Combo Robotic eTEP Recurrent Incisional Hernia Repair with Spine Access for L4-L5 ALIF Video


Transcript of Narration

Presenting a robotic eTEP recurrent incision hernia repair in combination with spine axis for an L4-L5 anterior lumbar interbody fusion ALIF.

So this is a patient who had a recurrent hernia following colectomy. The hernia was 5 cm and was below a previously placed mesh. We obtained access to the… Given that we normally do spine access for L4 or L5 from the left side to avoid the IVC, we planned on a right-sided eTEP with three trocars at the semi lunar line, as well as a pre-costal axis, which is later used as an assistant trocar. Also, the patient had a left lower quadrant colostomy.

Right side, in order to have good visualization of the retroperitoneal axis, that’s going to be done over on the left side. The patient had quite a bit of adhesions into the retromuscular space related to previous mesh fixation. The literature is very useful in those instances. You can see here some mesh fixation sutures. After the docking on the right side, we have incised here the right posterior rectus sheath and entering the prepared needle space behind the falsiform and identified the contralateral left-sided posterior rectus sheath and will incise and enter the left posterior rectus sheath.

One of the challenges was mobilization of the previously placed mesh. And here we are taking some adhesions into the preperitoneal space and reducing the lower hernia and incising the left posterior rectus sheath. Then the hernia contents which mostly contained omentum and preperitoneal fat were completely mobilized and reduced. And we proceeded with the vision of the posterior rectus sheath. Here is the patient’s previous colostomy site where there is a defect in the posterior rectus sheath which will be reconstructed at the end of the dissection.

We then proceeded with developing the left space of Bogros and posterior rectus sheath release, similar to a bottoms up TAR. We would want to release the posterior rectus sheath to the lever of L4-L5 which had been marked using fluoroscopy at the beginning of the case. Similar to a TAR again, very similar dissection here. And then entering the correct plane here in front of the psoas, the idea was to try to mobilize as much as possible, given the patient’s central obesity and to minimize the amount of dissection needed in a small hole and to minimize the length of the incision that was needed.

This exposure won’t allow us to reach the spine unless the patient is in a lateral position. But we were able to complete a good amount of dissection, which greatly facilitated the exposure once we made our lower abdominal incision.

Here I’m just showing some pictures of the setup that we had. We had a large room that had all the spine instruments and the robot. And as you can see here, we placed the cage between L4 and L5. On the right side, you can see the cage behind the left common iliac. And then using that incision, we placed a 30 by 18 centimeter medium-weight polypropylene mesh into the retromuscular space. Thank you for watching.

Posted on March 12, 2024

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Dr. Iskandar, MD, FACS is a board-certified general surgeon with fellowship training in minimally invasive surgery and bariatric surgery. He is an accredited Surgeons of Excellence in Hernia Surgery by the SRC. The Iskandar Complex Hernia Center is one of only two North Texas Hernia Centers deemed Centers of Excellence. As a globally respected complex hernia expert, he specializes in complex hernia repair and abdominal reconstruction. He is also an Associate Professor of Surgery at Texas A&M School of Medicine.