The abdominal cavity is accessed right or left upper abdomen via a 5 mm subcostal incision and is later exchanged for a robotic 5 mm trocar. A 12 mm trocar is placed for the camera, and a final 5 or 8 mm robotic trocar is placed in the lower abdomen. These are placed in the lateral abdomen under direct visualization as far lateral as possible to maximize distance away from the fascial defect.

The robot is docked to the patient immediately if there are no adhesions or there is a sufficient distance from the adhesions to safely visualize and move within the peritoneal cavity. A 10 mm Intuitive robotic camera positioned 30° up is used. The lysis of adhesions is performed with sharp and blunt dissection using limited electrocautery or ultrasonic devices. Robotic instrumentation used for the adhesiolysis is typically the 8 mm monopolar shears. After reduction of the hernia contents, the peritoneal sac is generally left in place. The hernia defect is measured, and an appropriately sized prosthetic mesh designed for intra-abdominal use is prepared to overlap all margins of the defect or defects by 5 cm prior to primary closure of the fascial defect.

If the defect is midline, the robot can be docked at 90° to the bed from the opposite side of the trocar placement. If the defect favors a particular side, the robot is docked from that side with trocars placed on the opposite side as the defect. It is important to be familiar with the setup of the da Vinci Robot and to approximate the ideal placement of the trocars so as to obtain the optimal range of motion for repair of larger ventral hernias. Depending on the location of the ventral hernia, all efforts should be made to position the robotic camera and trocars as far away from the fascial defect as possible. Considerations for port placement must be made to accommodate the 3–5 cm overlap of mesh and fascia. In general, a 10–15 cm circumferential circle can be drawn around the edge of the fascial defect. The robotic trocars can then be placed anywhere along the semicircle outline as long as they are 8 cm apart from one another along a perpendicular line to the axis of the robot and the hernia (see Fig. 28.2).

As the external arms of the robot typically articulate down with this repair, a docking approach over the head or pelvis will be inadequate for arm movement. Optimally, one should keep the side of the bed elevated where the trocars insert to insure proper movement of the robotic arms. The cart comes in directly in line with the defect and the camera port. Also, a utility port should be placed at the start of the operation for delivering the mesh into the abdomen; however, a utility port is not necessary for most patients. The location of the robot cart must also accommodate the bed, anesthesiologist, and bony prominences, such as the shoulder and anterior superior iliac spine, which may limit the range of motion. In addition, the trocars should be placed at the most extreme lateral, cranial, and caudal positions that will still allow anterior work without interfering with the bed, anesthesiologist, and bony prominences. The most lateral possible position of the two instrument arms will allow the most range of motion and anterior abdominal wall suturing. The extremes for instrument length must also be considered prior to trocar placement. The current da Vinci instruments have a 34 cm reach; however, close proximity to trocars and camera, especially in smaller, lower body mass index patients, is the most common difficulty.

The fascial defect is typically closed using the running 0-absorbable suture (see Fig. 28.3). Typically this suture is run from one end of the defect to the other and then back again in a continuous fashion. The suture is tightened periodically to remove any slack and afford fascial approximation. The use of absorbable sutures is to not leave any unneeded permanent material in the fascial that could cause chronic postoperative pain. We feel that approximating the fascial edges allows us greater overlap for the mesh and its fixation. Once the mesh is fixated underneath the defect, there is little to no tension on the primary repair; therefore, there is less concern about tension on this repair than if this would be a primary repair alone. Nonetheless, it is not our main concern if the primary closure does not hold completely or not since there will be an underlay of mesh to prevent the hernia recurrence. Simply put, the primary repair is to allow greater overlap and additional security to the repair.

Once the fascial defect is closed, the mesh is positioned superiorly and inferiorly as it was outside the abdomen, and a spinal needle is inserted at each marked point through the abdominal wall for verification of correct placement. A strong, permanent suture already fixated at the 12 o’clock and 6 o’clock positions of the mesh is then used to circumferentially suture the mesh to the abdominal wall taking care to take bites of the posterior fascia with each pass (see Fig. 28.4). These bites are full thickness through the posterior fascia and into the abdominal wall musculature. While the musculature does not add to the overall strength of the fixation, it is important to know that full-thickness purchases of the fascial are being obtained. Care must be taken not to acquire too big of a bite through the muscle because this may cause undue pain with little gain in repair strength. If the defect is below the arcuate line, one must obtain transversalis fascia with each bite. The suturing is started at the 12 o’clock position on the mesh, run to the 6 o’clock position, and then back to the 12 o’clock (see Fig. 28.5). It is easiest to start on the side of the mesh that is furthest away from the camera. That is, if your ports are on the patient’s left side, the entire right side of the mesh is sewn first. Once the suture from the 12 o’clock position is run to the 6 o’clock position and tied to the next suture, the left side of the mesh, closest to the camera, is run back up to the 12 o’clock position and tied to itself. The suture is kept loose so as not to tighten the mesh closely against the abdominal wall until the opposite suture is again started in a similar manner.

No trans-fascial or transabdominal sutures are placed. No drain is used. The 12 mm trocar site is then closed with absorbable suture using a suture passer, pneumoperitoneum is released, and the skin is closed.

The robotic assisted ventral hernia repair should be considered a hybrid technique unless the hernia is a primary defect with no adhesions or contents to reduce. In this case, all sutures and mesh can be placed before docking and the case can be completed with one dock. It may be necessary at times, however, to perform lysis of adhesions laparoscopically or robotically and close the defect, at which time the robot is undocked to assess the size and shape of mesh to be used on the defect. In these particular cases, the arms are simply lifted off the trocars for measurement and placement of the mesh. The robot does not need to be moved away from the bedside.