Robotic-Assisted Transabdominal Preperitoneal (rTAPP) Repair for Ventral Hernias

This case describes a 58-year-old man who developed a symptomatic incisional ventral hernia following a trauma laparotomy and left nephrectomy after a motor vehicle collision. The patient presented with multiple midline hernia defects associated with bulging and discomfort. This video demonstrates a robotic transabdominal preperitoneal (rTAPP) repair with mesh. The case highlights practical strategies for managing intra-abdominal adhesions and a prior gastrostomy site, while outlining alternative operative approaches for cases in which preperitoneal flap development is technically challenging.

Incisional hernia; ventral hernia; transversus abdominis plane block; robotic.

Incisional hernias are a common complication of laparotomy occurring in up to 20% of patients.¹ Incisional hernias can cause abdominal pain and risk of incarceration, affecting abdominal core health and impairing quality of life.² Patient risk factors associated with higher incidence of developing an incisional hernia include a history of diabetes mellitus, obesity, smoking, chronic obstructive pulmonary disease, malnutrition, immunosuppression, or steroid use. Technical factors at the time of laparotomy closure can also impact the risk of developing an incisional hernia including closure method, reoperation, and surgical site infections. Long-term complications of incisional hernias include mesh infections, fistulas, chronic pain, and hernia recurrences. In this film, we demonstrate the repair of an incisional hernia following a laparotomy incision using a rTAPP approach using prosthetic mesh to reinforce the repair.

This is a 58-year-old man who underwent an exploratory laparotomy with left nephrectomy for blunt abdominal trauma sustained in a motor vehicle collision over ten years ago. He remained asymptomatic until several years ago, when he noticed a progressively enlarging abdominal bulge. This was associated with mild but persistent abdominal discomfort, described as dull in quality and exacerbated by certain positions and movements. He denied obstructive symptoms such as nausea or vomiting.

His body mass index was 31 kg/m², and he was classified as American Society of Anesthesiologists (ASA) physical status III due to stage 3 chronic kidney disease and hypertension. He is a nonsmoker and has no history of diabetes mellitus (hemoglobin A1c < 8%). Routine preoperative laboratory studies and a non-contrast CT scan of the abdomen and pelvis were obtained as part of the preoperative evaluation.

On examination, there was evidence of a well-healed midline scar. There were two fascial defects along the midline scar that could be appreciated on deep palpation, which were concordant with radiologic findings.

Non-contrast enhanced CT of the abdomen and pelvis demonstrated two fat-containing midline hernia defects on axial imaging. According to the European Hernia Society (EHS) classification, these correspond to an M2 hernia measuring 16 mm in width and 8 mm in craniocaudal length, and an M3 hernia measuring 37 mm in width and 30 mm in length. Sagittal reconstructions revealed additional fascial defects as well as areas of attenuated fascia along the prior midline incision, consistent with subclinical hernias.

Figure 1 illustrates the fat-containing M2 and M3 hernias on axial images. Sagittal views provide a more comprehensive depiction of the pathology, demonstrating attenuated fascia spanning the M1–M3 zones, fascial undulation suggestive of additional interparietal hernia defects (dashed arrow), and a small hernia defect superior to the M2 zone (arrow) that was not apparent on axial imaging.

Figure 1. CT abdomen and pelvis with axial and sagittal views. CT imaging demonstrating midline fat-containing hernia defects.

Incisional hernias do not resolve spontaneously and require surgery for definitive treatment. Over time, these hernias tend to enlarge and may be associated with progressive symptoms. If left untreated, incisional hernias carry an increased risk of incarceration. Incarceration of fat may cause localized pain and erythema but is not life-threatening and can be managed in a semi-urgent setting. In contrast, incarceration involving bowel necessitates urgent evaluation and reduction. If bowel-containing hernias cannot be reduced at the bedside, emergent operative intervention is required.

When the incarcerated bowel is viable, hernia repair may proceed, with evidence supporting the safety of mesh-based repair in this setting. However, if there is bowel compromise or ischemia requiring resection, many surgeons favor primary fascial repair with delayed reconstruction. Emerging evidence, however, suggests that mesh-based repair may still be safely performed in selected clean-contaminated.³

Several surgical options are available for the repair of incisional ventral hernias of this size and selection is based on a combination of factors including ease of adoption, safety, and affordability. Initial considerations include the operative approach: open, laparoscopic, or robotic. A minimally invasive approach is often favored, as it is associated with reduced postoperative pain, fewer wound complications, and shorter hospital length of stay. Surgeons must also consider the plane of mesh placement, including intra-abdominal, preperitoneal, or retromuscular positions. Although debate persists among hernia surgeons with available evidence suggesting comparable outcomes between intraabdominal and extraperitoneal mesh placement, many surgeons favor extraperitoneal positioning to minimize the risk of bowel adhesion to the mesh.⁴

In this case, the hernia was repaired using a robotic approach with placement of mesh in the preperitoneal space, and thus outside the abdominal cavity. This was achieved by creating a peritoneal flap, which allowed direct visualization and primary closure of the fascial defect, followed by placement of the mesh between the peritoneum and posterior rectus sheath. This treatment approach affords patients with the benefits of a minimally invasive surgery including decreased pain and shorter length of stay, as well as reducing the risks associated with intra-abdominal mesh placement.

The rTAPP approach is generally favored for patients with relatively small hernia defects (< 5–7 cm) in close proximity. Contraindications to this approach include a hostile abdomen, an inability to tolerate carbon dioxide pneumoperitoneum, as well as the need for extensive soft tissue resection that would be better addressed with an open approach.

In summary, this case demonstrates the use of an rTAPP approach to repair a moderate-sized incisional ventral hernia. Careful operative planning and preoperative optimization were considered, incorporating both patient-related and technical considerations. From a patient perspective, preoperative criteria included an HbA1c < 8%, non-smoking status, and a BMI < 40 kg/m². 

From an operative standpoint, particular attention was paid to port placement. Initial trocar placement was performed using an optical trocar entry at Palmer’s point, though some studies have highlighted the increased safety of Veress needle entry making it a viable alternative based on surgeon experience. Trocar placement is guided by both the location of the hernia defect and any prior abdominal operations. As a general principle, we position trocars approximately 15 cm from the hernia defect to ensure adequate working distance for peritoneal flap development while avoiding excessive lateralization and instrument collision with the patient’s body. In this case, we started with a standard optical entry at Palmer’s point but had to transition from the typical left-sided docking to the patient’s right to avoid adhesions predominantly located on the left abdomen. The trocars were placed 6 cm apart along the patient's right hemiabdomen to prevent collision. Additional strategies included flexing the operating table to improve exposure of the abdominal wall and tilting the bed to the patient’s left, using gravity to displace the hernia away from the operative field. 

During the operation, the prior gastrostomy tube site was identified 7.2 cm lateral to the midline hernia defect based on preoperative imaging and found to be densely adherent to the abdominal wall. The tract was ligated with clips and divided in a controlled fashion without spillage or contamination. This step allowed for adequate development of the preperitoneal space and sufficient mesh overlap of 3–5 cm from the hernia defect. As a result, the case was classified as clean-contaminated (CDC Class II). Historically, mesh placement in clean-contaminated (CDC Class II) and contaminated (CDC Class III) fields has been controversial, with many surgeons favoring biologic mesh in these settings. However, a landmark study published in 2022 demonstrated that permanent synthetic mesh is not only safe in clean-contaminated and contaminated ventral hernia repairs but also associated with lower hernia recurrence rates and significantly lower cost compared with biologic mesh.³

One of the most technically challenging aspects of this case was preservation of peritoneal flap integrity. A helpful principle of flap development is staying above the preperitoneal fat planes, which typically follow a characteristic “fatty trident” distribution along the abdominal wall. However, due to the presence of multiple closely spaced hernia defects, prior intra-abdominal adhesions, and areas of attenuated peritoneum, several inadvertent defects in the flap were encountered during dissection. Several techniques can be used to facilitate peritoneal flap closure including dropping insufflation pressures to 5–8 mmHg as well as using a dolphin stitch to better approximate thin peritoneum. Though the peritoneal flap was successfully closed, this case highlights the inherent challenge of selecting the optimal operative approach for small- to medium-sized ventral hernias with multiple closely spaced defects with unpredictable degree of intra-abdominal adhesions until the time of surgery. 

As described in the video, an alternative operative strategy would have been a laparoscopic or robotic intraperitoneal underlay mesh plus (IPUM+), thereby avoiding the need for preperitoneal flap development. To perform an IPUM+, the hernia defect is first closed by reapproximating the fascia using slowly resorbable or permanent sutures. Defect closure is a critical step that has been shown to reduce the rates of seroma, surgical site complications, as well as hernia recurrences.⁵ This is followed by placement of coated mesh with adequate circumferential overlap of 3–5 cm. However, the primary drawback of IPUM+ is the risk associated with intraperitoneal mesh placement, including bowel adhesions and higher rates of enterotomy or bowel resection during reoperation.⁶ Consequently, many modern hernia experts consider IPUM+ a “bailout” procedure when more complex minimally invasive extraperitoneal repairs cannot be safely performed.⁷

Another viable alternative is the laparoscopic or robotic extended totally extraperitoneal (eTEP) hernia repair. This approach involves entering the retrorectus space using an optical trocar, followed by development of the retrorectus plane and a crossover maneuver to access the contralateral side. The primary advantage of the eTEP approach is that it remains entirely extraperitoneal, thereby avoiding the intra-abdominal adhesions all together and the technical challenges associated with preperitoneal flap creation. 

There remains ongoing debate among experts comparing robotic IPUM+ and robotic eTEP approaches. A multicenter randomized clinical trial evaluating ventral hernias ≤ 7 cm demonstrated no significant differences in postoperative pain, length of stay, opioid consumption, or quality of life between the two techniques.⁴ Robotic IPUM+ was associated with reduced operative time, lower surgeon workload, and fewer surgical site occurrences; however, concerns persist regarding intraperitoneal mesh placement, even when coated mesh is used.

In this case, we selected the rTAPP approach because its primary advantage over eTEP is the preservation of the retromuscular plane, ensuring that this plane remains available for any future hernia repairs. While rTAPP is an established technique, this video demonstrates its application in a technically challenging scenario involving multiple closely spaced hernia defects, thin and fragile peritoneum, and prior gastrostomy tract that required controlled division and adhesiolysis. This case also illustrates intraoperative decision-making when preperitoneal flap development is difficult and reviews criteria for considering conversion to alternative approaches such as an IPUM+ or preoperative selection of an eTEP. This case highlights the importance of decision-making principles in patients with prior midline laparotomies, where preoperative imaging may not fully reveal small or interparietal defects that must be addressed at the time of surgery. 

Postoperatively, the patient was discharged home on postoperative day one after resolution of transient urinary retention. At the time of discharge, he required minimal narcotic analgesia and was prescribed methocarbamol. As part of our standard practice, transversus abdominis plane (TAP) blocks were administered intraoperatively to assist with postoperative pain control. Strong evidence supports the use of TAP blocks in hernia surgery, with multiple meta-analyses of randomized controlled trials demonstrating reduced postoperative pain scores at 24 hours, decreased need for rescue analgesia, and lower cumulative opioid consumption.⁸

At one-month follow-up, the patient had no postoperative complications. On examination, the incision was well healed, the hernia bulge had resolved, and the patient reported complete resolution of pain.

The procedure was performed using the da Vinci Xi robotic platform. A lightweight polypropylene mesh (Bard Soft Mesh) was implanted and tailored to the dimensions of the hernia defect measuring 23 cm x 11 cm mesh with curved corners.

Nothing to disclose.

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.