2.1 Patients’ inclusion
A retrospective search on a prospectively collected dataset was performed to identify patients treated for primary or incisional hernias of the epigastric region with a robotic-assisted approach over a 2-years period, from April 2018 to March 2020. Epigastric hernias were defined as bulges situated above the transverse umbilical line within the rectus abdominis space.
The dataset included demographic and clinical records such as age and sex, past medical history, hernia etiology, symptoms, dimension of the hernia and the mesh, operative times, conversion rate, length of hospital stay and complications (Table 1).
Descriptive statistics were presented as absolute frequencies and percentage for categorical variables and median with interquartile ranges (IQR) for continuous variables.
2.2 Surgical technique
The patient is in supine position, the adjustable lower section of the table is bent to some degrees in order to avoid conflicts between the thighs and the robotic camera and instruments. The pneumoperitoneum is established inserting a Veress needle into the left upper abdomen under the costal margin.
Afterwards, three 8 mm trocars are inserted in the suprapubic area, ideally 8 cm distant from each other on a straight line, whereas, in patients with a narrow pelvis the distance can be reduced to 6 cm and the two lateral trocars can be placed somewhat cranially (Figure 1).
It is recommendable to first insert one of the lateral trocars to avoid struggle due to the median umbilical fold and a thick preperitoneal fat tissue. Once the first trocar has been placed, the other two can be inserted under camera view. The robot Da Vinci Xi is docked from the right side, the camera is used 30° up, bipolar forceps and hot shears are introduced.
The hernia defect can now be evaluated. The transverse peritoneal incision, respectively peritoneum and posterior rectus sheath in case of sublay mesh placement, should be made at least 5 cm caudally the inferior hernia border in order to ensure a proper mesh overlap.
When choosing a preperitoneal mesh repair, it is useful to dissect leaving the preperitoneal fat adherent to the peritoneum, that would otherwise tear. The hernia sack is reduced and, once dissected the preperitoneal plan at least 5 cm in all directions around the hernia defect, the fascia is closed with a continuous suture using a V-Loc 0 (Covidien).
After being cut to the required size and shape to cover the hernia defect as above described, the mesh is rolled and a knot is placed in its middle. After insertion, the rolled mesh is placed along the cranial line of dissection, fixed with one stitch (Vicryl 3-0) and then enrolled from the distance to the camera. The mesh is finally fixed to the anterior wall with further 3 Vicryl 3-0 stiches and the peritoneum is closed with a continuous suture using V-Loc 3-0.
When choosing a sublay mesh repair, the transverse incision is so made, that the peritoneum and posterior rectus sheath are prepared “en bloc” from the rectus muscle on both sides. In the midline, the preperitoneal fat is left adherent to the peritoneum. After the reduction of the hernia sack, the sublay space is dissected at least 5 cm in all directions around the hernia defect. Fascia closure, mesh shaping, introduction and fixation resemble those of the preperitoneal technique. To close the transverse incision, the continuous suture with V-Loc 0 incorporates the peritoneum and the posterior rectus sheath together. Video 1.