Overview
Definition:
Robotic Rives-Stoppa ventral hernia repair is a minimally invasive surgical technique that utilizes a robotic platform to perform a large-component separation and mesh reinforcement for complex ventral and incisional hernias
It aims to restore the abdominal wall anatomy and function by creating a large retromuscular space for mesh placement, inspired by the open Rives-Stoppa technique, but with the enhanced visualization, dexterity, and precision offered by robotic surgery.
Epidemiology:
Ventral hernias, including incisional hernias, occur in 5-20% of patients undergoing abdominal surgery
Recurrence rates can be high, especially in large or complex defects
Robotic approaches are increasingly being adopted for their potential benefits in managing these complex cases, particularly when extensive component separation or large mesh coverage is required.
Clinical Significance:
This technique is significant for managing large, recurrent, or complex ventral hernias that may not be amenable to standard laparoscopic or open repairs
It offers potential advantages in reducing postoperative pain, improving cosmesis, and enabling a wider dissection plane for mesh placement compared to traditional methods, making it a valuable option for complex abdominal wall reconstruction and crucial for advanced surgical training.
Indications
Primary Indications:
Large (>10 cm) or multiple ventral/incisional hernias
Recurrent hernias after previous repairs
Abdominal wall defects requiring extensive component separation
Patients with previous mesh complications or infection where a new mesh placement strategy is needed
Cases where improved visualization and maneuverability are crucial for dissection and mesh fixation.
Contraindications:
Uncontrolled sepsis
Significant coagulopathy
Patient refusal or inability to tolerate pneumoperitoneum
Active intra-abdominal malignancy requiring urgent oncologic resection
Severe cardiopulmonary disease precluding prolonged anesthesia and pneumoperitoneum
Extremely obese patients with limited access for robotic instrumentation.
Patient Selection:
Careful patient selection is paramount
Ideal candidates have good nutritional status, adequate respiratory function, and realistic expectations
A thorough preoperative assessment, including imaging to define hernia dimensions and involvement of abdominal muscles, is essential.
Preoperative Preparation
Imaging Assessment:
CT scan of the abdomen and pelvis with thin slices is crucial for assessing hernia defect size, fascial defect dimensions, abdominal wall muscle integrity, and identifying any incarcerated bowel or omentum
It also helps plan the extent of the component separation.
Nutritional Optimization:
Patients should be counseled on smoking cessation and optimized nutrition, particularly protein intake, to promote wound healing
Addressing obesity and managing comorbidities like diabetes are also important.
Bowel Preparation:
While not always mandatory, bowel preparation may be considered for selected cases, especially if extensive bowel manipulation is anticipated
Prophylactic antibiotics are administered intravenously 30-60 minutes before skin incision.
Anesthesia Considerations:
General anesthesia with endotracheal intubation is required
Careful anesthetic management is needed to tolerate pneumoperitoneum and ensure adequate ventilation, especially in patients with compromised respiratory function.
Procedure Steps
Patient Positioning And Port Placement:
The patient is placed in a supine position
Typically, 3-5 robotic ports are placed strategically to allow optimal triangulation and instrument maneuverability
An initial camera port is usually placed in the contralateral mid-clavicular line or in an area away from the primary hernia defect to avoid interference.
Trocar Insertion And Insufflation:
After establishing pneumoperitoneum, ports are inserted under direct vision or using techniques to minimize the risk of visceral injury
The robotic system is then docked to the ports.
Hernia Sac Dissection And Reduction:
The hernia sac is carefully dissected off the anterior abdominal wall
Contents are identified, reduced into the abdominal cavity, and any adhesions are lysed
Bowel loops or omentum are mobilized as needed.
Component Separation And Mesh Placement:
This is the core of the Rives-Stoppa principle
The external oblique fascia is incised laterally, creating a plane between the external oblique and internal oblique muscles
The dissection continues anteriorly to the rectus sheath, allowing significant mobilization of the abdominal wall
A large piece of synthetic or biosynthetic mesh is then introduced and secured in the preperitoneal or retrofascial space, extending well beyond the fascial defect to ensure adequate overlap and prevent recurrence.
Fascial Closure And Drainage:
The anterior rectus sheath (linea alba) is then approximated using strong, non-absorbable sutures, bridging the gap created by the component separation
Drains may be placed in the retromuscular space or subcutaneous plane, depending on surgeon preference and defect size.
Closure And Dressing:
The robotic arms are undocked, and the ports are removed
Fascial defects from larger ports are closed
Skin incisions are closed in layers
A sterile dressing is applied.
Postoperative Care
Pain Management:
Aggressive pain management is essential, utilizing multimodal analgesia including patient-controlled analgesia (PCA), epidural analgesia, or scheduled oral/intravenous opioids
Regional blocks can also be effective.
Ambulation And Activity:
Early ambulation is encouraged to prevent deep vein thrombosis and atelectasis
Patients are advised to avoid heavy lifting and strenuous activities for 4-6 weeks, gradually returning to normal activities as tolerated.
Wound Care:
Wound dressings are changed as needed, and patients are instructed on signs of wound infection
Monitoring for seroma or hematoma formation is important.
Dietary Advancements:
Patients can typically resume a regular diet as tolerated, starting with clear liquids and progressing as bowel function returns
Adequate hydration is crucial.
Monitoring For Complications:
Close monitoring for early complications such as ileus, wound infection, bleeding, seroma, or mesh-related issues is vital
Patients are provided with clear instructions on when to seek medical attention.
Complications
Early Complications:
Wound infection
Seroma formation
Hematoma
Ileus
Urinary retention
Pneumothorax (rare, due to pneumoperitoneum)
Visceral injury during port placement or dissection
Mesh infection (rare but serious).
Late Complications:
Hernia recurrence
Chronic mesh infection
Mesh migration or extrusion
Adhesions leading to bowel obstruction
Chronic pain
Abdominal bulge or deformity
Seroma formation that persists or becomes symptomatic.
Prevention Strategies:
Meticulous surgical technique, including careful dissection and adequate mesh overlap
Strict adherence to sterile protocols
Prophylactic antibiotics
Appropriate wound closure and drain placement
Aggressive pain control and early ambulation
Patient education on activity restrictions and signs of complications.
Key Points
Exam Focus:
Understand the principles of Rives-Stoppa in the context of component separation for large hernias
Know the indications, contraindications, and crucial preoperative assessment steps for complex ventral hernias
Differentiate between laparoscopic, robotic, and open approaches for these repairs and their respective advantages/disadvantages.
Clinical Pearls:
Adequate mesh overlap (at least 5 cm beyond the defect) is critical for preventing recurrence
Component separation significantly increases the potential space for mesh placement, allowing for better abdominal wall closure
Robotic systems offer superior visualization and instrument articulation, especially for complex dissections in the retromuscular space.
Common Mistakes:
Inadequate mesh overlap
Insufficient component separation leading to tension on fascial closure
Failure to identify and manage incarcerated bowel
Inadequate preoperative imaging leading to surgical planning errors
Overlooking signs of early postoperative complications
Incorrect port placement leading to restricted instrument movement.