Critical view of robotic-assisted transverse abdominal release (r-TAR).

INTRODUCTION: Establishing straightforward and reproducible steps to describe the technique performed with the aid of the robotic system for complex hernia surgery is key for good outcomes. Even using the description of open surgery as a parameter for performing the robotic technique, it is important to stress the particularities of this access. To describe the steps to perform robotic-assisted TAR (r-TAR) in a standardized technique, with a critical and safe view of all the anatomical structures. DESCRIPTION OF THE TECHNIQUE: We defined 8 landmarks for the critical view of safety in r-TAR which include: (1) patient position, trocar and docking; (2) posterior rectus sheath mobilization; (3) transversus abdominis release (TAR)-Top-down technique; (4) transversus abdominis release (TAR)-bottom-up technique and mesh insertion; (5) contralateral trocar insertion and redocking, 6) posterior sheath closure; (7) final mesh positioning; and (8) anterior defect closure and drains. DISCUSSION: Complex hernia surgery using a robotic-assisted posterior component separation requires well-established steps so the procedure can be reproducible and achieve better results.

Signs and landmarks in eTEP Rives-Stoppa repair of ventral hernias.

BACKGROUND: After years of playing second-fiddle to laparoscopic underlay repairs, the retro-muscular Rives-Stoppa repair is rapidly gaining popularity thanks to the endoscopic eTEP approach. It extends all the advantages of a retro-muscular mesh placement-increased tolerance for infection, mechanical robustness, reduced need for mesh fixation-in an ergonomically acceptable system. METHODS: The eTEP technique described by Belyansky's group requires a "crossover" from one retro-rectus space to the other. The aim of the crossover is to safely amalgamate the retro-rectus spaces for placement of a large extra-peritoneal prosthesis. By salvaging peritoneum in the midline and operating in the extra-peritoneal plane, one can avoid large defects in the posterior rectus sheath (PRS)-peritoneum complex which need closure. Correct identification of anatomical landmarks is imperative to safely perform the surgery. RESULTS: The "lamppost sign" signals the lateral limit of retro-rectus dissection, preventing iatrogenic injury to the neurovascular bundles and linea semilunaris. After crossover has been safely achieved, the medial edges of the divided posterior rectus sheaths are found connected to each other by a strip of pre-peritoneal fat and peritoneum in the midline. These structures, along with the neck of hernia constitute the "volcano sign". For inferior defects, the vas deferens, the inferior epigastric and gonadal vessels form a triradiate conformation termed the "Mercedes-Benz sign". CONCLUSION: These signs serve as tools to identify the composition of the surgical field, avoiding iatrogenic injury to the linea alba and linea semilunaris, while reducing the time taken for posterior closure.

Early operative outcomes of endoscopic (eTEP access) robotic-assisted retromuscular abdominal wall hernia repair.

BACKGROUND: The enhanced-view totally extraperitoneal (eTEP) hernia repair technique was first described for laparoscopic inguinal hernia repair and later applied to laparoscopic ventral and incisional hernia repair. We present our center's early operative outcomes utilizing principles of this technique during robotic ventral and incisional hernia repair for implementation of the robotic eTEP Rives-Stoppa (eRS) and eTEP transversus abdominis release (eTAR) techniques. METHODS: A review of a prospectively maintained database of hernia patients was conducted identifying 37 patients who underwent robotic eTEP for ventral, incisional, flank or parastomal hernia repair between March and October 2017. All patients underwent retrorectus dissection with selective utilization of transversus abdominis release (TAR) as indicated. RESULTS: 37 patients including 13 male and 24 female with mean age, body mass index, and ASA score of 54, 35.5, and 2.4, respectively, underwent a mean operation room time of 198 min. Mean length of stay was 0.7 days. There were no intraoperative complications. Two patients developed subcutaneous seromas requiring interventional radiology drainage. One patient was readmitted at 30 days for PO intolerance that was managed expectantly. Mean postoperative follow-up visit occurred at 36 days with no sign of early hernia recurrences. CONCLUSION: The enhanced-view totally extraperitoneal approach is both safe and feasible in robotic-assisted repair of ventral and incisional hernias. Although long-term outcomes and patient selection criteria require further study, we believe this technique will become an important tool in the armamentarium of minimally invasive hernia surgeons.

Intraoperative indocyanine green fluorescence angiography to predict wound complications in complex ventral hernia repair.

INTRODUCTION: Complex ventral hernia repair (VHR) is associated with a greater than 30% wound complication rate. Perfusion mapping using indocyanine green fluorescence angiography (ICG-FA) has been demonstrated to predict skin and soft tissue necrosis in many reconstructive procedures; however, it has yet to be evaluated in VHR. METHODS: Patients undergoing complex VHR involving component separation and/or extensive subcutaneous advancement flaps were included in a prospective, blinded study. Patients with active infection were excluded. ICG-FA was performed prior to incision and prior to closure, but the surgeon was not allowed to view it. An additional blinded surgeon documented wound complications and evaluated postoperative photographs. The operative ICG-FA was reviewed blinded, and investigators were then unblinded to determine its ability to predict wound complications. RESULTS: Fifteen consecutive patients were enrolled with mean age of 56.1 years and average BMI of 34.9, of which 60% were female. Most (73.3%) had prior hernia repairs (average of 1.8 prior repairs). Mean defect area was 210.4 cm2, mean OR time was 206 min, 66.6% of patients underwent concomitant panniculectomy, and 40% had component separation. Mean follow-up was 7 months. Two patients developed wound breakdown requiring reoperation, while 1 had significant fat necrosis and another a wound infection, requiring operative intervention. ICG-FA was objectively reviewed and predicted all 4 wound complications. Of the 12 patients without complications, 1 had an area of low perfusion on ICG-FA. This study found a sensitivity of 100% and specificity of 90.9% for predicting wound complications using ICG-FA. CONCLUSION: In complex VHR patients, subcutaneous perfusion mapping with ICG-FA is very sensitive and has the potential to reduce cost and improve patient quality of life by reducing wound complications and reoperation.