Robotic-Assisted Ventral Hernia Repair: Intracorporeal Primary Closure with Underlay Mesh Placement

Cheguevara Afaneh, MD, Rasa Zarnegar, MD. New York-Presbyterian Hospital/Weill Cornell Medical College

Introduction: In our short video, we describe our technique for a relatively novel approach for ventral hernia repair. In this video, we use the robotic platform to perform primary intracorporeal closure of a ventral hernia, followed by underlay mesh placement.

Case: Our patient was a 62 year old black female with no previous surgical history. She had a body mass index of 45.2 kg/m2 and an American Society of Anesthesiologist score of 2. She was positioned supine on the operating room table with both arms tucked at the side. She was prepped and draped in the usual sterile fashion and preoperative dose of a first generation cephalosporin was administered.

Technique: The Veress needle technique was used access the abdominal cavity and obtain pneumoperitoneum. A 12 mm optical camera port was placed lateral to the mid-clavicular line on the left. Two additional 8 mm ports were placed approximately 7 cm above and below the camera port. The robot is docked perpendicular to the patient. The hernia defect is first measured, which in this case was 5.5 cm in diameter, thus an 11 cm diameter mesh was used. We then primarily close the hernia defect using a 2-0 V-loc suture. We decreased the pneumoperitoneum to 8 mm Hg during this closure. Once the hernia defect is closed, the mesh is introduced into the abdominal cavity through the 12 mm port. We used a Ventralight^TM ST Mesh. An Endoclose device is introduced through the now closed hernia defect to position the mesh by pulling up on the balloon tubing device. The balloon is insufflated and now the mesh is held in place against the anterior abdominal wall. The pneumoperitoneum is now decreased to 6 mm Hg. The mesh is then fixated to the peritoneum using a 3-0 V-loc suture. Four 6 inch sutures were used to circumferentially secure the mesh. The sutures were then cut and the needles straightened prior to removal. The balloon was desufflated and the balloon insufflation system was removed. The 12 mm port fascia was closed and the remaining ports were removed under direct visualization. The total operative time was 96 minutes with minimal blood loss and no complications. The patient was discharged home the same day. After 1 month, she has had no complications and reports no pain.

Conclusion: This technique represents a novel way to both primarily repair and buttress a ventral hernia with underlay mesh. We have now completed a series of nine patients who have had either ventral or incisional hernias. We have had no complications to date and plan to proceed with a formal trial comparing this to the “hybrid” laparoscopic technique of primary closure with laparoscopic mesh underlay placement.