Chapter 107: Repair of Ventral Hernia with Bilateral Transversus Abdominis Release, Robotic

INDICATIONS

Ventral hernias in the anterior abdominal wall include both spontaneous or primary hernias (e.g., umbilical, epigastric, and spigelian) and, most commonly, incisional hernias that occur after an abdominal operation. It is estimated that up to 40% of all abdominal operations result in an incisional hernia. Risk factors for the development of an incisional hernia include obesity, multiple abdominal procedures, diabetes, wound infections, and the use of immunosuppressive medication(s). In larger hernias or recurrent hernias, myofascial release techniques (i.e., component separation) can facilitate repair and restore a physiologic anterior abdominal wall. These techniques can be technically demanding and result in increased complications unless care is taken for appropriate patient selection and preoperative optimization.

PREOPERATIVE PREPARATION

The indications for repair should be thoroughly discussed, and a careful evaluation of the goals and expectations after repair should be communicated with the patient. Review of previous operative reports can greatly facilitate operative planning by identifying potentially free myofascial planes for reconstruction of the abdominal wall. Preoperative optimization is critical to ensure a successful repair with minimal morbidity. Nicotine use should be stopped at least 6 weeks prior to and 6 weeks after the repair. Many patients use these operations as an opportunity to halt nicotine use indefinitely. Diabetes should be well controlled with hemoglobin A1c ≤8%. Patients with a history of respiratory compromise or chronic pulmonary disease should be referred to a pulmonary specialist prior to repair. If a lengthy lysis of adhesions is anticipated, a bowel preparation can be used. Microbiology results from any history of previous abdominal wall infection should be considered in the selection of preoperative antibiotics. Importantly, the patient’s functional status should be sufficiently optimized to allow safe major abdominal wall reconstruction and subsequent recovery.

ANESTHESIA

General anesthesia with an endotracheal tube is required.

POSITION

Patients are placed in a supine position.

OPERATIVE PREPARATION

Patients are given perioperative antibiotics. An orogastric tube is passed for gastric decompression. If significant dissection is anticipated, a nasogastric tube may be placed for postoperative decompression of the stomach in the event of an ileus. A Foley catheter is placed, and pneumatic sequential stockings are applied. Pharmacologic deep venous thrombosis prophylaxis is initiated. The skin is prepared in routine manner with attention to prepping the patient’s abdominal wall laterally because this may be accessed as part of the operative procedure. Sterile drapes are applied according to the surgeon’s specifications. Then a time-out is performed.

INCISION AND EXPOSURE

The operation begins with both arms tucked and the abdomen prepped from the pubis to the rib cage (FIGURE 1A). Peritoneal access is gained with a Veress needle technique at Palmer’s point in the left upper quadrant (see Chapter 14). The initial trocar then can be ...