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

CHAPTER 1

Hello, I'm Jerome Lyn-Sue, one of the minimally invasive and robotic surgeons at Penn State Hershey Medical Center. And the case I'll be doing is a robotic-assisted transabdominal preperitoneal hernia repair. The patient is a 58-year-old male. He underwent a laparotomy in 2013, about 12 years ago for a motor vehicle accident. He had a partial nephrectomy and was relatively well until two or three years ago when he started noticing bulges in the anterior abdominal wall. And workup showed that he had at least two or three hernias along the midline scar. And we opted for a robotic approach for his hernia repair. For a robotic transabdominal preperitoneal repair, rTAPP as we call it, we're gonna have to do a few things. We have to get in safely. So, we do it with an optical trocar into the abdominal cavity. We kind of assess the abdominal cavity by looking for adhesions, lysing adhesions, and reduce the hernias. And for the repair of the hernias, we create a large preperitoneal flap, which is where the robot kind of helps a lot by the dissection, allowing us to identify the planes, reduce the hernias, and then repair the hernias. So after we create our flap, reduce the hernias, we'll close the defect with running barbed heavyweight suture. And then we put a custom fashion mesh after we measure the pocket as a sublay mesh, it's kind of buried under the muscle and above the peritoneum with no contact to the intestine. A few things kind of allow us to do an rTAPP, or make us not do an rTAPP. So, if the abdomen's hostile, so if they've had multiple abdominal surgeries, you'd expect a lot of scarring, that might be a relative contraindication. But he only had one surgery 12 years ago, so we thought we could proceed. But there are folks out there with multiple surgeries, which we still can do the procedure, but we just have to bear that in mind where, you know, the abdominal cavity is not as friendly as we would like. The next step is what type of hernia. Is it one hernia, is it multiple hernias, the size of the hernia as well. So, certain sizes are not as good, are kind of prohibitive for rTAPPs. If it's too wide, that means you'll have a little more tension on the repair. To choose our patient, we look at the size of the hernia, number of hernias, and the location of the hernia. So, it has to be, I guess, in my practice, anywhere from say two to six centimeter damage of a hernia could be along the midline, which there typically are. Anything greater than eight centimeters would require a different procedure.

CHAPTER 2

So a 12, eight, eight. Okay. Try to stick. If I can't get it here, I'll try here. And then cut down by top. I think the hernia is somewhere here and there. Top of the mesh. Bottom of the mesh, top of the mesh, so probably that way. All right. Knife, please. White balance. White balance. All right. All right, Alpha, scariest part of the day. If you see something, say something. All right. White balance. I'll take this one, Olivia. Is it okay for bare hugger? Yep, bear hugger good. All right. Lots of twisty. Looking for two layers of muscle. His stomach's under there, so we'll see. Muscle number one, I don't know. Yep. Just up here. Muscle number two. Yep. And then that's peritoneum. Let's give it a shot. All right, Trip. I don't know, gas on high flow, let's hope that works. All right, insufflating. Take this off, Olivia. Yeah, he is blowing up I think. He's just scarred from his previous surgery. Try again. All right, so we're in it. It's just all stuck. Are we up to 15? Yep. All right, window. Let's got a bunch of fives in the room just to kind of figure out where we are. So, let's do everything here. So why don't we - marking pen. Another eight. Help you, corner traction. Yep. Yep. Oops. Good. Yep, level off. Good. All right. Can we see... 12, thank you. 12. Yep. You got yourself? Good. Do a little, rather than just kind of lift it. Yeah, perfect, perfect. Uh-huh, oops. There you go. Good. All right, let's go over here. Let's go robo cam. Switch out under 30 up, and see what we have. I'll come around. All right, we can dock this and get our stuff done. So, we can see there, so we're not too bad but, okay. Can we do a TAP block while we're here? Why don't we try. Oh, go on the other side, Olivia. It's a four-quadrant TAP block to help with post-op pain.

CHAPTER 3

Gimme half syringe above. Half syringe below. Lemme try to wipe this guy. Bounce again, Olivia. Let's get some clear views first before we inject. Are we fully relaxed? I just redid... Oh, great. Yeah, yeah. Not fully relaxed. Do it, Olivia. That's it. Few minutes? So quarter percent marcaine with epi, TAP block, transversus abdomins plane. 15 cc per quadrant. Alpha, hold camera right there for me. You got it. It was different. You just had to threaten me. Yeah. Good, good. Like it. All right, let's look at this port, see if we can make sure we're didn't get ourselves in trouble. I don't think we can see it. Before we get adhesion, we can see it later on, but wouldn't mind warding off the evil now. I think I'm through the soft tissue stuff. Okay, we'll get it later. All right, Alpha, step up under the right armpit. Fingers breath above, fingerbreadth below. I'll try to show you. Yep. I'd say go more medial. Stay away from the colon. Needle to Alpha, one hand on syringe, one hand on needle. Put your left hand on the needle so you don't stick yourself. Yep, take your left finger off the patient. Yep, good. Good, yep. Pop, pop, pop, come on in. Keep coming. There you go. Little more. Little more. Half syringe. Perfect. Like it a lot. Next time maybe a little more deeper but that's okay. Okay. I'll back up, show you. Yep, and then try to go on this side of the metal port. This side? Yeah, go closer to the... Here. Closer to the middle port. Yep. Somewhere there. Yeah. Yep. That's right, keep coming. It comes and it comes. Yep. See above. Probably. Little deeper. Yeah, little more. Oh, there you go. Good, back it up. Pickup. Yep. Shift side to side. Yep, do it. Like that. All right, Trip, can we deploy the robot?

CHAPTER 4

All right, so Trip, green line to Olivia's right hand. The robot down about six inches after. All the way down. Go, go, go. Danielle, I'll take a hot scissor. All right, Olivia, you set up number two and number three for me. Robot right hand, port left hand, great. 30 up camera first. Good. Come on in. Look for the left port. So, progress left hand. Let's take a look. There you go. Let's aim up. There you go, there you go. Perfect. Why don't you burp here, your port back. Yeah, lock it there. Take camera, swing to the left screen, so we can see right. Hot scissor. Come on in, advance and drop your scissor tip. Aim it towards the belly button. Yep. Now a little bit of that. There you go. All right, let's break scrub, guys.

CHAPTER 5

Olivia, I'll get started, we'll see where we are first. So, other thing here, Alpha and Olivia, I don't wanna mess up the peritoneum that much. Yeah. That'll effect our repair, so we will see. So, that's falc there, all that is adhesions. That's adhesions too. I'll step away a little bit from peritoneum. I would like hernia here, probably. Or 30 down, that's why. That the other little hernia right there? Yeah, it's by the falc. It looks like we have fatty tissue enough for the flap, but we'll see. Right, so there's one there, one there, one there. One more than I thought. I don't think that's bowel below. So, Alpha only the clear stuff. And if you're not sure where you are just stick a blade in the back, make sure you set the blade, have cutting stuff. It's getting thin there. Hopefully it's okay for the flap. So Olivia, I like this part, I like this. Yeah. Don't like this that much. So, we'll see if we can do what we're supposed to do. Some of that. All right, Olivia, take that. Let me do a little bit here first. Okay. Try to get you, okay, so that's the noted peritoneum. We're gonna have to patch that if we do do rTAPP. Air area. Yeah. All right. Take for a minute. Let's take this off and then I'll start again. There's buzz, buzz, push, push, and nibble across if you must. Mm-hmm. Yep. So get your left hand over there and go from right screen to left screen. Buzz, cut, yep. Good. Good. Mm-hmm. Force yourself to move that left hand every once in a while. You can re-grab and look around, make sure there's no bowel. Good. I'll take for a minute. Okay. Try to get to some clear spots up here. Oh, beautiful. All right, good. So that might be okay. All this thing is bowel behind you but just be careful. Lemme take this front layer then I'll set you free. Okay. So, that's gas from the other side blowing on it. So, I think we're near there. So why don't you, just gonna figure out this stuff here. Move your left hand around, kind of move around, see what's behind it. Kind of hook it around like so, a little blunt will work. And so get this, get that, get that and then start again. Imagine there's a maybe bowel behind you, yeah. Start with this chunk of fatty stuff first. Try to divide it. Mm-hmm. Good. Can get into some of that fatty stuff as well. Preserve the peritoneum. Aim from your scissor tip to my triangle. Mm-hmm. Yep, get your left hand in there, the left sweep. Yeah, bring it up again and the left sweep and push. There you go, yep. Go deep, do it again. Uh-huh. Get that hemostasis. Buzz some of that red stuff. Mm-hmm. Get past point that left hand in there, hook it around. Yep, there you go, there you go, do it again. Good. Get this red stuff. All right, let's work up top now or foreground. Yep. Get this by the rim. Mm-hmm. And towards your, to my dot. Yep. Yep. That fat stays. The rest we'll take. So that band. See those little bands there? Yep. Stick a blade and lift it. Buzz it, cut it. Mm-hmm. From there to my dot. Good. Start over. Is he breathing, we're like doing a lot of... It's probably the gas from, yeah. Yeah, make him lighter. Yep, good catch. Yeah, that's longer. Good. Head back down there and let's clear the bottom. So hook it all the way around. There you go. Yep. Mm-hmm. Like it. Good. Pause for a minute and get some of this red stuff. Make it stop bleeding. Something in the foreground here. Yeah, get some of this stuff. Good, re-grab, do it again. Yep, get the deeper stuff. Mm-hmm. There you go. Good. Mm-hmm. Just giving it to you. Take it. All right stop for now. And go, come foreground, figure out this stuff. Yeah, right there. So, I say push it, yeah, put your hand up. Yep, just score it across, just kind of buzz, buzz. You're gonna leave some fat. That's okay. You want me to just buzz through this? Yep. Just trying to break. Point the left hand up, grab the stuff and pull it down. Yep, that's the plane there from my dot to the falc. Mm-hmm. Yep, there you go. Keep pushing, the push will give you. All right, good. Keep working here. This will give it to you. Yep. Yeah, that little bloody thing. Yep, you'll see the plastic port eventually. There it is. Good, I'll take for a minute. You can see it baffling. That's a plastic port. He should have his stomach nearby, right, from his G-tube. It might be up in there. Do we need all of this down? Yeah, kind of. Take the falc down to lay it flat or are you gonna bring that down little? No, I'll break it down with a flap. This stuff which is not falc I'll take. Alpha, do you see that plane between the falciform and the stuff that he's taking down right now? Do you see the planes that he's like falc that he's grabbing versus underneath that is not falc, and like this has got a layer of peritoneum, other little hernia. Mm-hmm, a bunch. So, there's more midline, so the falc kind of goes off to the right. So, this is actually a midline hernia, although it kind of looks like a left-sided hernia. Stomach's gonna be up here. Also, this is a swiss cheese hernia defect, we're looking at. See all those holes next to each other. Danielle or Taylor, if we find stomach, I'm gonna clip it and drop, and let it fall. Take it off the ab wall. So, let's get some large clips in the room. He has a scar from a previous G-tube by the left upper quadrant. Gonna be a little bit north of our port on that side. You see a scar there? No. Almost like a drain site. Yeah, there you go. Yep, that's the one. Okay, thanks. On the scan I saw a piece of stomach. Where are you? There it is. There it is. Let's see if we can kind of... So the next question, do we even have to take it down? Is there... Would it affect our mesh placement? We'll check, we'll check Lateral. Yeah. Let's take a look. Just way over there. So if we do flap here. So, that's midland. So, it was top down there, down to infraumbilical. This width is about 1.5, so we need a 1.5, 3 overlap. Maybe a little bit. We can probably get it here. 1.5, 3, and a little more. We're gonna be right up on it. Let's just do it. Let me see. A little more here. So, always think you know, will this contaminate mesh? Probably not. All right. Can I do more? Let's see. Okay, Taylor, please give Olivia two clips. Olivia after you get the clips, just take a little bit of mini fascia with it, and let it fall. Okay. And we'll start our hernia repair. So, grab that stomach, straighten it out. Go around it like a cystic duct. Flip it, yeah, 180. Mm-hm. Make your stomach vertical. All the way around it. Yep, push it in. Slide down just a tad. Right there? Yeah, a little more down. Yep, take it. And see if we could sneak on just above it. Pushing all the way. Push, push, push. Use the left hand to kind of cinch it in to the jaws, yep. Yep, get your left hand up there, above the clip as well. Yep, yep, squeeze, take it. Right on top of the first one. Yep. Hot scissor. So a good distance above. Not too much muscle but some muscle. Yeah, like, score it. Close the tips. Let's use it like an L-hook kind of thing. Mm-hm. Yep, yep, and whatever you think it, yep. If it's jumping too much, go closer to the clip. You gave him some more relaxation? You gave him some more relaxation? I did, I just gave him some. All right, great. Keep burning. Yep. Burn. Yep, burn, cut, burn, cut. Good. All right. Olivia's making him twitch at the moment. All right. Hold the clip a little more. Yeah, right on the clip now, it's all muscle fiber. Good. All right. I'll take for a minute. Let's hope for the best. All right, we're 30 up. Oh, boy. All right. Is that little defect where we took the stomach down gonna cause another hernia? No, if we get our thing covered, we're gonna close the peritoneal defect and cover with mesh. We can always put a figure of eight if we wish. Okay. I was hoping not to.

CHAPTER 6

All right, this is the moment of truth. Where's the last defect? In there. So we probably need to be... Oh, camera fighting. Okay, so we'll probably be here. All right, let's try that. That's gonna be awkward. Long way. All right, let's go down. That's the trouble. Taylor, please untelescope the scissor hand and pull out this plastic port for me all the way back, and see if we can turn it 180 as well. Good, perfect. We'll take that for now. Bottom defect here. Belly button probably there. Press on his belly button for me, Taylor. Where's the near side? There you go. All right, let's try. Huh. Little meat to it. That's great. Now the question is, will we be in trouble here? 'Cause I wouldn't mind, I'm okay we have holes here, but if we have a hole starting here to there, that's a problem. His peritoneum is pretty thick, so I'm happy. Okay. Here it goes. No turning back now. Left hand's not working. Can we suture this back? I guess so. So, Olivia, just trying to recruit not only peritoneum but all these little fibers here. I'm sure there's a name for it, but these little extra fibers just kind of get it, whenever it gets too thin, recruit a little more. Okay. If you see the red stuff above, you're too deep. If you see too thin, you're too shallow. So, rather than going through here, you go a little bit above. As it buzz, cut, it'll slide, or a little push. Push up, yeah. Keep it dried, don't stain the tissue. Getting thin. We we get to the fatty stuff, we're better off, but... I find upper quadrant by the falc, usually the thinnest as you go up. So, here is pretty thin. If you can make it through here, it should be okay for the rest. So I just start off here when we're starting on the opposite side. Who knows? That's instructions, yeah. That is pretty good right there. All caught up, let's do something else. Keep working. So, it's arcuate line I think. It should be okay there. Really beautiful. Wouldn't mind getting back into like a film. We'll see. We'll see. Yep. All right. There's the hernia there. Hernia there is where it becomes tricky. Yep. This falc not too bad. Getting thin, getting thin. So, we're saying that's hernia there. Hernia up there. So, we have to work up there eventually. Strike some volcano stuff. Getting thin where it's... Danielle or Taylor, I don't know, maybe another, who knows, hour, or less we'll ask for a number one, Stratafix, maybe two of them. Number one? Number one, yeah. Okay, I got it. Thanks. We will see. We didn't open any V-Loc. Yeah, maybe a nine-inch V-Loc. Yeah, thanks. Nine-inch? Nine-inch, yep. Some holes. Danielle, poke on his belly button for me. I think it's down here. Oh, that's it, okay. Ah, right there. There you go. Poke a hole in it. All right, so we'll close some of those. This is the other one. Let's see if we can get outta here without too much drama. Hmm. Tattered. I guess if we can't close it, we'll put a sheet of Vicryl or something on it. Sometimes we can run it, run a stitch on it, we'll see, if I could mesh on it, we'll see. Got this thicker stuff. Danielle, how does it look up top? Any significant puckering? It's puckering at like - not coming through. All right, no holes yet, great. Here you go. Great. What do you think Danielle less puckering? Yep. Okay. Still puckering a lot. Still puckering a lot, okay, good. Getting better. Getting better. Over here. Hole's are getting bigger, good. Whoops. Camera clean for me please. Trouble, trouble. Oops. Too deep. All right, let's keep working there. I soon get you in here, Olivia, let me get this flap. We'll have you close up the second layer of the defect. Look at all these. I know, I'll be in trouble closing it. How are we gonna close it? That's the next problem. Let's do one more clean. Put me in at 30 down. All right, we do need to get over there, a little ways to go. That's the problem. Am I hitting on the arm, Danielle? I'll take it. I'll be okay. Can we try maybe moving the arm towards the side? Yeah. Ooh, thin. Super thin. Let's get through here a little. Can we get this? Yep, that's what I want over there. Some more fibers. Yep. Mm-hmm. Another hole. I will take some of these. Yeah, we get some peritoneum from it. Here we go. Do it anyway. All right. Well, lateral enough? Nope, still gotta work. I'm making some progress, nobody knows. Get a little more, a little thicker. I'll be sad if we have all of this stuff, I can't close it. Gonna get a little deeper. Need to go past rectus and it'll get into that TAR plane. Easier said than done sometimes. Trying this guy here. Yeah. Oh, great. I will need a bunch of Vicryl to close the stuff when the time comes. I think I'm in the right plane, carving it out. It's on the right plane still, we're below belly button. All right, Alpha, we're in the TAR plane. Some say you can take this all the way back to the, what do you call it? Erector spinae muscles, and so on. Hopefully we don't have to do that today. Keep going on until we start making holes, great. Little more relaxation please. It's kind of, more. Yeah. It's never ending. Yeah. Yeah, a little more - a little less light, little more deep. Yeah. Thanks. Well, I'd give him some more still, maybe. We're kind of picky. You think it's me? No. No. Hands up more. Yeah, some... Something to do it. Yeah, give him some other, oh, we're by the port. Yes. Okay, so we're good. We're where we need to be. I don't know if it's enough though. Hope for the best. All right, so we are good here, but we still got two up there, yeah. All right, let's see. There it goes. Here goes nothing. Danielle, what time is it? It is 1:45. Oh. Honestly, it feels is like five o'clock. Everything hurts. All right, I think that's gonna hurt us a little bit with this thin stuff. Let's try. One cell left. There we go, got it, opened it up. All right, well, here we go, keep working. I know. I give up. Is left hand stuck on the outside? Nope, nevermind, it's okay. Let me clear that hole and we'll figure out if we can close it. I think it's closable, we went far lateral. We'll see. How are we gonna close all this stuff? It's another problem. Well, rumor has it when we close the defect, the flap becomes more ideal, we'll have more coverage. So hopefully, that'll be help in our favor. Appears so thin, so if at any point we have problems, we just put a Vicryl mesh, but try not to do it, but we might have to give up on this part up here. We'll see. It's so thin up here? Yeah, because it's already thin and it's not gonna get - the upper quadrants are notoriously thin. So, even if we get into good peritoneum, it's still gonna be pretty thin. Thinner than the bottom? Yep. Getting lucky here or what, let's see. Maybe. I'm at 30 down. So, we did one. We did two. Let's get the third one and runaway. Okay, that's where we were, good. Getting somewhere. Okay, rectus, rectus, diastasis, hernia. So, if we get a little bit of here, that might be our end point. Alpha, there is light at the end of the tunnel. Hopefully won't collapse enough before we get there. All right, so that's good. Still gotta make a bigger pocket. Turn it down. Camera clean. All right, so we'll close that, we'll close that. That's covered. That distance is good, we'll get some more here. We'll get a little bit more here, and maybe some there. Okay, well we do need a bunch here even to close. All right, let's see. I'm sure the anesthesia drug's not expired. Something's wrong here. Something going on. All right, we'll make it work. How far? 1.5, 3. Try that doggy paddle again. Can back up that port for me? As long as no gas is going in, let's back it up to the subcu. Okay. I'll stay steady, so it doesn't hit you. So, like a TAR. Okay, gas is on a 12. I did wiggle that 12 back a little bit. Okay, that's good. I'll move it to 10. Yep, five back. Yep, that's good. Thank you. Perfect. This might be enough. I'll be okay. Good. Where the holes, the holes are up here, so we do need extra... Question, if we bring this up here? So I'll close this first. Let's see if we need more. Danielle, next stitch I need is a nine-inch V-Loc. Let me just try to close this hole first, these holes and... See how it looks? Yeah. Is V-Loc the one to use or is Vicryl, who knows? I think it's okay. Let's head down here. Oh, made more holes. Okay, so that's middle, three, three, let's get some more. A port probably. Oh, great. That's the hole from the port. Got it. All right, so, gilding the lily. Doing more and more. Hmm. I wanna skip this, but I don't think we should. All right, let's give it one try. Is this because the diaphragm was earliest? I'm thinking. Retrorectus now on the wrong plane. Let's pause there. Okay. We'll get ourselves in trouble. Oh, let's get a suture cut. Let's go scissor out, untelescope. Let's get the nine-inch V-Loc for starters. Okay. And put a 10-inch Vicryl as well.

CHAPTER 7

It's kind of awkward there. Maybe it's my, where I put my port. Maybe it's kind of torquey, but it's okay. I'll be done this part soon. Okay. Yeah, the right hand's kind of funky. Jump here. Yep. That'll work. Say again? Oh, and the - okay. All right, I'll go steady and you reset it. So, hold there. Get that with a Vicryl. Let's see. Go backwards. Mm-hm. Uh-oh, great. That's a problem. So, the problem with the V-Loc, you run into barbs, so you gotta kind of know when to stop sewing. Ask for another one or Vicryl or something. That's the last bit. Actually, there's a loop there. Let's try get the loop out. Don't cut it, don't cut it. I'll put these sutures. This needle driver has a scissor in the back of it. So if he grabs it in the wrong spot, you'll cut the thread. Done that before many times. All right, so more. Okay. Left hand stuck, stuck on. Let's double back on itself. Maybe reverse it. Let's try reversing it. I'll do another one since it's, oh. Let just park it here, so we don't lose it. Worst case scenario. If we wanna close this, can it come? Kind of heavy, kind of tight? All right, we'll put our mesh here. What is it? Three at least should come. Here's heavy. I think it'll come. All right. We'll close these at the end. Danielle, please give me number one Stratafix. I'm gonna give you back this V-Loc needle, and then gimme a non-cutting needle driver.

CHAPTER 8

All right, yeah, let's just do it here. So, Alpha, Stratafix is a different kind of barb suture. It doesn't have that loop like the V-Loc does. It does has a little tab on the back. This is the only one that's FDA approved to do this. Can you see how he's not pulling it all the way through? That makes the suture easier to manage because it's really long right now. - [Jerome] So let's treat it like an ellipse and go up. That's good muscle there. Probably don't need to go that far back but do it anyway. And that works too. Yep. We usually kind of say we do rTAPP, because we just do like belly button hernias with it. It's good for that but it's tedious to do like other true hernias with it. Like swiss cheese, the extraction point incisionals, and that's where we should do it. Belly button, you know, if it's small, why would you do a rTAPP if you do it open? It's a lot of discussion there. So, this one, he'll benefit. Yeah, he's gonna love it. Yeah, 'cause if we didn't do it robotic, he'd have to do it open. That would've been a huge... Yeah. And then we won't burn the bridge to say to a TAR. Yeah. So I think this is a good option. All right, let's get down here. Another thing people do is actually pull the sac, that and get it. Yes. I typically don't, because I think it messes with integrity to repair. 'Cause now you have it up there to another anchor point which prevented from being tight. Okay. They're gonna get seroma no matter what, I guess. But, who knows? Will it close, Alpha? That is the million dollar question after all of this work. What do you think, Alpha? Better close, 'cause no option left. Why we're here. So this is the reason to use these barbed sutures. Can you imagine trying to do this without this tension that this suture's able to maintain, which is all immediately pulled back out? Yep. Huh, maybe I'll... Yeah, we'll see. That looks good. Yeah, something's happening, great. That's good. Hmm. I'll just keep working. I'll just grab both at the same time. So, a couple of tricks you can use, Olivia, you could decrease the pressure. Have them fully relaxed. Sometimes I've had to do a Carter-Thomason, like a figure of eight, just to kind of hold the tension a little bit. So, a couple of things just to kind of get it done. That's when you're at the extremes of, I guess, physiologic tension. You don't want it to be too tight. But this, you know, it'll come over time or just lay the suture tend incrementally, it kind of helps offload the tension. Lori? Yeah. Is the number one Stratafix, is it only one length? I'm trying to figure out if Olivia can run it back a new one, just a little bit shorter. This is 18-inch, right? Yeah, so let's get a 12-inch or so if possible. All right, don't lose that home, Alpha. Don't put two instruments on the same stitch. It'll break it, so... Yeah. Once, as you pull your release, no double pulling. Like that. It'll break it. If you break it, start over. How do I know that? Done it before. Never happened to me, but I read about it. Yep. As our old program director used to say. Yep, there you go. Let's try again. Let's keep going. Yeah, trick here. Good, so we're closing. Extra layer, mesh, and we'll place the flap up and then we'll patch all these holes. It'll be a while where we can see, we can see the end. End is nigh. So, this part, let's get some of that. Pressure to eight. Let me see if we can get this thing, is he fully relaxed up top? Give him some more stuff. You just dosed him some stuff? All right, so the 0 is not as strong Olivia, so definitely don't double pull on this guy. Got it. Back in the day, I used to use like the tool Stratafix, but no way 0. It has a loop instead of the tab. Okay, that'll work. Nine-inch is easier, manageable. When you get up here, the left hand doesn't work as well, so just do what you can with the right and then move the stitch to where the left hand's more ergonomic, and then we'll cut it, and you start wherever you want to, somewhere up here. Go here. Get some more. Oh. I think ideally could have gotten a little more overlap up top. I'll try to get a few, but I think that the hernia is here. That's just diastasis, so that's our excuse. So, there you go. A little more. All right. All right, Danielle, let's get a suture cut. We'll switch out needles. Olivia, I think you should start from right to left. Yeah, a lot of suture to manage up there when the right hand or the left hand... Yeah, it's kind of harder, yep. So Alpha, we're changing the pressure so we can try and get better visualization, and that the space up there will close down a little bit because we're tenting it all open right now with high intra-abdominal pressure. Start from there. Let's get a non suture cut, regular needle driver. Don't need to double hit us, make it shallow and go right through. Okay. So rather than going through the keyhole, go through here. Yeah, yeah. That's strange. Okay, I think that's always made. Whatever. All right. So, I would say, a little bit of shallow action. Get both. And obviously, right here, the right hand doesn't work as well. Left hand doesn't work as well either, okay. It's a big needle. Yeah, okay. Go for it, Olivia. It didn't look... No, the screen looks clear. So, the monitor looks clear. Yeah, pull, pull, pull and let it be tight. And then let it, yeah. For this one, might as well do that. And then do two, then pull two, then pull. Good. And you can space it out a little bit. Yep, right there. Yep. Turn hard, perfect. Keep working. Actually, it is kind of foggy. All right, do two, Olivia, and we'll clean camera for you. Ah, Lori, we have the 30 by 30 mesh in the room? Yeah, it's pretty long. All right, hang on there Olivia, don't do that yet. Let me take a camera clean. Okay. I'll come back into the console and kind of help. That's why we like to pull right after because it locks on the first row. Plug into that. Oh, there you go. There you go, it's coming. I loosened it. Oh. Oh, this is mine, is it mine? I don't know. That's what I was trying to pull. Oh, yeah. It wouldn't come. It's coming. Okay, great. Perfect, okay. All right. I think that was the first layer, yeah. Traction, counter traction. And then, good, yep. Yep, empty space. Get a little more. That's fine, turn hard. Good. Better. Yeah, so next time you go a little further back and you'll land a little early. Perfect, yep. Why don't you tighten that up. Pull, pull, pull, tighten and make it cinch down when you pull, make it last to the top hopefully. Cinch it down, good. Turn hard, yep, yep, perfect. Hand over hand. Yep, we'll let it cinch, it won't break, hopefully. Good. Next one, now cinch it again. All the tension is in the middle one. If we got the middle one, good we're okay. Yep, yep, turn hard. Yep. Not hard enough. There we go. And it is really short. Yeah. Why don't you get two more out of it. The current direction you have, I want the opposite direction, that kind of helps lock it. One up, one down, and just cut it. Yep. Cinch it down. Let it stop bleeding and then go reverse. Yeah. Good, and head back, just above the red stuff and back down. Yeah, just a little nibble off anything doesn't have to be perfect, just to lock it. Yeah, that's too deep. So, you wanna be shallower. Yeah. Just turn it hard. Push up with the left hand. One hand grabs the needle and kind of push up the tissue. Yeah, I said pull it back a little bit, and then get a better and hard turn. So, whenever you go deep, it's harder. So, shallow is good sometimes. Push it through, get some metal out. Danielle, we'll take a suture cut in a minute, and then we'll go needle out, ruler in. Give us a width in the middle, width at the top, width at the bottom. Yeah. Leave a centimeter or two. Push out a little bit more. Yep. Cut it. Good. All right.

CHAPTER 9

So, line it up along the suture line, upside down, or on the roof. That's on the full dimension of the pocket. Not even the staple, the suture line. It's a 15-centimeter ruler. So, 15 plus seven. 15 plus like seven or eight, yeah. You sure, eight, eight? Yeah. Okay. 23. Give me a width. All right, and just push it up here, give me that edge. That's about 10. Okay, give me a top one. So, 23 by, what did you say, what did we say? 11. Yeah, 23 by 11. And it's made the top and bottom like a centimeter smaller. So, 23 by 10, all the way up top. Olivia, up here. Yeah. Camera right. Put your camera to right. Yeah, 23 by 11 at the widest. 23 by 10 at the top and bottom, like an oval. All right, good, grab it in your left hand. She'll switch out, take ruler, give you the mesh. So, that's gonna be the length of the mesh. So, measure horizontally now. Measure 11. Good. Good. 11 down below. Bring the rule up to the top. Is that still 11? Remember that mark that you made at the 23 mark all the way down, is it still 11? So, give me a 11 by 23 rectangle. And then it will help you curve it, and go across at the 23 mark. So, that's the mesh we're using. So, remember that 23 mark that you made? You're gonna fold it in two, longitudinally. You're gonna trim off the edges to make it look like an oval of sorts. Danielle will hold one corner. You hold one corner, and you just trim. Trim a little more like make it curvy. There you go. All right. Camera to the left. Let it go all the way deep on you. Far left, yep, yep, yep. Good. Release. Suture cut. Place it like you do a typical inguinal mesh. Push it away from your eyes and work your way back towards you. Look to the right side from you, Olivia, look at the plastic port. Danielle, pull back a little bit for us. No problem. Good. Rotate somewhere if you can, the plastic, yep. All right.

CHAPTER 10

Let's push it all the way. Let it crumple onto the ab wall, and you're gonna have to drag it right, far right. From the right - no, no. So, camera on both hands, way right. Oh, let it go, yep. Good. Let it go, yep. And drag it up and stuff it into that corner somehow. Yep, yep. Mm-hmm. Yep, use two hands and make it work. Yep, grab it, stuff it in there hard. Yep. And then work your way back to the left while kind of opening it out a little. Yep. It's more of a like a tap, tap kind of move. Two hands move in thing. You don't need to press on it. Just kind of tap, tap and move left. Tap, tap, move left. Yep. Small move. There you go. Lift, push on it. Lift, push on it. Hand should always be moving. Yep. Yep. Good. Move it there. Release that left hand, yep. Just keep going left, keep going left, straighten as you go. Eyes go left. Unravel that, and we'll drag it towards us later. Yep, yep, yep. Two hands together, yep, yep. Good, good. Even more left there, get a corner, like it. Good. Now, work up here now. So, camera way back. Good. And kind of unravel it and pull it towards this edge because we made more. Yep. Gentle pull. I'd say work on the edge. So, try not to deform the mesh. Just let it touch, let it stick. Sometimes it sticks. The right, the left hand in trouble, yeah. Keep going right screen. Like it. Yep, yep. Come in, look up. Camera in, look up. Good, good, good. All right, good. Thank you. I think you got it. So, I'll take for a minute. Okay. And then, so here the left hand's gonna hurt us. So, we'll do more right-handed work. And it's more of a touch, touch. You know, a little touch, little touch, little touch. See what happens. Let's pull this down. All right, let's get this one's. That's good. Little long. Drag it down. That's good. That's good. Hold the pocket up top. All right, let's drag it up so we can do more. And then we'll kind of do some tacking sutures just to kind of hold it, it's not gonna go anywhere. That's good, that's perfect here. We got good. We've got at least three, maybe more, three and a half. It might work, it might work. We'll make it work. The left hand is messing us up. Alpha, see how he's not letting go of the suture with his left hand at all. When he did that, he grabbed it in the right spot, you don't have to readjust. This is doable. So, hit that and give me one maybe here. After these two, Danielle, let's get nine-inch V-Loc, 10-inch Vicryl. Oh, eight inch, eight inch, fine. Both hands to tail, yep. Take anything, you got eyes closer. That's all right, good. One way, right hand. Two is fine, and then cut it, where this is dropping like somewhere here. Okay. One throw is fine if you can get it. Okay. Good, let's get one near side if you can get it. Yep. Yep, get a little stretch on the mesh if you can. Yep, do it, turn. Yep, perfect. All right, let's get a camera clean, and we'll swap out two needles. We'll give you a Vicryl. You give us another Vicryl and V-Loc.

CHAPTER 11

Sew with the left hand, see if that helps. All right, this is a test. See if it'll work. Yeah. All right. So, you got a baseball stitch, you can do dolphin stitch. I'll start out with the easy one first. The other stuff later. Roll this out. Good. Right up on the eyes. Good, good, like this move. All right, some holes, not too bad. I'm worried about the top parts. We'll see. A little bit of mesh. Can get some mesh, maybe not, let's see. Yep, let's get some mesh. That should do it. This left hand is kind of older position. Let's try that, too thin. Hmm, left hand won't come up, great. Okay, not too bad. Let's see if I can just do this all on the way down. I pull it. Okay. I try not to use the left hand, let's see. Can you burp the needle driver for me? Just press it a little and see what happens. Yep, great, that might work. Oh, I think you're locked. Oh, oh, yeah, you're right, thanks. Tough, tough, tough. Do you need to push that trocar back in? No, I think, it might be okay now, it's just gonna block it, yeah, we'll take it. We'll work with it. Did I lock it here? Oh, good. Carter-Thomason the bottom one. Is this the top one? Why is it? Yeah, robot can cause holes. All right, let me try this one. Okay. There. Is there a barb on this one yet? I think we're at the end of it. So, no barbs. Taylor, do you have that second V-Loc? Yeah. Might be too long but we'll take it anyway. I'll just lock it here. Suture cut. Another V-Loc. I'll just lock it, do a full lock on it. Yeah, let's try that. One more time. Okay. No, just give me the V-Loc. I'll just leave it hanging, we'll cut it at the end. Robot is good until it's not. There you go, all right. All right, oh, here we go. Now, like that, not lucky. Okay. Huh? All right, Olivia, figure of eight here. Okay. Maybe one here. Is that one? Yeah, but I think just figure of eight here, and just figure of eight here. Figure of eight here. That'll be three and then four. So that might be - figure out how to get this, yeah, like that. I don't know. Yeah, careful there. If you pull hard enough, things will happen. Let me get the bottom one first. Okay. And I'll shorten the stitch for you. So, four figure of eights total is our thought. The flap comes with you. I think there's enough laxity on it for you to take a decent bite, I don't know. Oh, careful. Don't do that. Do what I did. Yep. Huh? Where did it go? Hm. Follow the curve. It's so thin, it's gonna, it can rip easily. Maybe not. Taylor. Let's got another eight-inch 2-0 Vicryl for Olivia. Okay, that's all right. Good, great. Yeah, figure off 16, somehow do like three throws in it. Okay. Yeah, take it. Okay. Should hold. I'd say right here to there. Yeah, sure, that'll work too. Come up here, yep, yep. Follow that curve. Good. Get the tail shorter. Yep. Yep, lift this little fat up and kind of see it. Get under there. Yep, and come make a little progress. Yep, yep, good. Follow the curve. Yep, good. And then, keep going again, I think. One again? I think so. Untangle yourself, yep. Yeah, so you think right here, yep. And come up again. Good, good. And try to tie that up and see if it works. Cinch it up. Push, pull, push, pull. There you go, there you go. Tail's under there, yep. Yeah. Hello, yep, yep. Bring it out, good. Throw it and see, we'll get a new stitch for you for the next one. Yep, yep. Controlled pull when you get it. Uh-huh. Right. Release that left hand, bring it up, and watch it as it closes on you. Love that. Okay, that's enough, that's enough. Okay, two more, or one more throw and then cut it. Yeah. Yep. Yep, hold further back. Yeah. Good. You cut that. Good. Unloop it and cut it. The other one. Yep. Grab it, grab it. Yeah. Park it in the falc, to the left screen and get another stitch from Taylor, and then do your two figure of eights there. Alpha, you scrub? All right, good. We're coming in shortly. So, eight-inch Vicryl. Look to the right, Olivia, and then she'll work right there. Good, perfect. Watch the bowel when you come in. Let me just look around before I go scrub. I think we only have two holes, yep, so we're good here. These small ones are not too worried about. A little small ones in the back of bow. Yeah, so I'm not too worried. That's good here. Two figure of eights, I think, so one there, one there, yeah. Or like a figure of... Run it? Sure. Feel like a Carter-Thomason eith Ethibond for the 12. Perfect. All right. Lauren, tie me up please. Going back in already. So four, so half an hour should be done. Perfect. I hope. Matt, half an hour around and then Toradol. Okay. IV Toradol, yep, thanks. Good. All right, run that back hand. Olivia? Yep. Backhand, so point upwards, yep, yep. Can you pull on - you can pull on the Vicryl as it comes outta the body. Yeah, and that'll kind of guide you. Yep, yep, perfect. Keep going. I'm gonna tie this one and then I'm gonna do a figure of eight up top, and then... Oh, I thought you were gonna run it? Oh, no, I changed my mind. Okay, all right, fair enough. Good, I like it. And the next one, you're good. Yep. Good. Yep. Take less. Take less, yeah. Into the fatty stuff on the left. Can you torque the needle, turn it, needle to the left screen. Okay. Yeah, yeah, there you go, that's it, yeah. But that'll make it rip if you go too much. Okay. Yeah. That should work still. Tighten it up, that should be fine. Cut the tail short and tight, that's the last one. Yeah, grab it. Traction, counter traction, cut it. Good, one throw is fine. Tight, tight, tight, yeah, there you go. All right, cut it, park it in the falc, and we'll undock. Alpha, when she's free, you're gonna pull two instruments, one and three. You pull camera last.

CHAPTER 12

Pull out one, I'll go scrub, Olivia. Pull hard, pull fast. Pull out number three, camera, you grab from underneath. All right, so undock it now. So, careful not to pull the port out. Same lever and the button. One hand on the port, port stays steady, robot goes away. So, thumb on the lever and index finger on the button. Left hand on the port, and then the robot moves but the port stays steady. Thank you. All right, let's get that one. All right, let's look around, make sure we're all happy. It's all good.

CHAPTER 13

Lots of needles, so I'm not too worried about the small holes. Olivia, you come around? Yeah, pull out the sutures right under the falc one by one. Can you get up there? Needle one. Needle two. Needle four. All right, so let's look around, make sure we didn't have any misadventure. No blood welling up. All good, that's all scar tissue. Okay. Alpha, go between me and Olivia, and you're gonna get the bullet, and we'll do a Carter-Thomason. Put the camera right at that hole. Bullet for Olivia. Yeah, lift up, like it. Lift up the stuff. Yep, that's muscle, so I'll take it. Are we losing gas? Yes, yes we are, we didn't do it apart. Grab the cord, grab the suture into the body. Good. All right. Did it work? Yes, it did. Lights up, gas off. Matt, hit level for us please.

CHAPTER 14

So, in this patient, he had previous surgery, and he had a feeding tube in the left upper quadrant. I typically enter through an Optiview access in the left upper quadrant, so I was able to get a little bit below the feeding tube site. Where we got in, we saw lots of adhesions, and we kind of had to navigate our way through the omental adhesions to the other side, which is not our typical port placement site. We typically go on the left side. So, after we got in, we found a clear area on the right side. We kind of reversed everything, flipped everything, put our ports on the right side of the abdomen. We did our TAP block as expected. We were able to see both abdominal walls clearly, at least on the flanks to be able to place our TAP blocks. Then, we docked the robot. And the robot is actually very good in allowing us to lyse the adhesions with very fine dissecting maneuvers. So that took, it did take a while, it took about at least 45 minutes to get the adhesions down to a point where we can actually see the hernias, and try to reduce the hernias. So, we ended up taking the adhesions down, and reducing the hernias. So that adhesiolysis part was a little more, I'd say a little bit unexpected in this case. So first of all, I'd say get your ports in safely. If the robot is - if you can't dock the robot early, then you can add extra ports, and laparoscopically light adhesions to get extra ports or the appropriate port placement for the robot. Then you can, as soon as you get to dock the robot, you dock the robot and continue the adhesiolysis with the robot because it's a better tool. But you may have a little bit of difficulty the first, I'd say 15, 20 minutes just to get everything cleared. So, we created a large peritoneal flap, which kind of encompassed all the hernias with overlap laterally as well as superiorly and inferiorly. And we kind of knew whenever there are hernias, especially after laparotomy, the peritoneal layer at the level of the hernias is pretty thin. So, we got through relatively with some difficulty. We expected holes in the peritoneum. As long as we had enough overlap, enough laxity of the peritoneum, we could close it without affecting the reposition of the flap at the end of the case. So that was another I'd say variable. If we're in a position where the abdomen was hostile, adhesiolysis was difficult, we're usually capable enough to get the adhesions down laparoscopically or robotically. Now the next question is if you have a tattered or a very thin peritoneum, then your one might wanna change from an rTAPP to say an IPOM. Just placing a dual layer mesh after closure of the defect rather than creating a flap, putting mesh in, and then repositioning the flap. So that would be my backup plan, an IPOM mesh placement. Probably wouldn't need to open. I'd say open would be - I'd probably offer an open or convert to an open procedure if the hernia is not reducible, there's bowel in the hernia where too much traction laparoscopically might injure the bowel, so I may do a, like a counter incision on the abdomen to help reduce the hernia safely. That's pretty much it. And we'll try to get back in laparoscopically to do the rest of the hernia repair. In this case, we expected adhesions, we had a little more than we expected but there were, we call it flimsy or filmy adhesion between the omentum and the anterior abdominal wall. So, we just took a little bit of time to lyse the adhesions with the robot, with cautery, with blunt dissection and that was pretty uneventful. He did have a previous gastrostomy tube site where the stomach stuck to the anterior abdominal wall. Usually, I to take it down because I need the mesh coverage to extend far enough laterally for good coverage to reduce recurrence. But whenever you say you have bowel and you're gonna have to divide bowel, you always wonder, is there gonna be a risk of a mesh infection. So, my goal at that point was to clip or divide the stomach in a controlled fashion where there's no open stomach and, you know, minimize the contamination. At the time of adhesiolysis of the stomach from the anterior abdominal wall. So after that, we created a large flap. We had enough coverage laterally as well as cephalad and caudad to say, all right, we can get this done. While doing the flap creation as well as reduction, we encountered a lot of small holes, but we realized that we could close them easily without much tension on the flap, and then we proceeded. The next step was the suturing of the hernia defect. So, we had multiple hernias, we call it swiss cheese-type defects with some diastasis. So, we created almost like an elliptical type defect measuring around 15 by 3 centimeters. So, we closed that elliptical defect incorporating all the hernia defects. Under, I'd say, physiologic tension, we had to drop the pressure to allow closure, but we were able to get it closed. We used two layers of a barbed suture. The next step was to put our ruler inside to kind of measure the pocket of the defect with good coverage above, below, and laterally. That came up to around 23 by 11 centimeters. We kind of custom fashioned a Bard Soft Mesh in the sublay manner, so we put it into that pocket that we created. Because of the size of the mesh, it took a while to kind of get it placed properly. We had to use a few tacking sutures to keep it in place, and we use 2-0 Vicryl for that typically. And then, we close the flap, because of the size of the defect, it kind of abutted our robotic ports. So, at the extremes of motion, extremes of the cephalad or the caudad side of the mesh, we had to, one of our arms, one of our robotic arms wasn't working well, so we had to do a lot of our dissection using the opposite arm. So, we always say try to be a two-handed surgeon, but there's certain spots where you have to do one-handed because that's what's available to you. We're able to close the defects. I close a few before replace the flap, and then close a few defects after we place the flap up. And I find that that kind of helps closing it before to kind of make the hole smaller. But you don't need to close every single thing immediately. Just replace the flap, kind of see what the tension looks like, then we can decide how to close it. If it's a figure of eights or running sutures, and what type of suture. Few tips and tricks of this hernia repair. We kind of position the patient in a way where the hernia is a little bit away from us, so we tilt the bed to the opposite direction. We flex the bed to kind open up the abdominal wall to allow our instruments to come in and go with good range of motion. I find that if we go too far laterally with our camera port, or whatever port, we may end up hitting the thigh, or the chest wall or the patient's face. But if you go too close medially, you end up not getting enough lateral coverage. So, there's kind of a sweet spot. Not too near, not too far, when we set up, and the setup is key because if it's not done properly, each following step becomes, I'd say exponentially harder. So, setup is key from the get go.