Overview
Definition:
Robotic ventral hernia repair (rIPOM) is a minimally invasive surgical technique utilizing a robotic platform to repair large or complex ventral hernias, typically through an intraperitoneal approach with mesh placement
This method aims to leverage the enhanced dexterity, visualization, and precision offered by robotic systems to achieve outcomes comparable to or superior than traditional laparoscopic or open repairs.
Epidemiology:
Ventral hernias, including incisional hernias, are common, with an incidence of up to 20% following abdominal surgery
Large and recurrent ventral hernias pose significant management challenges
Robotic surgery adoption in hernia repair is growing, particularly for complex cases due to its perceived advantages in dissection and closure.
Clinical Significance:
Ventral hernias can cause significant pain, compromise abdominal wall function, and lead to complications like incarceration and strangulation
rIPOM offers a less invasive option for complex cases, potentially reducing postoperative pain, hospital stay, and promoting faster recovery compared to open surgery, while offering improved visualization and instrument articulation over standard laparoscopy for challenging dissections and repairs.
Indications
Primary Indications:
Large (>10 cm) ventral or incisional hernias
Recurrent ventral hernias
Complex hernia anatomy with significant tissue defect or fascial loss
Patients requiring concomitant intraperitoneal procedures
Hernias with compromised overlying skin or subcutaneous tissue.
Patient Selection:
Suitable candidates generally have a good performance status and are amenable to minimally invasive surgery
Preoperative assessment should rule out contraindications such as severe comorbid conditions that preclude pneumoperitoneum or extensive adhesions that would necessitate an open conversion.
Contraindications:
Absolute contraindications include inability to tolerate pneumoperitoneum, uncontrolled sepsis, or severe coagulopathy
Relative contraindications may include extensive adhesions making intraperitoneal dissection unsafe, or a history of multiple previous abdominal surgeries with dense adhesions that might favor an open approach.
Preoperative Preparation
Patient Assessment:
Thorough history and physical examination focusing on hernia characteristics, previous surgeries, and patient comorbidities
Nutritional status and smoking cessation are critical for optimal wound healing.
Imaging Studies:
CT scan of the abdomen and pelvis with thin slices is essential for accurate assessment of hernia dimensions, fascial defect size, presence of adhesions, and any incarcerated bowel
MRI may be considered in select cases
Ultrasounds are less informative for complex ventral hernias.
Anesthesia Considerations:
General anesthesia with endotracheal intubation is required
Careful anesthetic management to tolerate pneumoperitoneum and potential prolonged operative times
Consideration for nerve blocks for postoperative pain management.
Bowel Preparation:
Routine bowel preparation is typically not required for IPOM procedures unless contamination is suspected or a concomitant bowel procedure is planned
Prophylactic antibiotics are administered intravenously within 60 minutes prior to incision.
Procedure Steps
Port Placement:
Typically 3-5 robotic ports are placed
Initial trocar placement is usually supraumbilical or suprahepatic for pneumoperitoneum
Additional ports are placed strategically based on hernia location and surgeon preference, ensuring adequate triangulation for robotic instrument manipulation.
Dissection And Mobilization:
The peritoneal flap is raised circumferentially around the fascial defect, mobilizing the sac contents and creating a wide margin for mesh overlap
Careful dissection to identify and preserve vital structures like the epigastric vessels and to lyse adhesions is crucial.
Mesh Selection And Placement:
Synthetic, non-absorbable, dual-layer meshes (e.g., composite meshes with an visceral protective layer) are commonly used for IPOM to prevent visceral adhesions
The mesh should be sized to provide at least 5 cm overlap on all sides of the fascial defect
Mesh fixation is achieved using tacks, sutures, or fibrin glue, ensuring adequate fixation without compromising the mesh.
Fascial Closure:
Primary fascial closure is a critical step to restore abdominal wall integrity and reduce recurrence
This is often challenging with large defects
Robotic instruments provide excellent dexterity for precise, tension-free suture closure of the fascia using durable, non-absorbable sutures
The quality of fascial closure is paramount for long-term success.
Postoperative Care
Pain Management:
Multimodal pain management including IV or oral analgesics, NSAIDs, and potentially patient-controlled analgesia (PCA)
Epidural or regional nerve blocks can significantly improve early postoperative pain control.
Ambulation And Diet:
Early ambulation is encouraged to prevent deep vein thrombosis and promote bowel function
A clear liquid diet is initiated postoperatively and advanced as tolerated
Nausea and vomiting should be managed aggressively.
Monitoring And Discharge:
Close monitoring for signs of complications such as infection, bleeding, ileus, or recurrence
Patients are typically discharged within 1-3 days if pain is controlled, they are ambulating, and tolerating diet
Wound care instructions are provided.
Return To Activity:
Patients are advised to avoid strenuous activities and heavy lifting for 4-6 weeks
A gradual return to normal activities is guided by symptom resolution and surgeon recommendations
Full return to athletic activities may take longer.
Complications
Early Complications:
Bleeding
Infection (port site or mesh)
Seroma or hematoma formation
Ileus
Urinary retention
Pneumothorax (rare)
Mesh dislodgement or detachment.
Late Complications:
Recurrence of hernia
Chronic pain
Mesh infection or migration
Bowel obstruction due to adhesions
Granulomatous reaction to mesh or fixation devices.
Prevention Strategies:
Meticulous surgical technique to minimize tissue trauma
Appropriate mesh selection and secure fixation
Adequate fascial closure
Prophylactic antibiotics
Aggressive pain management and early mobilization
Careful patient selection and preoperative optimization.
Key Points
Exam Focus:
Indications for IPOM vs
other repair techniques
Mesh types and rationale for use in IPOM
Importance of fascial closure for recurrence prevention
Management of incarcerated hernias
Common complications and their management.
Clinical Pearls:
The success of rIPOM relies heavily on meticulous dissection, secure mesh fixation, and tension-free fascial closure
Preoperative CT imaging is invaluable for planning
Robotic platform advantages include enhanced visualization, tremor filtration, and superior instrument articulation for challenging closures and dissections.
Common Mistakes:
Inadequate mesh overlap
Insufficient fascial closure or tension on sutures
Premature port removal leading to trocar site bleeding
Misjudging the extent of adhesions
Failure to consider open conversion in cases of severe adhesions or bleeding.