Robotic Ventral Hernia

Background Information:

A ventral hernia occurs when a defect in the abdominal wall musculature allows underlying tissue to push through the muscle layer. Ventral hernias occur within the abdomen wall and are typically divided into three types:

1. Epigastric hernia: occurs anywhere in the midline between the breastbone and the navel 
2. Umbilical hernia: hernia surrounding the umbilicus
3. Incisional hernia: develops at the site of a previous surgery

Ventral hernias occur commonly with severity ranging from small umbilical defects to complete disruption of the abdominal wall musculature. There are various risk factors for developing ventral hernias including previous abdominal surgery, congenital abdominal wall defects, and weakness in the abdominal wall caused by conditions that put strain on the wall.

Ventral hernias may be repaired through either an open or minimally invasive approach (laparoscopic or robotic). In general, minimally invasive ventral hernia repairs are preferred over open repairs. However, not all ventral hernia repairs can be performed using a minimally invasive technique due to complexity of adhesions, abdominal disfigurement, or contamination. The choice between the separate minimally invasive techniques is based on equipment availability and surgeon expertise.

Surgical Indication:

Treatment for chronically incarcerated or reducible ventral hernias include expectant management or planned surgical repair. The management choice depends on patient health, risk of acute presentation, probability of successful long-term outcomes, and impact of the hernia on patient quality of life. Acutely incarcerated or strangulated hernias require urgent and emergent surgical repair, respectively.

Surgical Techniques:

The patient is placed in supine position with both arms tucked at their sides. Initial abdominal entry is accomplished by Veress needle, direct Hassan open cutdown, or via an optical trocar. Once abdominal entry is accomplished, insufflation of the abdominal cavity should be maintained at 15 mmHg. Visualization of the peritoneal space upon introduction of the laparoscope will confirm adequate initial port placement. 

Port placement depends on the size and location of the hernia defect. Traditional port placement for a midline mid-abdominal ventral hernia includes three ports along the patient's right or left side spaced approximately 10 cm apart. Once the hernia is identified laparoscopically, the edge of the fascial defect is marked. In anticipation of at least 5 cm of mesh coverage, the additional ports should be placed at least 10 cm from this edge.

Once the fascial edges are exposed, the defect can be closed using sutures to approximate the fascial edges. Multiple layers of suture can be placed to reinforce closure.

Positioning of the mesh involves placement of sutures into the four corners and center of the mesh prior to introduction of the mesh into the abdomen. The mesh is affixed to the abdominal wall over the defect using sutures or tacks. The mesh size should cover the defect with at least 5 cm of overlap in all directions. Using a suture passing device, these sutures are pulled transfascially through the abdominal wall and held in place while the mesh is affixed to the abdominal wall.

Key Anatomy:

• Layers of the abdominal wall at the umbilicus, lateral to the midline, and superior to the arcuate line (superficial to deep): 

• ~Skin, superficial fascia (Camper’s fascia), deep fascia (Scarpa’s fascia), anterior rectus sheath, rectus muscle, posterior rectus sheath, transversalis fascia, preperitoneal fat, parietal peritoneum
• ~It is important to understand the different layers of the abdominal wall based on the location of the trocar. 

• Musculature & Fascia

• ~External Oblique 
• ~Internal Oblique
• ~Rectus Abdominis
• ~Transversus Abdominis
• ~Abdominal wall fascia

• ~~Camper’s fascia, Scarpa’s fascia, transversalis fascia

• Vasculature

• ~Inferior epigastric artery & vein

• Ligamentous structures

• ~Round ligament of liver (ligamentum teres)

• ~~Remnant of the umbilical vein

• ~Falciform ligament

Risks: 

General surgical risks:

• Bleeding 
• Infection

Risks specific to ventral and incisional hernia repair

• Persistent postoperative pain (rates vary widely)
• Hernia recurrence (37% for primary ventral hernias and 64% for incisional hernias at 140 month follow-upⁱ)
• Enterotomy

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