In this video, Mazen Iskandar, MD, FACS, FASMBS, narrates as he performs a Robotic incisional hernia repair post ALIF (eTEP, bilateral transversus abdominis release).
The imagery of surgical hernia repair appears in this video.
Transcript of Surgical Procedure
Case Overview
Presenting a case of a robotic incision hernia repair after anterior lumbar interbody fusion. The approach was an eTEP with bilateral TAR. The patient is a 63-year-old male, normal BMI, who had an L4-L5 and L5-S1 ALIF 4 months prior and developed a bulge. You can see on the CT scan he had a 10-centimeter wide defect.
Considerations in Post-ALIF Hernia Repair
Some of the nuances of post-ALIF hernias include that the left preperitoneal and retromuscular spaces are usually accessed to avoid the IVC on the right side. In L5-S1 cases, there is typically no disruption of the posterior rectus sheath above the arcuate line. In L4-L5 and higher, PRS release is more common. Pain management can difficult sometimes due to chronic pain. On the other hand, most patients are optimized preoperatively for the ALIF.
Right Retromuscular Space Access and Crossover
We obtained access to the right retromuscular space using optical entry. After dissecting the right space and placing trocars, we initiated crossover into the left retromuscular space. Here we are showing the incision of the posterior rectus sheath on the left side. We then reached the hernia defect. There was also an umbilical hernia. Dissection of the hernia sac showed the defect was slightly left-shifted.
Left Retromuscular Space Dissection and Hernia Sac Release
We continued releasing the posterior rectus sheath and omental adhesions to the sac. These adhesions were slightly inflammatory due to the recent spine surgery. Dissection of the left retromuscular space continued, connecting it with the preperitoneal space. We dissected the space of the Retzius and the space of the Bogros on the left side, taking down the final attachment of the posterior rectus sheath.
Preservation of Inferior Epigastric Vessel and Dissection Plane
The inferior epigastric was scarred and adherent to the posterior rectus sheath. We carefully preserved it and dissected between it and the sheath, which is the proper plane for reaching the space laterally. We then visualized the previously dissected TAR plane and used sharp, and blunt dissection to continue in that space.
TAR Plane Development and Adhesion Management
We completed dissection and release of the epigastric. Below the umbilicus, there was no posterior rectus sheath left. Despite some inflammatory adhesions, the plane developed well. We began the TAR in the left upper quadrant, using a bottoms-up approach, aiming to connect it with a top-down approach. We incised the posterior lamella of the internal oblique and transverse abdominis muscle.
Completion of Left and Right TAR
We continued releasing the posterior lamella of the internal oblique. This included the last intact part of the posterior rectus sheath at or just above the belly button. We transitioned from scarred to virgin tissue and dissected laterally, placing contralateral trocars for the right TAR. On the right, we initiated a bottoms-up TAR, releasing adhesions between the pre peritoneal fat and transversalis fascia and incising the posterior lamella of the internal oblique. The TAR was completed in the upper abdomen with subxyphoid dissection.
Closure and Mesh Placement
After completing TAR, we re-approximated and closed the posterior rectus sheath. We closed the defect and anterior fascia using #1 symmetric stratafix sutures, placing as many as possible and cinching them sequentially. A 35×30 cm medium-weight macroporous mesh was deployed, ensuring it lay flat and fully covered the space.
Postoperative Outcome
This is an image of the incisions at 10 days post-op. The patient later presented to the ED with abdominal pain. A follow-up CT scan showed an intact repair and a small seroma. Thank you for watching.
