Robotic Extended-View Totally Extraperitoneal Transversus Abdominis Release (eTEP/TAR) Without Crossover for a Large Right Boundary Incisional Hernia

Vivek Bindal, FNB, Daksh Sethi, MS, Mukund Khetan, MS, Sudhir Kalhan, MS, Suviraj John, FNB, Rohit Dadhich, MS, B. Ramana, MS

Institute of Minimal Access, Metabolic and Bariatric Surgery, Sir Gangaram Hospital, New Delhi, India (Drs. Bindal, Sethi, Khetan, Kalhan, John, Dadhich).
Department of Minimally Invasive and Gastrosurgery, Apollo Gleneagles Hospital, Kolkata, India (Dr. Ramana).


Introduction: The enhanced-view totally extraperitoneal (eTEP) approach is increasingly being used to tackle large ventral and incisional hernias. We are presenting a case of robot-assisted eTEP with unilateral transversus abdominis release (TAR) without crossover through all midline ports for an open appendectomy site boundary hernia.

Materials and Methods: Patient presented with a large incisional hernia at the open appendectomy site. Contrast- enhanced computed tomography revealed disruption of linea semilunaris on right side, with a 12-cm defect having large bowel and omentum as content of hernia sac. We planned a unilateral eTEP approach without crossover. We performed a diagnostic laparoscopy to inspect the contents of the hernia sac by inserting a 5-mm port in the left subcostal region. The peritoneal cavity was deflated, and access was made in the retro-rectus space via right subcostal region using optical entry. Three ports were inserted on the right side on linea alba, in the retro-rectus space. Robotic system was docked, eTEP space developed, and right-sided TAR was done saving the neurovascular bundles. The posterior rectus sheath complex and anterior defect was closed using barbed sutures. A 20 􏰀 25-cm medium weight polypropylene mesh was placed.

Result: The operative time was 160 min and estimated blood loss was 50 mL. Postoperative stay in the hospital was uneventful and the patient was discharged on postoperative day 2. She is doing well at 9 mo followup. This case was unique as it was a unilateral eTEP/TAR without crossover, using robotic approach. We could not find any published report of similar approach of posterior component separation using robot.

Conclusion: Robotic eTEP/TAR is a safe and feasible approach to tackle large incisional hernias. Robotic system provides distinct advantages in dissection, identifying the planes and suturing in eTEP space.

Key Words: hernia, ventral hernia, incisional hernia, robotic hernia surgery, extended-view totally extraperitoneal, eTEP, eRS, eTAR, AWR, abdominal wall reconstruction.

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