L3W3 Incisional Hernia with LOD - Robotic eTEP-TAR Repair (with video).

video width="640" height="480" controls controlsList="nodownload" poster="https://www.revistachirurgia.ro/pdfs/video/Victor_Gheorghe_Radu_L3W3_Incisional_Hernia.jpg" style="margin-top: -20px;" source src="https://www.revistachirurgia.ro/pdfs/video/Victor_Gheorghe_Radu_L3W3_Incisional_Hernia.mp4" type="video/mp4" Your browser does not support the video tag. /video Introduction: The Rives-Stoppa procedure has emerged as the preferred method for ventral hernia repair, and the principles of this technique are similarly applied in minimally invasive surgery using the eTEP (enhanced view totally extraperitoneal) approach. It appears that the eTEP approach offers excellent outcomes in terms of less post-operative pain, faster recovery, and shorter hospital stays for patients undergoing abdominal wall reconstruction (AWR). It's important to note that there are some contra-indications of this procedure. In general, laparoscopic eTEP may not be suitable for cases with large hernias and loss of domain where the working space is limited. In such cases, alternative approaches, such as using a robotic platform, may be considered to ensure an adequate working space for abdominal wall reconstruction (AWR). A robotic platform can create a working space by using the robotic arms as a "laparo-lift," enabling the AWR to be performed. Case Report: In this case, we have a 65-year-old female patient with a BMI of 28.5 who presents with a large incisional hernia with LOD. This hernia is located on the right flank and occurred after a Jalaguier incision. The CT scan provided valuable information regarding the size of the hernia, the remaining volume of the abdominal cavity, and the content of the hernia sac. Based on these radiological details, the LOD diagnosis was confirmed using the Sabbagh equation, which revealed that the hernia volume accounted for 46.47% of the total peritoneal volume. Based on the location, size of the defect, and the EHS classification for incisional hernias, the diagnosis for this case is a Complex incisional hernia of L3 right W3 with LOD. The protocol for optimization in this case involves chemo-relaxation, which refers to the injection of botulinum toxin A (BTA) into the large lateral muscles of the abdomen. This is done approximately 6 weeks before the surgery. Based on the successful reduction of the hernia during the consultation, the decision has been made to perform the Abdominal Wall Reconstruction (AWR) procedure using the robotic eTEP-TAR technique. Conclusion: The post-operative course was favorable, with the patient experiencing early active mobilization, reduced pain, and early return of bowel movement. The patient was discharged the day after the surgery.

Abdominal Wall Reconstruction Performing Posterior Component Separation without Transversus Abdominis Release, for a Complex Incisional Hernia (M2W1, L3W2 left) after TRAM Flap Breast Reconstruction (with video).

video width="640" height="480" controls controlsList="nodownload" poster="https://www.revistachirurgia.ro/pdfs/video/Diana_Teodora_Cucu-Abdominal_Wall_Reconstruction.jpg" style="margin-top: -20px;" source src="https://www.revistachirurgia.ro/pdfs/video/Diana_Teodora_Cucu-Abdominal_Wall_Reconstruction.mp4" type="video/mp4" Your browser does not support the video tag. /video Breast reconstruction with a pedicled transverse rectus abdominis muscle (TRAM) flap can result in significant abdominal wall donor-site morbidity. Although the pedicled TRAM flap donor area reinforced with mesh results in decreased rates of postoperative abdominal bulging and hernias, the best technique to accomplish that is yet to be elucidated. Antonio Espinosa de Los Monteros all. published recently a novel technique of posterior components separation with transversus abdominis muscle release and retro-muscular mesh reinforcement for donor-area closure during pedicled TRAM flap breast reconstruction (1). In this case we present this technique using the robotic technology. The robotic surgery allows a delicate dissection of the pre-peritoneal and pre-transversalis space, which represents a posterior component separation without transversus abdominis release (TAR). It is about a 40 y.o. lady, BMI 25 who underwent a radical mastectomy and TRAM flap breast reconstruction. She developed a complex incisional hernia, M2W1 and L3W2 on the left flank, considering the EHS classification (2). Our robotic approach is a minimally invasive surgery (MIS), enhanced view totally extraperitoneal (eTEP)(3) access technique which respects and follows the principles of the original open technique. The key-stages of the procedure are: 1. development of the retro-rectus space, using an optic trocar; 2. placement of the ports, medially to the linea semilunaris; 3. crossingover the midline; 4. dissection the contra-lateral pre-peritoneal/pre-transversalis space (without trans-section of the transversus abdominis muscle); 5. closure of the lateral defect and then, restoration of linea alba; 6. mesh placement. Combining the eTEP approach together with the posterior component separation (but avoiding TAR) and also with the benefits of the robotic surgery, this technique offers a fast recovery and excellent cosmetic results.