safely. And so that's the operation that you're going to see us do today. I'll review the imaging subsequently that sort of shows the size and the content of the hernia. The basic steps of doing a robotic intraperitoneal operation are to gain access somewhere safe to dock on whatever side you've gained access to clear adhesions. Subsequent to that, it's retrorectus release, followed by a transversus abdominis release with the dissection wide enough to cover not only the midline defect, but any lateral defects that may exist. Once that's done, we will place ports on the contralateral side. Not necessarily in a mirror image position, but similar. And then complete a retrorectus release in a transversus abdominis release. From that same contralateral docking position, we will reconstruct the posterior layer and close the floor of the repair, which basically extraperitonealsizes all of the abdominal content. At a reduced insufflation pressure, we will close the anterior fascia. I like to plicate any remaining hernia sac above to reduce the size of a seroma cavity that may exist. And subsequent to that, to place a mesh in the retromuscular position. You'll also see that our enhanced recovery protocols do include the use of a transversus abdominis plane block, utilizing a long-acting liposomal bupivacaine medication. Ports are removed, skin incisions are closed, and the patient heads to recovery. Our anticipated post-op stay is usually overnight. Occasionally people meet criteria and can be discharged the same day. This is our patient who is going to have a robotic transversus abdominis release, and I wanna scroll through the CT scan to show some of the findings. For starters in the upper midline here, we do see that he does have a bit of a diastasis. These are axial images three-centimeter thick, and this is a non-contrast, no IV, no PO contrast scan because we don't need that for hernia care. But if we measure the size of the midline here, he's got a four-centimeter diastasis in the midline. And you know, that may have contributed to the development of a hernia and then a recurrence following the mesh removal. As we get down to the low midline, we have an eight-centimeter hernia defect. The content includes the small bowel, portions of the colon, and a fair bit of omentum up in this defect. A large bit of omentum here. You know, he's got a very high neck-to-sac ratio as well if you wanna do the neck-to-sac ratio. Below the level of the umbilicus, the abdominal wall is more or less back together. As we scroll down, more inferior. He does have a piece of mesh here. He had an open inguinal hernia repair. This is a piece of ePTFE. For a while, there was ePTFE for open inguinal hernia pairs. This is now off the market, but that's what he has in that location. We also see the patient does have nice pyramidalis muscles right here. We don't always see pyramidalis muscles on humans, but there they are. By the way, his staple line for the appendectomy is here. Things that we're not seeing on the scan that we have to think about are that he used to have a piece of mesh in situ to, and that was an IPOM mesh. That mesh got infected and it was removed. And so we don't really know the integrity of the abdominal wall. We also know that with the mesh removal for infection, that, you know, you have to anticipate some amount of intra-abdominal adhesions are going to be present. The thing that I did earlier was to put some measurements on this. And I would say that from a measurement perspective, if you look at the width of the rectus muscles and compare that to the width of the midline, he's really right at the borderline of that Carbonell ratio where we want two times the rectus width as the hernia distance to have an understanding of where we're gonna put mesh and can we close this defect without additional components. And so my concern in doing this patient as an eTEP retrorectus operation alone is number one, he's got a lot of bowel up in the hernia; number two, I know that he may be missing some portions of the posterior sheath from the mesh excision; number three, the content, at least in in exam for me, is partly incarcerated; and then number four, he's right at this Carbonell ratio. And so those are all things that I considered when deciding to do this as a robotic intraperitoneal operation. The last thing that I want to point out and that we are aware of is that in his left, I'm sorry, right upper abdomen, where we are going to obtain abdominal access. He's got a bit of hepatomegaly here just from fatty liver disease. And that liver comes down well below the costal margin. So as we are gaining access here, we know that his liver is going to be stuck here and we know that the liver is in play. We could certainly attempt a left upper approach and just have to deal with some pericolonic fat and some omentum. But my choice for getting in for most of my bilateral dock robo TARs is right upper quadrant. And so that's how we're going to approach the case today.

CHAPTER 2

You're far enough away. Take mine. Can we get rid of the picture in picture on that screen for Katie just so she's got a full screen to look at and we'll take the room lights down then. Who's got the camera there? Let's get the room lights down. Let's get the camera all, get your focus all focused correctly there, Ben? Is it okay? Fine. Yeah. All right, one hand is the gas, one hand is the break, okay? Lots of twisting. A little bit of pushing. Let's talk about the layers as we go. Fat, fat, fat. Some layer of superficial Scarpa's fat. More fat, fatty fat, fat. Yep, watch your angle. I like that. Fat, fat, fat, fat, fat, fat, fat, fat. There's some muscle in the distance. Good, some anterior layer of fascia and some muscle. Nice thick muscle. Some posterior layer of something, keep going. Yep, you're not in yet. That's probably the fat between the external oblique and the internal oblique. So there should be more muscle coming, right? I think so. Yep, I think so. Yep. Yep, there's more muscle. Yep, keep going. That's a liver in the distance. You're not through the peritoneum yet. That's liver in the distance. It is, but I feel like I'm almost... Give it a little twist, it'll go. You're just stretching the peritoneum now. You think you're in? No, I think, I also... That's fine, that's fine. Yeah, I definitely, I think I'm just like on top of the liver though. And that's... Yep, let it slide. There you go, good. Okay, give it some gas, yep. Just back it up a little bit. Let your gas crack in there. What's the pressure? Got a little crack in the liver there. We'll have to buzz it. Take a look down first, Katie. You just got a little bit of ooze there, I'm guessing. It's fine, back it up. Just got a little bit of a bump in the liver there. Back your port out to the edge. That's the liver. Is he fully paralyzed? He is. Awesome, thank you. Let's get a port in and we're gonna stop that, okay. Good, eight. This will be an eight. We'll get an L-hook for the Bovie. So it's a stretchy. It is a stretchy peritoneum. Yep, that was the problem. That bodes well for your component separation, but less good for now. Yep, lots of twisting. Good, yep, keep twisting. Okay, in? Yeah, I'm in. Okay, good. Yep, come on in. Let's find that edge. Find the liver. Yep, it's already done. Get your Bovie. Bovie. Touch me. Stop, do it again. Whenever you guys want. Stop, do it again. Leave it to the side for now. We probably don't need it. Yeah, I think we'll be open, okay. Take a look at that real good. I think that looks good. The only concern is... and I've never done this, but I've seen it. Give me a little buzzy buzz buzz again. Is that it goes through and through? Is that you go through and through. I've definitely seen that. I feel like I could tell when I was close to liver and then I angled away. That's exactly what you did. You just bumped in. When we had this little ding into the capsule, you weren't even in the peritoneum yet. No, I wasn't. Okay? It was just the stretch of the tip coming through. We're gonna have the entire case to look at that. And so we'll make sure it looks okay as we're working. Okay, now. Do you wanna switch this one out? We can switch it out now if you want, yeah. I'll take a robo eight. Let's move the gas. Here, you're on the proper side. You switch it out. There we go. I'm gonna give that to you so you can push it away from the liver. I just can't push down. Get your remote center set so we can just dock right away when you're square. I don't wanna get too close to his leg and his head. That's close. Yeah, I would stay... Let's make, where's your... So I was gonna stay up a little bit. That should be good, yep. I like your angle. I think that's a good angle. You don't need to go crazy steep on it, but I think your position is good. Yep, lots of twisting. He's got really good connective tissue here. Big twists, yep. Okay. Fine, fine, I think we got room to dock there. Let's get that down. Hang onto to this for one second. Let's just see. I mean, it looks like it's mostly momentum, yeah? Yeah. And so the extra hand will help, but you'll have room to get in there and dock and get that all down. Give it a look up into it and just get that... Yep, fine. Let's do it. Let's dock a robot please.

CHAPTER 3

Now keep going toward the patient's head. Stop, now angle toward me. Stop, come straight in, yep. Can you lower the bed a little bit? Will it go down? Keeping the spot. We're gonna take a fenestrated bipolar, scissor hot. Camera. All yours Katie, go for it.

CHAPTER 4

Yeah, cut the easy ones Yeah. And work your way around. That's the upper edge. We're a little close on this near side. I'm just trying to help get this down for you. I'm gonna have to work from up down. I'm trying to pinch the hernia sac here without really collapsing the abdominal wall. I think this is edge right here. Yep, I think so. Is the patient fully paralyzed? Yeah, I just gave him one. Oh, thank you. Yeah, he uses rocuronium at home, okay. Okay, you got it. So just be mindful. I mean, he's probably gonna go through it pretty quickly. Got it. We talked about it pre-op, but he was unwilling to quit. Fair enough. Who is that at the head of the bed? Brenna. Oh, sounded like Selena Reed for a second. I thought I was like, did Selena pop in here? That's probably your sac right there, Katie. Right here, right? Yeah, I think so, yep. So I mean, don't burn the skin but you know, it should sweep down. I think this will start to sweep once I get through this. Yep. Yep, buzz, buzz, sweep. (Tara faintly speaking) Maybe I'm not gonna plan to be here very long. As soon as she gets past this near, that's, yeah, there's your edge right there. Yep, do it. Buzz, buzz, sweep. There you go. I'm not gonna be here for very long. As soon as this near side is down, I won't need to be here. Okay. And I'm gonna get up. I am changing my angle. I'm not doing anything now. I definitely am helping you. Let me get a good grip here so I can push this all down. Yep, I'm pushing. There we go. That's the best I can give you right now. Yeah, work the top edge there Katie, 'cause you can see the whole top edge. That's the bottom edge. You want me to go... That way. Yep, that's the whole top edge. Yep, that's where it joins right there. I don't think there's bowel in this, but... No, I don't think so. Have some element of healthy skepticism. Yep, there's your edge. Yep, it'd be right there that I'd be mostly concerned if there's gonna be anything. Yep, dude, keep sweeping, I like it. So tiny. Yeah. I gotta regrab. Yep. All right, keep working down. You can see the edge. Yep, I like it. Yep. Oh, it feels so weird on the outside here. I will get that better here. I'm just gonna get this up here down real quick, then I'm gonna use my bipolar. Yep, kill it with bipolar. I would work the near stuff. You want me to come in closer? I would just work the near... The stuff in the middle? Yeah. I gotta relax, give me one second. My hands are cramping. Oh, that's hard. Whenever you're ready. I'm ready. Because if you can get that down, then I don't need to be here at all. Once you're across the midline, you should be able to reach up there. Yep, it should mostly sweep. Yeah. Don't burn the skin. Yeah, he's got really thin skin. I can feel your instruments hitting me. You can feel me? Okay. And then I think I need you for this part here, and you should be good. I just don't see the edge. There's the edge. Oh, it's so weird. You're fighting me. Take a look at the floor. Make sure nothing's oozing down there. I'm gonna stand up and push from here. Grab it, pull it toward yourself. Yep, take it, that's fine. I don't want to get too close to the skin. Yep. Yeah, just buzz it down. If you leave a tiny little bit of fat up there, no one's gonna lose a lot of sleep. Okay. Look at the floor, I'm letting go. Yeah. It looks pretty good. You can do it, yep, okay.

CHAPTER 5

I would start by jumping preperitoneal on the falc. And start taking that down. You want to get it on my side? Yeah, but I mean you can... I'm gonna unscrub so I can draw. I mean I can come here. Yeah, you know, just get it started right there and then, you know. Fine. I'm gonna... I can move this. I just need to be able to draw, so I'll move here. Yep. Yep, you can take... yeah, that's all peritoneum. So you can take that peritoneum down. Yep, fine. And sweep it down. Yep. Beautiful, yep. I'm starting to see some rectus muscle back there. You know, you're probably at the medial edge of the rectus there. Yeah, it's probably right there. Sweep it down, yep. Get it before it bleeds. It's over here. That guy, I get that. Just get it, yep. All right, so then, you know, somewhere up here where you can see the rectus, jump retrorectus. Buzz it, make sure it jumps somewhere in there. To me, this... Take that in there? Yeah. No, no, I mean, it's all through here. Right, okay. Yeah. You can stay farther lateral though, right? You can go out here 'cause you've already got the pocket created. Does it jump? Yeah, right there. Show me some muscle. Again, you can go farther lateral. You don't need to be as medial. That jumped to me. I think it's... Yep. Yeah, I think it is. So make a small hole. Show us some muscle. There's some muscle. Just looking at his scan. This is not him. He's got a little bit of a diastasis, but it's not particularly big. So I mean, listen, if you don't see it there, obviously then just go farther wide until you see some muscle. You know, don't divide the linea alba. Go until you... Yeah, I mean this... From there over, that's jumping now. You go open right there, yep. When you buzzed here, it twitched down here. Yep, do it. It's transversus. Do you think I still need to go deeper? I don't see his... I mean, those muscle fibers are going medial, they're going mediolateral. And on the scan... No, he doesn't have fibers that go that far medial, so... Just see if you can find the posterior rectus space. You're in the right spot. You're over the muscle. You're in the right spot. Everything you're doing is fine. Let me drive for a minute. You can also just stomp here Katie. And we could just say, look, let's just go here. Like, here's the edge right here, right? Yeah. So you could restart your plane here. This is preperitoneal. And then just open the plane here and then just carry it and just carry it upward. But I promise you, you know, you're gonna be in the right spot when you get to the top part of this edge. It's all gonna connect together in that location, okay? It's a little bit of preperitoneal here. There's definitely rectus jumping, right? There's our rectus there. So now you're in. I would just work from here then up. And again, you're gonna follow it. I mean, it's gonna wind up being here. You're gonna be much farther lateral than you think. Okay. Yeah. So I feel like I was lateral, but I'm like... They may just be little bits of the transversus. I mean, remember it comes very medial on some people, okay? Yep, there you go, do it. And you're just trying to connect that way. You don't need to stay super medial 'cause you've got all this peritoneum already taken down. Okay? Yeah. It's gonna be a little fused in here because this is where he is got, you know, it's surgically scarred from them being here. Yeah. Yep. Yep, get a scissor behind, cut it open. Yep, a little bit of denervation of the muscle there. Right there. Yeah. Yep. So you're doing a little bit of pant leg. You've already got the peroneum down here and you're retrorectus here, so you're kind of pant legging it. Yep, so you could have been way up there, okay? So where, where you were was totally fine because you're way out there. Exactly. It was probably some transversus fibers you were seeing. Again, we both recognized those fibers went the wrong direction. This is where you originally started right there. So you were in the right spot there as well, okay? I guess it's just deeper than I thought it was because I was like, I feel like if I go deeper, it would be tricky, but... Yeah, he's got very good musculature. Yeah. Alpha agrees. I saw him shake his head. Yep, stay off your linea alba. All right, you can start going lateral and work back inferior. You're gonna eventually need to go a bit higher, okay? But you know, I would work from there out and then I'd work from there down, okay? It's the medial edge that's holding you up. So get your instrument behind it. Get your grasper behind, cut in between, yep. You can just, yeah, just cut. There you go. You're good. All that can come down with you. You can stay even higher. Yep. So this is RP fat that should come with you. I like it. Yep, now remember that we wanna leave a little bit of a lip here so that as we're on the opposite side sewing, we can see that lip to suture too, okay? Linea alba is gonna be, you know, roughly where you're working. So you know, you may wanna jump into the preperitoneal space and just bring the peritoneum down here now. Yep, just get peritoneum and kind of bring it that way. Okay, that's preperitoneal. And then go back retrorectus. You're gonna have a branch of the epigastric, you know, somewhere in there coming up to the midline. So just be mindful. You're gonna eventually see it in here somewhere. That's the posterior rectus sheath. My goodness. It is. It is. There's your branch. Right there, it is, yeah. I can see it Should I take it? Yeah, I would. Yeah, take it now while you see it. Now remember though, you're about to come through there, okay? And so it's possible that you cauterize it on the near side and it still bleeds from the other side, okay so... All right, I would open up more of your preperitoneal space first. Make your life easy. Yep, bring that down. Bipolar that thing. It's probably the vessel on the other side. There's nothing up here that's important. And start taking that down. Thinking about where that vessel is. Right there. Yeah. This is clearly surgically scarred. Even though there isn't a hernia here, his incision must have come down at least to that level. Should I open this down like this? Well, if you open it that way, you're gonna have to close it back up. So, I mean, you certainly can. I mean, you're just gonna have to close more of the floor. Yeah. This is the trouble with him having a hernia that's not crazy big, I guess I can't see down to see it. Yeah. Usually what I try to do is come back up here and just drop it from up top. Like here? Yeah. Yeah, leave it. You can take it from this side. Just open more down the middle. Open the posterior leg. Open the posterior, sorry, open the peritoneum down the middle. Okay, I think I'm gonna go lateral. That's fine, you can go lateral. You gotta do it anyway, go ahead. Nice, keep going. So Alpha, you've seen this before when you were on service previously, yeah? You've seen us do a TAR before. Yep. Maybe not robotically. Yeah, I've seen on... Fine. So the nice part... So it's technically easier to do open. I mean, I think in general. But to understand - there's a neurovascular bundle right back here Katie. So you're close to the semilunar line. Yep. I think... That's one for sure, yep. Yeah. But seeing all of the layers that we normally talk about and all of the leaflets and all the things that we just go like, here it is, here's this, here's that. And as the student, you go, yeah, sure, uh-huh, uh-huh, I understand. You get a much nicer view of them today, okay? And I would say in particular, the view of the semilunar line here that you're gonna get is really gonna be awesome, 'cause you're basically staring straight in at it, and you got a magnified view. So all the little neurovascular bundles that come in at the semilunar line, this is a branch that's gonna connect over to the epigastric probably Katie. You're still mid abdomen though. You know, you're not very far inferior here. The hernia is really just a M2, M3, M4. And so you're probably high to see the epigastric fat pad yet, but keep working inferior. you're gonna get there pretty quickly. That can go. Yep. So there's a lot of different ways to fix this guy's hernia, Alpha. We could certainly have done it open. And open, we probably would've been able to salvage most of the hernia sac to flip it down. And it's got pretty wide rectus muscles. And so you probably could have done this as an open retrorectus operation, okay? I didn't think that the anatomy was gonna be good enough for us to do a robotic retrorectus alone. And I based that off of two things. Number one, he had content incarcerated in it, and you don't know what that is. Now it turns out it was just fat. But when there's bowel incarcerated and you're doing an eTEP operation where you can't really see what's in the hernia until you get there, it's a challenge. In clinic, he's very difficult to examine. He has a lot of pain and discomfort associated with this. And so it's not easy to push it all back in like I did here. But even after we pushed it, there was still incarcerated content. All right, so you're gonna have to go higher and lower Yeah. Before we can get any farther. And it probably means doing more pant-leggy maneuver. So that's gotta come down kind of going that way, yep. Exposure begets exposure. You don't need to be that high up. You can take it right here. You mean down here? Take it somewhere where you can see it, yep. You've already got the floor down below you. And so the closer to the midline you go, the more you're gonna injure the linea alba, okay? Yep, now you're thinking about epigastrics, everything should go up. -Yeah. I would be surprised if he doesn't have a very robust fat pad around the epigastrics, okay? Yeah. So we talked about doing this as an eTEP operation, but I think the second issue beyond content incarcerated, when you do an eTEP operation, the hardest... Usually when we do that, it means that the defect is not crazy big. And we believe that when we release the posterior sheath alone, two things: number one, we've got a big enough pocket to put the mesh in and we can measure his rectus. There are at least eight centimeters. So there's plenty of room. Number two - there's your epigastrics there, there's your fat pad, yep. Fat pad there. Yep. Thing two is that the fascia will come together without a TAR because there's not a lot of tension. And again, his defect is not crazy big. So I believe those two things are true. But one of the unique parts about doing an eTEP operation is that sometimes the hardest part to manage is the floor. And if you have a hernia defect that you can't salvage a lot of the sac... So, Katie, pause. Yeah. This is the blood vessel that goes to the epigastric that you buzzed back here. But if you push that, if you push down a little bit, you're gonna see it's over here. Push down so you can see. See it back there? Yeah. I would buzz it somewhere in the distance, okay? 'Cause you gotta divide it. And then that's gonna go up with you, okay? 'Cause all of this fat needs to go up. There's a third branch that goes that way, sort of. Yep, fine. Get it all going up there. Yep, Alpha, you can see the epigastrics right there. Yep, buzz, buzz, sweep. Grab it there. Pinch burn the whole thing. Yep, okay. There's still one more branch of that thing going that way. Nice maneuver. Give it a buzz. Give it a pinch burn. Very nice, good. Now I would just divide it somewhere like there. That way it doesn't rip. Okay, main drag epigastrics are back there, right there. This is a branch coming off, main drag. Okay, back up. See how far down you are. You're farther than you think, okay? When you're on the contralateral side, so take a look here. When you do the contralateral side, look here and you're taking this down. Yeah. You're gonna be able to get the rest of that pant leg down if you need to for your inferior coverage. But again, your hernia defect is all the way over here. Yeah. So you know, you don't need to do a stem to stern dissection for a central abdominal defect. Okay? Yeah. So look back at your hernia. There's the edge of the hernia there. And then ask: where's my inferior coverage? I mean, you're way down to there. You may have a little more in the midline to take down. Yeah. But you'll be able to do that from the other side. Go up? Yeah, I would go up. But before you do that, show Alpha how far this posterior sheath has retracted. So Alpha, if there's not a lot of hernia sac to recruit, okay? As soon as you disconnect that from the midline, look, it's kind of zipped back over. Right. So now you're doing an eTEP operation, you've got a big hole in the floor, and when you pull, you can't get that posterior layer together, okay? And the worst thing about an eTEP or a Rives-Stoppa operation, just a retrorectus operation is when that floor is under tension. I would just go headward, Katie. Yep, so these are the nerves? Those are the nerves, yep. There's one, there's one, there's one. Okay. Easier to see robotically. Much easier, yeah, much easier. So do some pant leggy. Swim in the preperitoneal space. Go headward. Yep, get the little vessels before they break. So is that why you're gonna do like a TAR to relieve that tension? Yeah, so... Again, this is - this guy's hernia is at the borderline of... we could do it open... Yeah. And it's probably faster open and it probably requires a little less dissection. Because open, you can take that entire hernia sac and peel it down and leave it as part your posterior layer. So that when you have that gap where the hernia is, you now have stuff to fill in the gap. And it's not under any tension 'cause it's a loose hernia sac, okay? But when you do this robotically, you're probably doing a TAR as a consequence of the need to alleviate tension, which you can't get by pulling the hernia sac down, okay? So you have a decision to make. Do I want to give this guy some morbidity of getting a transversus release? You know, risk of bleeding in the TAR plane, the risk that we accidentally injure neurovascular bundles because we do it wrong. Or do you want to give him the risks of... And Katie, just to say it out loud, this is the linea alba going that way. Yeah. So just be careful that you don't, you know, take this that direction and cross the linea alba. I'm gonna go down like this? Yeah, yep. You know, or do you just do an open retrorectus, then he has to have an open operation. More pain, more discomfort, higher wound complication rate, but also a little faster and not as much dissection, okay? And there's no right or wrong answer here. You know, I think, in the middle would be nice if we could have done an eTEP. And I'm sure someone out there and maybe even someone watching the video that we're making today is gonna go, "I would've just done an eTEP on that person." And that I would say fine, totally fine. Like Dr. Sodomin may wander in later and say, "I would've just eTEP that," okay? And that's, you know, if you understand that the problem with doing the eTEP is content incarceration, I wouldn't take that. Would? I would not. Okay, that's what I was thinking but it's bleeding then I'm just like... Just just grab that little thing that's bleeding, just give a little pinch burn. Yep, that littlest thing right there, yep. Yep. Good, okay. Yep, buzz, buzz, sweep. Yep, you're gonna have to probably take more of this down going headward. Yep. If you think about going... Am I...? You're... Get up here so I can see the best direction to take it? Yeah. Yep. Yep, nice maneuvers, good. Yep, I like it. So Alpha, you can see the linea alba's right there. And this is where the posterior sheath attaches to the linea alba. When she pulls, you can actually see it arcing. And what we were talking about is we don't want to go this direction accidentally. And your brain, you gotta make sure that you're following the rectus straight up. And we're looking at it initially straight in, but now we're looking at it kind of upward. And so the angle, you gotta make sure you're going this way and not back toward yourself, okay? When you do this operation open, it's very easy to reorient yourself. Because we all pause and we all look that direction together, and we all pause and we look this way, and then we all pause and we look down. But here, we're always from the middle. We're just kind of angling the view, okay? It's never a true up or a true down view of the world. All right, so again, Katie, your goal here is to have enough superior overlap, okay? Your goal is that you have enough room to get your ports in on the other side and that you have enough room to do a TAR. And I would say you've achieved the majority of those goals. If as you're working, you decide that you need to take more down, you always have the option to extend that retrorectus dissection flap up or down. Okay? Okay. I would do a bottom up TAR 'cause you're kind of working from that side. So go all the way to the bottom, and... Just watch that bowel below you. Let me drive for a second. Yeah, I just like don't have a great view. Well, you're still 30 up, right? I am. You can also go 30 down and see what looks like 30 down. You can also do sort of a Madrid maneuver at the bottom here. You could theoretically, because you're below the arcuate line, you've got the peritoneum here and you can see the posterior sheath. You could theoretically just take that transversalis fascia and I mean it's like a lower Madrid maneuver. You just cut straight across. Okay. And then you go up 'cause you've already got good peritoneum down. So it doesn't really matter what's below you at that point. And he has no surgical incisions out in that area. Like is this right here arcuate line? You're probably at it right here, yep. Right here? Okay. Again, he's gonna have very good transversus fascia. And so where the posterior sheath officially disappears and where it's just transversalis fascia on him may not be as apparent in somebody else. But I would say that you're looking it somewhere, somewhere in this range, okay? I mean, I think... I mean, this is clearly transversalis here. You can see the nice view of the epigastrics. So you're probably down. And you know, sometimes just by pushing like this you get a sense that, you know, again, I'm not dissecting anything, but you get the sense that I'm probably lateral to the rectus here. You know, and so have I actually done a little bit of the lateral dissection? Is he fully paralyzed? Is he fully paralyzed? Oh, yes. According to my monitor, yes. Okay, thank you. And before I do any of that, I just wanna back up and make sure that I don't have a loop of bowel hanging right below me. And I don't, so we're okay back in here.

CHAPTER 6

We're in a little bit of a cave, but... So this is probably just transversalis stuff then Katie. And so I'm just gonna do a little bit of picking at the floor. The transversalis stuff. There's your preperitoneal space right there, okay? And so now if we get in here, we're kind of separating transversalis on the floor from preperi... I'm sorry, transversalis up, preperitoneal on the floor. Yeah. And if you continue this dissection, as you get to wherever the actual arcuate line is, the line of Douglas, you know, somewhere in here where your line of Douglas begins, you're gonna wind up having... You're gonna basically be doing the TAR at that point. Not because you've changed what your location, but because the fascia changed from being anterior to being posterior and you're in the right location. This looks like an old drain site or something. An old port side, an old drain site like that looks like a surgical scar. But basically, we're just gonna continue this upward. And then, I mean I think from here... I mean, I think from here up that's definitely fascia. So, you know, was this an old port site? And this is kind of the beginning of the line of Douglas. Probably something like that. So long as I'm dividing it medial to where we see it definitely attach. When I push down, I'm actually watching out here to see where that attaches. And I'm also making sure that I have a floor layer that I'm not cutting through the floor. Wiggle, wiggle, buzz, push, sweep. All the Conrad Ballecer maneuvers. I try to say Conrad's name every time I do one of these Journal of Medical Insight videos, because I'm sponsored by Ballecer industries. I'm like a NASCAR driver. All right, so this is probably a little bit more transversalis stuff. And you're gonna be out there. Okay, so I think you're okay to start. Now, again down here, do we decide to do a little bit more division? Like maybe, we can certainly do more down there if we feel like the mesh isn't gonna sit or we need to get a port. But for now, I would just continue this, you know? I would just continue upward. I think you've got a pretty good view there and I would just work it up. And at some point, we've gotta figure out where we're gonna curve back medial. Because again, we're not as high up as we might be in a larger hernia. And so your hockey stick maneuver to come back medial may happen a little lower than we would normally do it, okay? Do the front layer first. Yeah, do the front layer first and then see what you get on the back layer, okay? So Alpha, that joins... The arcuate line is a little farther lateral. And so what she's doing is she's putting an instrument in. She's wiggling to separate the layers. And then she's cutting basically the floor, okay? Two things that are important. You gotta cut down onto the floor. We're not cutting lateral going in, we're cutting straight down. And number two, it's easier to do this open. You can't pull crazy hard towards you. Katie, this is a good example. Take that bite. I wanna show you this. So look, you see the second layer? You see how there's two layers there? Yes. So the transversus abdominis muscle actually has two insertion points. And as you're doing this division, it's entirely possible that what you're actually seeing are the individual insertion points. Either of the transversus and the posterior lamella of the oblique, yeah? Or it's just both anterior and posterior leaflet of the transversus insertion. Yeah, okay? That's where you wanna be, yep. Again, your goal is to keep working upward. Don't wander that way. Yeah. That's the posterior lamella of the oblique. And then the transversus insertion is below you. So you're seeing both insertion points as individual layers here. Yep, sweep like you're doing that little sweep back there. That's great. Remember that when we do this open, I tell you to go lateral. Yeah. And then go superior lateral and then bring the finger back. That little come hither maneuver, okay? You're doing the same thing. I know, I just like, not having to have to go back is... Like I feel like when I do it open, I can feel the layers coming apart, so I know for sure I'm actually separating them. Yep. And then with not having that, I just am always worried that I'm actually just putting a massive hole in this posterior layer, but... Push that straight lateral. Straight lateral, there you go. Okay, good, yep. All right, come back, keep working. Center yourself on the screen. Again, that centering is important so that we know that we're not wandering some other direction. Give this a little push. Give that stuff a little push up just so you can see how far away from the semilunar line you are. You're pretty far, okay. Yep, sweep behind. Yep, good. Again, don't wander. Keep aiming... I'm trying to come towards me. Yep. Yep, okay. You mostly just want to go straight up toward the head, but it's hard because you know, as you're sweeping from bottom to top, the angles change. Yep, sweep behind. Good, yep. Put your scissors behind and show it to yourself. Do the little hook maneuver. Yep, there you go. You can see what you want to cut, yep. I can see that layer. Yeah. Look toward the head a little bit more, yep. I think I wanna just keep coming like this. You got it. At some point as you get higher, you're gonna start to see transversus muscle fibers. So you know, as you start to open your first layer, which is just the fascia, it's gonna be fascia, but then your second layer, which previously has just been fascia, is gonna turn into muscle. Muscle, yeah. Keep going. Now just watch your angle. We don't want to go this way. We want to keep coming up toward the head. You can bring the transversus down with you if you want, okay? Why don't you look ahead and see what's bleeding and make it stop. Okay. You kind of want to go, you know, sort of at a direction it looks like, yep. I feel like this is maybe getting muscle fiber. Maybe, if it is, you should be able to then do it in two layers, okay? So if you can find a plane and wiggle in and get the posterior lamella of the oblique, then you'll see the muscle underneath. So Katie, put your hand above the transversalis fascia here. Put that instrument above and then push everything down and then push. There's your pocket. Yep, do it. Push, push, yep. All right, good, keep going. I would say you're approaching, this looks like the pant leg that you took down up top. Yes. So if that's the case, you gotta start thinking about your exit strategy. Yeah, coming across. But I would follow because we're not far down in the abdomen, But I can keep going up? Because we aren't inferior. Yes. Normally at this spot, when we're talking about coming across, you've already been taking a bunch of muscle. We really haven't seen a lot of muscle yet. You're gonna start seeing transversus in here. So your edge, you know, where you come medial is probably gonna be like way at the very tippy top of your dissection, okay? Again, I feel like that's muscle. That's muscle starting to show up, yep. Again, it'll start jumping and you'll say, oh, that's, that's muscle. I mean, at a minimum, you definitely have separate fascial insertions that are pretty clear. That's layer one and then there's layer two behind. Yep, sweep everything behind. I mean these are transversus muscle fibers. You can see them all coming that way. Yeah. Yep. Yep, good. Yep, take it in two layers. Take your anterior fascia first. That's muscle fiber itself now. Look ahead, see where you're taking that plane to. Look ahead, look up this way. Okay, so look, I think, if you follow along this ridge, Yeah. I think you're gonna be fine. I would just take the anterior fascia first. Okay. Yep, so that's the posterior lamella of the internal oblique living on top of the transversus. And then below it is gonna be the transversus insertion point and the transversus muscle itself. Go back and get your second layer now. Yep, you're right at the edge. You can actually see the muscle fibers. Yeah. Yeah. You can see the muscle fibers turning into a tendon and inserting on the posterior sheath. So you're doing a release of the tendonous portion of the transversus. And so it should be a little less bloody by doing that. Just be mindful that, you know, sometimes the peritoneum is thin here. Again, in general, he seems to have very thick peritoneum, which is helpful for us. Yep, so then start sweeping. Get your hand out there. Push down, sweep up, yep. They really should be minimal. This is the part where you normally just take a sponge stick or a peanut and just push. Those little vessels that ooze, you're gonna see a lot more of them because you got your eyes right down in here, okay? But this should be mostly... without any other surgical incisions out here, this should be mostly, you know, pushing and you should be in the spot. You want to be, you know, with some, you know, medium aggressive maneuvers and not a lot of bleeding or risk of holes. Okay, now obviously as you get higher up toward the costal margins it's gonna get a little bit thinner. Maybe not in him. 'Cause again, he's a dude with robust tissue planes. But work from top bottom and then just kind of, you know, you're making basically an upside down, making an arc shape. So work the arc. That's transversus fascia. You're just plane hopping there, see? Yeah, that's right here. All right, Alpha, so what are the goals here? We already have a big enough pocket for mesh. We probably had that just by going retrorectus, yeah? What are the rest of the goals then? Why are we still going lateral? So you wanna make a large enough pocket, so that... when you bring it together, you'd be able to... So we already talked about we want that floor, the posterior layer to not be under tension. And part of why I thought we needed - give that a little pinch burn there. Yeah. Part of why I thought we needed to do a TAR here to begin with was because I was concerned that the floor with just retrorectus was gonna be tight, okay? And we sort of demonstrated that's kind of what it looked like. So we definitely need that, I agree. Other things to think about are we need enough room on the other side to get our ports in, right? Right. And then obviously superior and inferior, we wanna make sure that we... That we have enough room to put the mesh above and below. Laterally, we got plenty of room to get mesh in here. Right. So I just keep working. Yeah, I like what you're doing Katie. I would just kind of keep working inferior. You know, that's lateral. So you're headed towards lateral parts of inguinal dissection in that direction. So I would maybe approach it from medial where you can actually see the epigastrics. Again, you're still lateral 'cause this is your transversus cut edge here. So you're still lateral to the rectus. So you're plane hopping. It's okay. So look this is a great view Alpha. This is a great view of stuff we talk about all the time. This is preperitoneal and this is pretransversalis, and there's a plane right here that connects those two. And you can see that the plane kind of does two things, okay? For the TAR, you're not cutting the muscles themselves, you're cutting it around kind of like tendon when it comes together? It all depends on exactly where you're working. We were able to stay very medial, but sometimes you can't do that. Some people's transversus comes very, very medial. Why don't we just do this entire operation... Start going this direction. Why don't we do this entire operation as a preperitoneal operation? Why not just grab the peritoneum and pull it down and not worry about going retrorectus or doing a transversus release? It's not thick enough to hold the, like, it might rip the peritoneum when you bring together the tension. Well, the peritoneum, if you make a big preperitoneal pocket, it's usually not under any tension 'cause you can go as far as you want, right? But you said, I think you said it's thin. It is thin and it's also very sticky. There are parts in humans where the peritoneum is really, really stuck in place and it's hard to separate those. And that primarily happens behind the rectus muscles, okay? Lateral where we're kind of working now, lateral to the transversus where the trans- to the semilunar line, that peels down pretty easily. And medially, in the middle of people, where there is lots of preperitoneal fat around the umbilicus, there's kind of this hourglass shaped area of fat in the middle of humans. That's the falciform ligament, the umbilicus and then the bladder flap. That's also very easy to get down. I would just buzz and sweep there. Yeah. Yep. Good. You're kind of separating... That's your transversalis that you're taking, yep. And again, every time, you know, before I got too far down there, I would back up and ask exactly where am I? Like reorient and also ask, do I need to be out here to do mesh placement, port placement, et cetera, or have I gone far enough now? I'm still 30 down. Yeah, but I mean, look, if I was gonna put a lower port, you know this hand right here comes in at about that level there. Your camera is gonna come in about here. You got room for an upper hand, you know, maybe room for an upper hand up here. You probably wanna do a little more up, okay? Yeah, I would take that down. So you could do this operation preperitoneal. There's a surgeon who is now in Chicago at Loyola- no, no at North Shore. His name is Todd Hannaford and he is sort of probably the number one. Is that a rib there already when you bump up? No, not yet. No, I don't... It's the transversus wiggling that I'm seeing. Yeah, I thought you were bumping a rib. It's just the transversus kind of jumping. He does open preperitoneal operations, okay? Instead of doing TAR. You know, when he just needs a big pocket but doesn't need tension alleviation. So how does he do that? Well, he goes into the bladder flap and he goes into the falciform ligament and then he wiggles out lateral and then he pulls everything back. It's always easier to continue a plane than to start it. But here we're kind of working from this side across. So, you could do this whole thing preperitoneal. Up here, I'm too, where I finished my pant leg, right? Yes. You think I need to go more? Well, but here's the thing, because you're preperitoneal all the way this way. Keep going, look. Look this way. It's all preperitoneal now. So without releasing any more fascia, you can just stay preperitoneal. You can bring that whole pocket down with the release that you did, yep. I would take some more down. You have a free angle at it. Just be careful. So up here, Alpha, where she's currently working is where the peritoneum tends to be a little more stuck to the back of the transversus and it gets a little bit thin up here in a lot of people. And sometimes this gets very, very thin. You can see it's paper thin there. And so what you might wanna do is if it's really getting thin and you needed to keep going that way as you stop and you say, I'm gonna grab the transversalis fascia and I'm gonna intentionally pull it down with me, okay? Okay, so you asked, you know, where did we cut the transversus and why? So sometimes, up here the transversus comes very far medial, sometimes it's very lateral. We want to divide it clearly medial to the semilunar line so we don't injure anything. We also wanna make sure that when we're dividing it, the floor is not so thin or so stuck that we can't easily make a pocket. And then lastly... do it more. There's a vessel that was running this way. Just a little ensiform vessel. Little ensiform. There's a... The diaphragm also inserts, and so... Yep, still bleeding. Yeah. Yep, that's it. The diaphragm inserts on the transversus below the level of the xiphoid in some patients. So if you're doing your transversus cut very high up, as you get up toward the chest wall, you may actually be dividing the diaphragm and not even realize that you're doing it. You're cutting muscle. It seems like you're doing okay. And then, but really you're cutting the wrong muscle. It's gotta be above you 'cause it's running down. It's gonna be up here somewhere. It's right there. Just use the back hand of your scissors to stop it. Great. We're gonna hang one minute probably over here. Well, yeah, I mean, I would do probably a little more sweeping here. I think I am on rib. That's gotta be a rib, yeah. Who's scrubbed currently? I can't see. Tara. Hey Tara, can you do me a favor? Can you go to the patient's left rib cage and just kind of give us like a one finger push on the ribs, you know, kinda like mid rib. One finger, just below the rib on the left. Okay, I think you're there. Yeah, so I think back be like... Fine, you know, so you can go a little farther lateral if you want. And what I would do is we also at some point wanna back way out and we wanna look at the floor, right? 'Cause we want to see if all of this is... how loose is this? What's it gonna be like when we close? It looks like this is sitting on the floor here. It's probably tented up a little bit at the rib cage. But it looks like your posterior layer is pretty loose on the floor there. Yeah. Yep, you're being too gentle. I feel like I'm not. So there's bowel below you here. So you definitely have the layer down on the floor. So keep going inferior. Yep, pull it medial, sweep it lateral. There you go. Good, that's great. Good, keep working inferior. Pull, sweep, I like it. You can see the different fat layers. That layer goes up. That layer comes down. There you go. That's where you want to be, good, yep. Yep, good, keep working inferior. There you go. There's your plane. Sweep it, yep, I like it. Wonderful. Yep, good. Take a look at the pocket you got, fine. You're headed towards inguinal canal there, yep. Yep, that's fine. Okay, so come back and look. Number one, grab your floor and pull. That looks pretty loosey goosey. Yeah. Okay, now, it may be tethered here and here still a little bit, but you also know that when you do the opposite side dissection, it's gonna take that down, okay? Oh, it looks very nice, Katie. Very nice. So Alpha, you can see these little fibrils here? I told you. You get to see planes you don't normally see. That's the transversalis fascia right there, okay? Part of why it's nice to bring it down is it's more robust. You get a second layer of stuff on the floor. But it also, you can actually see it interdigitating with the muscle, right? You can actually see it joining into the transversus abdominis muscle. And what that means is that when you get into this plane, while it is more robust, 'cause you're bringing a second layer down, it also is a little more bloody because it kind of interdigitates with the muscle and it's just that much harder to get down. Not much, but just enough that it's annoying, okay? So we're just plane hopping there slightly. I'm just taking the transversalis fascia down with me just to get a little bit extra distance here on some of this. This is probably the true arcuate line right here. Not everybody's arcuate line is black and white. In some people the layers separate. So some elements go anterior before other elements. That was probably the last little bit, because below that, it's pretty clearly just transversalis fascia, okay? So I wanted to get that down just so that this bottom section, your mesh is gonna sit very nicely in here. And again, there's some little bits of transversus nonsense here now that we can take. We got a good view of the epigastrics there. We're gonna leave all that up. I think your mesh is gonna sit here in a good position. We're not doing an inguinal today 'cause he doesn't have any inguinal hernia content or complaints. But from the contralateral side now, you don't need to really worry about this, you know, you won't be able to get down here from the contralateral side. But from, you will be able to get this direction. And so if any of this is in the way, you'll be able to get to this without a lot of challenge, okay? All right, so let's put our ports in on the other side. And then what we should also do is, why don't you drop a roller in and we can measure for our mesh, assuming you do a mirror image dissection here, okay? You do your upper port first, left upper.

CHAPTER 7

So that's through the rectus. I want you a little farther lateral. Yeah. and again, stay high, close to the rib. Yep, that's a great spot right there. Lots of twisting, a little bit of pushing. Yep, that's a great spot. You're in a wonderful location there. That's gonna be fine, yep. So still the 20 of Exparel. 20 of Exparel. And 90 of the saline. Let's do a total of 100. 20 and 80. When the Exparel is mixed up, give Katie the first 50 of it. And Katie, I would just do two or three point injection. Just try to stay lateral to your trocars over there. I mean, you're definitely getting 30 plus in there. It's at least 37 right now. We can potentially over dissect a little bit. It's gonna be at least 30 wide. That's 15 to there. I'll trim left right a little bit more to make it closer to, you know, it'll be like 40 by 30, something like that. And again, we always have the option to over dissect if we want to. If we say, oh, it's a little too big, just doggy paddle above, doggy paddle down below, it'll fit. Okay, Tara, you can take my arms out. Yep. Camera out. We're gonna dock on the other side. We'll need to spin the boom, okay? Okay.

CHAPTER 8

[No dialogue.]

CHAPTER 9

Summary of the first half of the case. What do you think you did well? What do you think could have gone better? I don't know. She doesn't know. Here for some color commentation, Alpha, what do you think went well? Everything. Everything. You want me to cut here? Katie, what I would do, which way are you looking? Are you looking up? I tried cutting through again, and I just don't see muscle. And I'm seeing it on the outer side. I know it's probably right. It's just so thick. Yeah, fine. So what I would do is just go to your midline, show me the midline hernia defect. Want me to show you here again? Yeah. So things, on this side, this is the side you're gonna suture from, right? So you don't really need to leave a big lip. If you buzz right here and it jumps, I would just open it right there, okay? You've actually got, this is all peritoneum that's actually being pulled up. Do you see it? Yeah. And then once you get in, just slip a hand in there. That may just be peritoneum you're taking. You may not be retrorectus yet. I don't think you are. I think you gotta get a little deeper to show the rectus muscle. Yep, you got it. Fine, slide your hands in, go to the head. You can make it bigger. That's just preperitoneal, but it's fine. Take your peritoneum down and then take your fascia down. There you go. Now you're retrorectus. And now think about, this is gonna angle, you know, angle kind of that way. You're just trying to connect your planes. So look up, show yourself where you're headed. Yep, all that fat can come down with you. That's all preperitoneal fat. At some point, your rectus is gonna go that way though. Yeah, it's gonna go that way now, Katie. I mean, your posterior layer is gonna go basically straight up. You're go headed, you know, you're gonna be going straight up toward the head. I wouldn't go any more preperitoneal. I would just take the posterior sheath right there, yep. Yep. There it is, yep. Take your fat down first. Do your preperitoneal dissection. You know there's gonna be some ensiform vessels in there. This is your chance to get a look at that thing that was bleeding that you had a terrible view of on the other side and make sure... I got it already. You already got it, okay. Yeah, I got it. So keep swimming headward. Yep, that's a vessel, kill it. So go preperitoneal. Yep, this is where you're making, you know, we were already 37. You're just making your superior overlap. And in the midline, it's free and easy because it's just preperitoneal. All right, so suture wise, we're gonna need two six-inch, 2-0 V-Locs and we'll need one, maybe two, number one Stratafixes. And I believe that's an 18 inch that comes in my cart, okay? Yep. At the moment we don't need... Oh, we'll need two 2-0 Prolenes cut to six inches. Not Prolene. Vicryl. Vicryl, thank you. Again, I don't know the names of the sutures. I know they have names, but... And then I would pause for a second and ask, you know, are you mirror image? How high up is your other? Yeah, it's right here. Right? So you're, because you jumped into the TAR plane early... Yeah. Your posterior sheath dissection stopped, you know. So you have a pocket to put mesh without releasing any of the upper posterior sheath. And so that's fine. Yep, work your way down. Did you take a look at the liver by any chance? No, I don't see, this one wasn't. There's the gallbladder. Looks good to me. All right. So I would take the peritoneum here, and then your peritoneum will be connected across the middle, right? Yeah. And then I would drop that peritoneum down. So you're doing a little bit of preperitoneal dissection here. You can see that this was involved in the original incision. That scarring is not normal. He didn't get a hernia there. He didn't get a hernia there, but somebody was down there. I would take this down here and then your posterior sheath is ready to rock, okay? Remember that somewhere in here you're gonna have that same traversing blood vessel. Yep, it's right there in fact. I think - I think it goes right there. It's always there. Yep, make your other hand do some helping, hold that layer down, something. There you go. This guy has crazy thick posterior layer. It's so thick. It's amazing. Makes you wonder how you can get a hernia, huh? Yeah. Yeah, that's gonna be preperitoneal fat and some amount of potentially transversalis fascia holding things together as you get lower, okay? This is all transversalis fascia here. But I mean, you know, I would drop it down. That's gonna clear. I mean, your midline linea alba is up here and there's zero diastasis. His rectus muscles are more or less in apposition. Bladder is on the floor, but really shouldn't be stuck here. There really shouldn't be anything concerning. Yep, this is your linea alba. Don't cut it. Yep, all right, take these. These are your lower pant legs here. It's just transversal stuff now. Yep, that's your near pant leg. Yep, that's into the true preperitoneal space there. Yep. Yep, nice, okay, good. And again, ask yourself, how far down do I actually need to be here to do what I'm supposed to be doing? And the answer is, you know, probably about where we are, okay? You know, you can see your symmetry, go back, you can see your symmetry here because you've taken down, I would just take that little thing, yep. Fine, watch the vessel in the back there. Yep, okay, that looks good. Fine, fine, fine. Yep, and you're clearly below the arcuate line there. So now you know when you're doing your TAR, where your ending point's gonna be somewhere like right in there, okay? All right, go lateral. Find a semilunar line. There's branches of epigastrics in there. Is your camera dirty? It looks a little dirty to me. Could we do... It's not on mine, but I can see it as well. Let's do a camera clean. All right, so that's the lower port there. Tara, can you come onto this side here? Yeah. And just grab the lower port and just push it to the ceiling. Push it to the sky. Just tip it upward. Other up. Tip it. Yep, tip it, yep, yep, yep. There you go. So that actually went through the rectus. That's fine, it doesn't matter. Tara, wiggle it back. Park it right there. Let it go. Yep. You're gonna have to do the TAR, I think, before you can... I think. I think so. Maybe not, it's fine. You know, get your whole pocket going. Yep. Nice. Drop your hand for this little one and then pull it back. Pull it back, yep. Hand to the sky. Pull back, now drop it low. Yeah, both of them came through the rectus. He has very wide rectus muscles. Look how far lateral we are. You're almost at the horizon. Some of that is a combination. He's got wide rectus muscles and also he's insufflated and he insufflates funny because he's got that big, that gigantic hernia sac, you know? Yeah. The defect isn't big, it's got a lot of content in it, so these muscles are probably a little farther lateral just because he's insufflating in an unusual configuration. Yep, okay. You gotta be close to a semilunar line there. This looks like nerves coming through. Go... That port is like, am I right at the cusp of that port? It's fine. But that's lateral to the rectus. We know 'cause we went through more than one layer of muscle, I think. Is it? I don't think it is. Maybe not. I think it's still out there. Yeah, maybe not. Is that the port there? Yeah. Tara, take the top port there. Move it to the sky, yep. Wiggle it back. Wiggle, wiggle, wiggle. Wiggle it. Perfect. Drop it. Just drop it. So actually pull it back a little more. Yeah, and then intentionally drop, push it down on purpose, yep. Well, that was dumb. Get it, make it stop. Try not to grab the nerve. Yep, get a little lower on it. Yep, okay, fine. Okay, that's all I wanna go. Yeah. Okay, so make your pocket up. Go headward, you gotta get that stuff there. All right, Tara, you can let all the ports go. We should be good. Could you reparalyze him please? Thank you. That's probably pretty high there, Katie. I think so, I think I can start TARing now. Okay.

CHAPTER 10

So there's muscle there. So again, I think, if you start your TAR here. Here? Here? Right here. So just wiggle to separate the peritoneum from the posterior sheath. Wiggle to separate. And then a small bite. And then remember that there should be two planes here. There should be... Well, I mean there should be multiple planes. There should be a posterior lamella of the oblique, then transversus, then transversalis, then peritoneum. So you know, you're trying to take two to three of those four planes. So just start at one layer at a time and you're gonna go that direction. Yeah. Yep. Looks like that's where you wanna be. Yep, connect him. Yep, do it. Yep, leave those things up. So try to stay here on the medial side. Yep. He's getting some paralysis, yeah? Yep. Thank you. Who's up there now? It's Chris. Hey, Chris. What's happening? How are you? Peachy. I didn't see you come in. Of course we're moving along here. We're on the second half of the dissection, but we probably have, I dunno, two hours? But we're moving along at a pretty good clip. I mean, for a robotic hernia repair. I'm not gonna lie to you. Yep. Very good, keep going. I like what you're doing. There's gonna be a hole below you because that's where your port went through. Yeah. Yep, just work around it, ignore it. Don't make it bigger. That's the transversus. You can see the fibers, yep. Yep, center yourself on the screen. Yep, there's your first layer. Just keep taking your first layer. Just come all the way down. Expose the muscle. Yep, keep going. You're gonna have a hole. We know where that guy comes through. So just keep it in mind. First thing to do. What's that? Am I gonna start on line, go through it. I would, I mean, you've already got a hole in some of the layers. I would just work right to it, you know? Yep. Yeah, I don't like that tension. Take a look ahead and see kind of roughly where you want to go. I feel like you have a little bit of schmutz to get down there in the retrorectus plane. It's kind of forcing you more medial than you might want to be. So just take some of that stuff down gently until you find a semilunar line. Yep, sweep. Okay, fine. So you can stay a little farther lateral. Yeah, you can stay a little farther lateral. Buzz it. Okay. So I would cut it back there, okay? So kind of restart. Don't continue this way. I would restart your TAR like right there. Yeah. Yep. There you go. Yep, that's a nice look around the corner. Take it down. You'll have a little flap there to close those two holes. Yep, pause. Don't keep going that way. You gotta come this way now. Yep. This is your semilunar line right there. Yeah. You're back at it. Those motions are really not doing anything. What motions? When you push down, it's just stretching and then it coming back. So if you're gonna do that, I would put my other hand in the plane, I'd push down and then I'd push up. Push that away. Just push away. One hand down, push the abdominal wall up and then work back, work back that way. Yep, there you go. You can take that. Yep, good. Go back and look ahead see which direction you're going. See where you need to get to. Let me play for a few minutes here. We have Vicryl, we have the V-Loc. Vicryl, V-Loc, Stratafix. No drain? I don't think we need a drain. He requested a drain. I don't think we need a drain. I remember that, he did say that. But he... He's prone to seroma. Yeah, but he would want a sub-q drain. You know what I mean? Yeah. Not a retrorectus drain. All right, so let's just see here Katie. So things. Are you as far lateral here as you need to be? And is that what's kind of slowing you down? I think the answer is maybe. This stuff is nonsense going to the posterior sheath with that little branch going to the main drag epigastrics. So with that on some good tension medial. The epigastric fat pad goes up. All that goes up. Okay. Fine, so your arcuate line is beginning somewhere like here, you know? Like there's a layer there. I mean, that to me is the dividing line. This is the line of Douglas. So I think... I mean, you're moments away from being there. This was just probably, I should have had you do a little bit more here, and I didn't. But also now that you're down here, you can bust through here and theoretically you could start a bottom-up approach. That's quite the transversalis fascia he has there. Okay. He was just extra stuck there. I mean, he did have some disease here in the left lower quadrant previously, you know? it may just have been sort of stuck from that. I mean, this is still not coming apart like it did on the other side. So I would leave that part for, you know, a little later on. You know, this will eventually come down. You can stay preperitoneal or pretransversalis here. If you think about your mesh overlap, it's monstrous even from your port. So I would just go lateral. This is already on the floor, you know. It's already sitting on the floor. You know, when we pull, it's a little bit tight. So you're gonna want to go to the horizon, but I would go to the horizon there, go all the way to the horizon there, and then I would just work your way back up. A couple holes to fix. Your TAR is basically done. Okay. I mean you started way in the upper abdomen and you did your, you know, kind of a Madrid maneuver up top, yeah? Yeah, I wasn't sure we needed to do any more down there. I just can't see it... Well, no, I mean, down below I came down through the arcuate line. So you know, you gotta go wider and stay preperitoneal, but you don't need to do any more... There should be no more formal myofascial release. I mean, if you needed to recruit a little bit of the transversalis fascia there down, you certainly could. But... When you push Katie, put one hand this way and one hand right over the top and then push. Yep. But it would be closer to the arc maybe? Yeah. There you go. Yep, that's looking nice. I also worry about taking, like, stitches with my scissors into the muscle. Do you ever switch out, or do you just always use the scissors? I just use the scissors. I mean, get that little bleeder while you're looking at it. I mean, there's nothing important there. Usually when I'm pushing though, Katie, usually when I push, I turn the scissor. So I'm not pushing with the scissor tip. I'm pushing with the back of the hand. Yeah. This is where you're plane hopping from pretransversalis to formally preperitoneal, okay? Yep, that's your plane hopping. Yep, it's very thin below you, just peritoneum now. Yep, you can snip those things formally. Yep, fine. Yep, get those while you're looking at 'em too. And then as always, I would back up and ask, am I far enough? Am I to the horizon? You're way to the horizon there, okay? Yep, and as you come up here, you know, at some point back up and ask: am I a mirror image of my other side? You know, have I gone preperitoneal above the ribs enough? Yep, recruit some transversalis fascia, good. Yep, I would just look all the way back and ask: am I mirror imagery? I feel like that needs to come down. Yeah, I mean, yeah, yeah. I mean, this is just some preperitoneal fat. It should just sweep down, plus/minus some little ensiform vessels. I think you're pretty far up there. I think you're pretty much a mirror image of the other side. You got one hole there over the liver to close. You got two holes here to close and one hole smaller down. I would just work your, you know, you're all the way to the horizon. I would just keep working that down towards kind of the myopectineal orifice, okay? That's great. Yep, big push, push that all the way, good. I mean that's ASIS that I'm hitting over there. Fine, to the horizon, yep. Yep, that could be inguinal content. And also think about where the epigastrics are here for a second before you... I think, you're probably lateral to them, but you're doing the lateral part of an inguinal dissection now if you hit the ASIS, right? So this is gonna be, you know, kind of more medial part of inguinal dissection and then... Well, I mean, again, just to make it a mirror image, yes. But that's really the only reason to mirror image it. I would buzz that before it bleeds, yeah. That's just a little branch that goes to the epigastric. And you know, you don't need to do a lot more formal. That was the epigastric. Is that epigastric? Yep. It's a branch of it right there. I was trying to lift it up a little bit more. It's there. It is just you have a bad angle at it. You're lateral to it here, I mean, obviously. Yeah. So again, come back, ask: where am I in relation to the hernia? Do I need to be here? You know, what do I need to take down, et cetera? Your epigastrics are right there. Have to go down? This is epigastric right here. Okay. Yep. Okay. Fine. I think you're plenty far to the horizon. Just check your bottom. Make sure you're connected in the bottom the way you like. You know, make sure your midline comes back together to the midline there. It looks like it does. This is midline way over here. Yeah, right here. Yeah, so those are your pant legs. Okay, I think you have plenty of room to get your mesh in here. It looks like it's gonna sit pretty evenly. We checked the top, we checked the bottom, to the horizon on both sides. Okay, Tara, you can go ahead and why don't you put in the two Vicryls to start and you can use one of these ports over here as a location to do that, okay?

CHAPTER 11

That's the middle port. So when she's done with these Tara, I'm gonna have you give her two 2-0 V-Locs and we'll take these two out. We'll two needles in, two needles out, okay? You guys can start opening up some things. If the glue is not open, you can open up 20 of Tisseel fibrin sealant. Would you also open up a 30-by-30 Bard soft mesh? One of them is kind of underneath the flap, so I'm curious if I can just like, that one there. And then, there's this one up here. Yeah, you can patch that over the top if you want, yep. Or if I actually close the holes. I would close the holes and use that patch to kind of help buttress. So just put your stitches in and then fly. Yeah, there you go. That'll do it. And then get a medial bite. Just kind of flop that thing down like a pledge it. Yep, I like the use of the needle like that. You know, that's a standard Halock laparoscopic tie that works really well here as well. So for those of you... I don't love doing it always, because I feel like I can snap something, but... I mean, I realize we don't tie a lot of sutures laparoscopically anymore. That's how I learned to tie from Randy. You take that with your left hand and you aim it toward your instrument because it does two things. One is it gives you the ability to have the needle and the instrument aimed at each other, which would be otherwise hard to do. And number two, because the needle is attached to the swage of the suture there. Just don't grab the liver. Because the needle is attached to the swage of the, at the swage on the... Because the suture is attached to the needle at the swage there, you have a little bit of ability to manipulate the suture in free space. It won't flop around. It's attached to something rigid and so you can manipulate it there pretty easily. So tie it up. Did you get the bottom one? The bottom-most one already? Yeah. Okay. There was the three from the ports, and then one next to that middle port. Unless you saw any other ones. I don't think so. Before you hand these back out, we'll lift the flap up one last time and take a look. Okay, that looks good there. Those are closed. And then there was a little guy down here, which we did closed. I like it. Tara, let's do two in, two out, okay?

CHAPTER 12

All right, so things we have left to do. Close the floor, close the ceiling, mesh and glue. We gotta TAP block the other side as well, okay? Oh, you can leave it along. Someone will put some marking sutures on the mesh. Okay. I'm just gonna mark the top and the bottom edges of it. Okay. I was so scared to tear this peritoneum. If you can see peritoneum on the medial edge, don't just get the fat. Roll the edge up, show yourself the peritoneum. There's the peritoneum back there. Get that good bite of peritoneum, good. And that's all you need, yep. Tara, that number one Stratafix may need to be skied just a little bit to get down the port, okay? The goal here is to get all of this stuff closed so that there are no gaps or holes. We're trying to keep any bowel from touching the mesh and we're also trying to make sure that the bowel does not get incarcerated or stuck into intraparietal defects, which are happening with any gaps and holes and defects might be in the posterior layer. So there are definitely some people who do not close their posterior sheath holes from the contralateral ports. If it clearly didn't work, people would never do that. And so the majority of the time I don't think that there's a problem if you don't close them. It took all of 10 minutes and two Vicryl sutures to close 'em up. And so my perspective is it's probably worth doing to keep yourself from having a problem in the immediate postoperative period.

CHAPTER 13

All right, I'm gonna scrub back in so that I can help push the ceiling down to you so we can plicate this nicely, okay? That's the top of the defect, isn't it? Yes. I would go to the bottom. Why? It's just easier to sew bottom up, that's all. I would just pull it forward, okay. We'll sew top down this time. Yeah. So back stitch over your tab. Once we're done here, give her a camera clean. Let's get the camera in and out and then change the pressure so that the ports are in. If we take it out at the reduced pressure, it's gonna back out and then the port will be out and then we'll all be sad. All right, pressure is at eight. Can I have a monitor that I can see? Yeah, that's perfect, thank you. All right, so this first one I would just get a good... Let me see if I can roll any of this down. Hold on, what's up there? Yeah, can you get that little bite of that stuff there? Kind of right in the middle line. Just grab that stuff there, yep. Good, take that bite. Awesome, I like it, good. Yep, and then get your near bite on the fascia. Yep, all right, run a little bit in to get your slack out. Most of this is gonna be about managing the suture. Yeah, my least favorite thing. Perfect, that's plenty, you're good. As we get into the bigger parts of the hernia, we're gonna do multiple bites of the sac. Far, mid, near, okay? All right, goodbye to the fascia to start. Yep, that's fine. I would just take that. That's good. Yep, roll through, take it. I'm gonna try and give you some of the sac now. I need to get my needle first. Okay. That's good. I'm gonna get my hand outta the way each time. Yep, good. That's good, get that. And I'm gonna push this far side down towards you like that. You're gonna have to grab it. Yep, that's how to do it. Yep, and I'm outta your way. Very nice. Yep, I like it a lot, good. All right, and then get the fascia. Look where your last bite... Ignore the ceiling bites. Look where your bite, yeah, yeah, beautiful. Yep, I like that a lot. That was good. All right, so yeah, I would grab, yeah, that thing there. That's fine. That's good, yep. That's kind of far. This'll be kind of, oh... That'll be kind of mid. Yep, my fingers are outta the way-ish. Ish. If I yip, it's me. Good, that's great. All right, good. And then I'm gonna push this down for you. Something up there, grab it. Yeah, that's a good bite. Yes, take it. Good, then get your fascia, I like it. Katie, hold your needle back farther next time. Okay. Pull, pull, move. Mid, see that band? Yeah. Get that big thick band. Now come a little more. Get your fascia, run the suture. As you continue to tighten up ahead of it, it's gonna become looser. Good, I'm gonna let go. We're gonna have to try to work ahead of ourselves some. We want to kind of go a little bit inferior lateral. That's pretty good ceiling stuff there, yep. That's the near side that. I'll hold until you run the slack, and then I'll get outta your way again. You know, you're sliding ahead, which I like. The sac is bigger than the fascial defect, so we kind of wanna imbricate ahead of ourselves. Let's maybe do a double bite. That's the ceiling, so get that. Let's get two bites here. So do one bite there. Let's try and do one bite even farther over toward me. I'll pinch down a little bit. Your ceiling is mostly staying down now. You've got an appropriate amount of tension in here to do what you need to do. Yep, fascia. You can do it in two, you know, stay there. I was gonna say just I was gonna have you do a little double dip. You're good. I was gonna grab this separate because I feel like I kind of wanna get... That's fine. Some lateral stuff. Yep. And then... My last... That's fine. And then, I'm gonna push. I'm gonna push this down to you then, like I've been doing. Watch the needle for a second. Yeah, that stuff there is really what you want. Pull that, yes. Yep, that's great. Yeah, you can do it. You can get another bite. Regrab your needle, you know. Yeah. It's not, I'm holding that down. It shouldn't go anywhere. Yeah, okay. Yes. Yep, I like it a lot. Get your fascia. I'm gonna let go. Wonderful, looks like a machine, did it? I like it Katie. Nice bite of the fascia. I'm gonna try and scoop from that corner. Yeah. To give as... I think I wanna get that. Yeah, that's low in that corner, yep. You know my hand is probably in the way, but there we go. As long as my hand is not in the way, that's what matters. I'm gonna try and push and give you a bit of the ceiling now. Yes. Yep, good. All right. I'm gonna try and then give you - this is the left lower corner of this sac I'm trying to push into you. Yeah, that's the stuff there, yep. Hold it down and then see if you can't grab above yourself. Just watch your needle as you aim toward the floor there. If you need to reset, you should be okay to reset. I feel like I should be able to... Nice maneuver, I like it, yep. With the sac...? We're definitely done doing four for bites, okay? Remember when we first did it, your very first bite went across. Yeah. And got one bite of the mid portion. We might do the same thing but run that in. We can also drop the pressure a little bit if you need us to. All right, pressure is at five. I'm gonna try and push the ceiling to you a little bit. I'm just trying to take some of the tension off of you closing the sac. Get a few more bites in and then run it back, okay? Probably gotta get one more bite at the low end there and you can run it back. Maybe one more at the very bottom. Yep. Fine, that's your far side. Yep, that's the near side. Fine, okay. I would pull that all the way tight then. We can put your pressure back up to eight once you're sure it's tight and you can just run it back, okay? Something is... It's me. I'm trying to collapse the sac but not crush the abdominal wall, and I can't really do it so... I can't see, I don't have any working space. Yeah. I can't see anything. Well, pressure is still reading six for some reason. Well it's definitely not. No, I know it's not. Gas is still attached. That's open, that's open. That's closed, that's closed. Give it a second, Katie. Don't do anything. Just let it go. Not yet, she's almost ready. You're good Katie, keep going. Yep, that's great. Pressure back to eight please. Okay. You gotta mesh there for me? Gotta stitch for me? You stick a finger on the mesh there. You can leave a long tail so we can find it inside. Let's put the pressure back up to 15. I'm coming through the mid port. Here. There you go. What's our pressure reading over there? 15? Yep. I gotta roll the mesh. I'm gonna change the gas insufflation to the mid port on the right.

CHAPTER 14

Okay, are you gonna come in the top? I'm gonna come in the top port and aim to the feet. Slide your hands up and out so that we're rolling from the farthest edge. You know what I mean? Pinch both there. Coming around with the mesh. Oh, you can grab that edge there. That's the free edge of the mesh there. Yeah. I'm gonna let go. Yeah. So get yourself centered top bottom, okay? Put it in the dead center. We wanna look, There's my scene. This is my scene. Right, but we wanna look, we wanna make sure that that's all the way tucked down as far down as it can go. Where's your midline? Right there. And there should be a stitch in the midline. Good, I'll hold this down. There's your stitch in the middle. Just unroll away. Away, okay. Unroll the far side. Yep, yep. Like a carpet, just unroll it. Yep, don't unroll me. On this side of you. Good, okay fine. Yep, make sure the top edge is tucked in how you want it. And that's out. It looks pretty good there, yep. Make sure your midline. It's pretty midline. All right, fine. Go back to the bottom, make sure we haven't moved it too far. Move that a little bit. Yep, yeah, I agree. I would unroll that a little bit more as you go. I know that goes out over the edge a little bit. Agree. Just get that unrolled and tucked out there. It'll stay, just kind of get it tucked down. It should stay. All right, fine. We can do the rest lap. Although if you hold down, just hold the floor down. Yeah. Just hold. Okay, I can't quite reach, I gotta push the port in a little bit. So we'll probably need to shift it a little bit. Want me to drift it towards...? But it's fine. You're mostly in.

CHAPTER 15

We'll undock, we'll get the robot outta the way and we can then port hop wherever we want, okay? Okay, we can get that outta here.

CHAPTER 16

We don't need to shift it much Ben. It's not very far off a midline. And obviously as we deflate that's gonna slide over, actually it looks pretty good. We just didn't have it unfurled as far as we needed it to, okay? We measured pretty well. The ports are all covered. That's you, where am I? That's me there. So are the ports covered? Yes, yes, yes, yep. We did a little extra, we did a little more dissection in this upper corner than we did on the other side. That's up the midline. So we'll take a look at that from the other side. Yeah. Don't come up Eric. Can we drop the pressure please? Let's go to 10. Thank you. Yep, you're good. Let me see the camera here. Go to your bottom port. We're gonna work up. I'll take a bullet or another grasper of some sort. Any kind of grasper is fine. Fine. That's the midline. So that's where we want it to be. Okay, give Ben some glue. Clear, hooked up to the secondary port. Secondary port is looped. We have someone on the pedal? Yep, you guys ready? All right, go ahead and push the pedal. Yep. How much glue do we have in total? 20. So just this one. Yeah. You have 10. That's 10 total. It's five and five. And we'll just switch sides and I'll go from over here. Yep, good, keep going. Oh no, I sprayed the camera. It's fine. Okay, take a camera clean. We'll take the next glue. Put the camera on your side so you can see. Get a camera clean. I'll take a bullet. All right, step on the pedal please. Yeah. Yep. Nice. Okay. You can stay there. They can stay on that side. You don't need to move that at all. Back those ports out. Who's got the pedal? Go for it. Looks pretty good. Okay.

CHAPTER 17

Let the gas out slow. Gas off. We'll need some Monocryl suture for the team and then some Dermabond, okay? We'll need a binder at the end and then Foley can come out. The nasal or orogastric tube can also come out. I'm not sure what his pain tolerance is. We'll see how he does. I would give him clears in advance and go from there. It's a good one to do kind of early in your practice, you know. If you had to bail 'cause the adhesions are bad, it's an open retrorectus alone with a bunch of hernia salvage. If you weren't getting that fascia together, or were concerned about the monster size of the sac, you do it robotically. You open at the end, you debride all that stuff, you close the fascia primarily, and you install a big mesh. If you were concerned about the liver getting in, getting it on the opposite side would've been totally fine. Like I almost always do right side access first. Again, it's the way that I've learned them over the last, I guess, decade now. If you're doing a robo PPHR, do you dock on the side of the stoma or do you dock away from stoma and do stoma side first? It depends on whether you're doing it because there's a parastomal alone or midline. Okay. Parastomal alone, I dock contralateral to the stoma and then I usually do preperitoneal dissection, cross the midline preperitoneal, then jump retrorectus, then do the TAR. And I do that because I want the mesh, even if there's no hernia in the midline, you need medial overlap. That's the easiest way to get it without doing like a TARM or something like that, or an fTAR up. If you're doing bilateral TARs, because there's a midline component, I still dock opposite the stoma. Do the stoma side first. So then when you're putting your three ports on that side, they have to be around the stoma. So you have to take that side down. You have to lateralize the bowel, you have to sew it to the abdominal wall, you have to close your fascial defect, then you gotta put your ports in on the opposite side. Then do the other TAR and then close the ceiling. Theoretically, if you didn't want do any of that or you didn't want to close the posterior layers or do anything until after you had done both sides, you could triple dock. I'm sure it would be annoying to do. If you really weren't getting the posterior layer closed or thought that you needed to do the other TAR before you started, then you could do that. I mostly choose to do them robotically when it's an ipsilateral dissection and I just have to do a TAR on one side.

CHAPTER 18

The majority of that operation went according to plan. As you saw at our initial port entry, even before we had traversed the peritoneum, his liver was low enough and also a fatty liver, which we knew radiographically that we had a very minor superficial issue related to an injury to Glisson's capsule. By the time we got our second port in, the bleeding was mostly stopped. That occasionally happens, and I spoke with the patient about it after surgery, so he's aware. We could have simply docked on the left hand side if we wanted to to avoid that problem. But again, minor injuries on access to the abdominal cavity happen. They need to be immediately recognized and managed, as you saw us do. He did have incarcerated content. It was mostly the omental fat that was stuck up in that hernia. The bowel was fortunately down. And so could we have done that as a totally extraperitoneal operation, as an eTEP, retrorectus, or an eTEP TAR? Yeah, probably. It probably would've been safe to do, but we were able to do it from an intra-abdominal position. You saw during the procedure a lot of discussion about how much to dissect, how to get that floor closed so that it's under no tension and we're not at risk of a posterior sheath disruption. And some additional conversations about closing the initial port sites in the floor to make sure that you don't have content that gets incarcerated post-op. Otherwise it went according to plan and I think procedure-wise, you saw that the majority of those steps were done by my fellows, Katie and Ben, who were with me during the operation. This video was recorded at the end of July and so these are fellows who are pretty much ready to graduate and be operating independently. You saw that the amount of help they needed to do the surgery was really minimal and most of it was me at the bedside kind of doing bedside assist stuff.