Robot-assisted Treatment of Epigastric Hernias With a Suprapubic Approach

Supplemental Digital Content is available in the text. Background: Robot-assisted ventral hernia repair has shown itself to be feasible and safe in abdominal wall surgery. Presently, the ports are placed laterally to meet the distance from the fascial defect. The aim of our study is to report our experience of epigastric hernia treatment with trocar insertion in the suprapubic region. Materials and Methods: On a prospectively collected dataset on robot-assisted surgery, patients treated for epigastric hernias with suprapubic approach were identified. Demographic and clinical data were collected and analyzed. Results: Twelve patients were selected. Median age was 58.5 years [interquartile range (IQR): 47.8 to 67.3 y]; 4 patients were male (33.3%) and the median body mass index was 23.9 kg/m2 (IQR: 22.3 to 26.2 kg/m2). All patients were referred to surgery because of pain. The median measure of the hernia defect was 30 mm (IQR: 13.75 to 31.0 mm); median larger mesh diameter was 13.5 cm (IQR: 9.5 to 15.0 cm); and median operative time was 136.5 minutes (IQR: 120.0 to 186.5 min). No intraoperative complication or conversion to open surgery occurred. Postoperatively, 2 patients presented a seroma and median length of hospital stay was 2.0 days (IQR: 1.75 to 3 d). No case of hernia recurrence was recorded at a mean follow-up of 11.2 months (range: 4 to 29 mo). Conclusions: In the robot-assisted treatment of hernias of the epigastric region, a suprapubic port placement can be considered instead of a lateral one to have a better field overview, especially in subxiphoid hernias. Further studies are needed to assess the benefits and limitations of such technique.

R obotic ventral hernia repair has shown itself to be feasible and safe in abdominal wall surgery. 1 Presently, the port placement depends on the location of the defect and on the surgeon's experience. In most described techniques, the trocars are placed in the lateral abdomen to meet the distance from the fascial defect. [2][3][4][5][6][7][8] In this work, we describe our experience with trocar insertion in the suprapubic region when treating hernias of the epigastric region.

MATERIALS AND METHODS
Written nonopposition consents were administered to all patients. The local ethics committee approved the study (Comitato Etico Cantonale Ticino n. 2019-01132 CE3495).

Patients' Inclusion
A retrospective search on a prospectively collected dataset which included all robot-assisted operations carried out at our institution over a 2-year period, from April 2018 to March 2020, was performed. Applied selection criteria were presence of primary or incisional epigastric hernias, defined as hernias located from 3 cm below the xiphoid till 3 cm above the umbilicus according to Muysoms et al, 9 and treated with a robot-assisted suprapubic approach. No exclusion criteria were applied.
The dataset included demographic and clinical records such as age and sex, body mass index, smoking status, medical history, hernia etiology, symptoms, dimension of the hernia and the mesh, operative times, conversion rate, length of hospital stay, complications, and length of follow-up.

Surgical Technique
The patient is in supine position; the adjustable lower section of the table is bent to some degrees 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 2 lateral trocars can be placed somewhat cranially (Fig. 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 2 can be inserted under camera view. The robot Da Vinci Xi (Intuitive Surgical) is docked from the right side, the camera is used 30 degrees up, bipolar forceps and hot shears are introduced.
The hernia defect can now be evaluated. The transverse peritoneal incision, respectively the peritoneum and the posterior rectus sheath in case of sublay mesh placement, should be made at least 5 cm caudally to the inferior hernia border to ensure proper mesh overlap.
When choosing a preperitoneal mesh repair, it is useful to dissect leaving the preperitoneal fat adherent to the peritoneum, which would otherwise tear. The hernia sac 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 nonreadsorbable barbed suture.
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 3-0 polyglycolic acid stitch, and then enrolled from the distance to the camera. The mesh is finally fixed to the anterior wall with further three 3-0 polyglycolic acid stiches and the peritoneum is closed with a continuous suture using a 3-0 readsorbable barbed suture.
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 and the linea alba is left anteriorly, in continuity with the anterior rectus fascia. After the reduction of the hernia sac, 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 resorbable barbed suture incorporates the peritoneum and the posterior rectus sheath together (Video 1, Supplemental Digital Content 1, http://links.lww.com/SLE/A283).

Statistics
Descriptive statistics were presented as absolute frequencies and percentage for categorical variables and median with interquartile ranges (IQRs) for continuous variables.
The median measure of the hernia defect was 30 mm (IQR: 13.7 to 31.0 mm); the median larger diameter mesh was 13.5 cm (IQR: 9.5 to 15.0 cm); the median mesh area was 135 cm 2 (IQR: 72 to 199 cm 2 ); and the median operative time was 136.5 minutes (IQR: 120.0 to 186.5 min). No intraoperative complication occurred and no conversion to open surgery was required.
Postoperatively, 2 patients presented a seroma. One of them was treated with a 1-step needle aspiration and the other one resolved spontaneously. Only 1 patient had prolonged postoperative pain, which required analgesics and resolved within a month after the operation. The median length of hospital stay was 2.0 days (IQR: 1.7 to 3.0 d). No case of hernia recurrence was recorded at a mean follow-up of 11.2 months (range: 6 to 29 mo). Details are reported in Table 1.

DISCUSSION
Since the first report on laparoscopic ventral hernia repair in 1993, 10 the video-assisted approach in the treatment of ventral hernias has gained attention to achieve an ideal abdominal wall reconstruction with the advantages of minimally invasive surgery.
The arguments speaking for the laparoscopic approach are mainly lower postoperative pain, shorter hospitalization, and faster recovery after surgery. [11][12][13][14] Consequently, laparoscopic intraperitoneal onlay mesh repair has become a popular surgical technique for the treatment of ventral hernias. With the increasing popularity of robotic surgery, many techniques have been described to combine the benefits of open hernia surgery and minimally invasive approach. 15 In fact, thanks to the robotic 3-dimensional visualization and instrumentation, maneuvers as component separation, fascial closure, mesh suturing, and, if needed, transversus abdominis release are technically feasible and safe, so that a preperitoneal or retromuscular hernia repair with mesh placement is achievable also in minimally invasive surgery.
Since the first report of robot-assisted modified Rives/ Stoppa for the treatment of midline hernias in 2012, 16 several further series have been published. [2][3][4][5][6][7][8][17][18][19][20][21][22][23] When the port placement sites are described, the trocars are inserted quite lateral through the abdominal wall, to enable the necessary working space and, in large hernias, perform a double-docking. Only Sharbaugh et al 7 describe an "inferior port placement" for the treatment of epigastric hernias. However, in robot-assisted colon surgery, the suprapubic approach has already been extensively described for complete mesocolic excision in right colectomy. [24][25][26][27] Finally, it is worth mentioning the work by Costa et al 28 about the laparoscopic treatment of midline hernias with defect closure and retromuscular mesh placement through a suprapubic port placement.
In our study, we report on 12 patients affected by hernias of the epigastric region who were successfully treated with robot-assisted abdominal wall surgery inserting the ports in the suprapubic region. Two postoperative complications occurred, namely 2 cases of seroma. One was managed conservatively and one required drainage but symptoms resolved in both cases after few weeks. At our institution, we systematically applied the International EndoHernia Society (IEHS) guidelines to choose proper mesh sizes. 15,29 Mesh radius/hernia radius is recommended to be at least 4× 15 and in our series it ranged from 2.7× to 5.1×. Two patients with concomitant epigastric and umbilical hernias required oversized meshes to cover both defects. One patient in 2018 was treated with a 10 cm mesh for an 8 mm hernia as the recommendations of 5 cm overlap from 2014 were applied. 29 Regarding the median length of hospital stay which was 2 days in our series, patients with small hernia defects were planned to stay overnight, while those with several comorbidities and larger defects stayed in hospital for 3 to 4 days. Once reached a proper level of experience, it will be feasible to manage patients with small defects as day cases to also reduce hospital costs. 30,31 Finally, after a mean follow-up of 11.2 months no cases of recurrence were recorded.
In our experience, as we switched from the lateral to the suprapubic approach, we observed some advantages. First, the orientation of the surgical field is modified and, in our opinion, enhanced having the linea alba over the midline of the camera (Fig. 2). In case of subxiphoid hernias, the dissection of the preperitoneal space under the diaphragm is pretty facilitated, so that a proper mesh overlap can be   cranially achieved (Fig. 3). The main topic is of course the lateral overlapping in large hernias, which leads to a doubledocking. Through the suprapubic approach, the side view of the operative field is so enlarged that a broad mesh can be placed with a single-docking. Finally, we find that the esthetic side of the suprapubic port placement can be interesting in young patients affected by a primary hernia. Unfortunately, the suprapubic approach has a major limitation. Hernias of the lower abdomen cannot be treated. In our series, we operated on 3 patients with combined epigastric and umbilical hernias. However, when the defect reaches a few centimeters below the umbilicus, the distance between the ports and the transverse incision starts to get limited and the technique becomes less feasible.
This study has many limitations. In fact, we present a retrospective case series with a small number of patients and inherent bias. Nevertheless, we thought it would be interesting to share our experience and remarks about this technique, whose benefits and limitations should be further investigated in large trials.

CONCLUSIONS
In the robot-assisted treatment of hernias of the epigastric region, a suprapubic port placement can be considered instead of a lateral one to have a better field overview, especially in subxiphoid hernias. Further studies are needed to assess the benefits and limitations of such technique.