Technical Feasibility of Robot-Assisted Ventral Hernia Repair

Nathan Allison • Ken Tieu • Brad Snyder •

Alessio Pigazzi • Erik Wilson

Published online: 23 December 2011

� Societe Internationale de Chirurgie 2011

Abstract

Background The da Vinci robotic laparoscopic incisional

hernia repair with intracorporeal closure of the fascial

defect and circumferential suturing of the mesh may offer

an alternative to current fascial closure and transabdominal

sutures and tackers.

Methods From 2009 to 2011, a retrospective review of 13

patients with a mean age of 51 years, median body mass

index (BMI) of 31.53 kg/m2, and small and medium-sized

ventral hernias (mean fascial defect 37.39 cm2) were treated

with the da Vinci robot system using intracorporeal primary

closure of the fascial defect with a running O-absorbable

suture followed by underlay mesh fixation using a continuous

running, circumferential, nonabsorbable suture. This study

aimed to assess the technical feasibility of the procedure. In

addition, the operating time and specific morbidity of post-

operative pain, and long-term recurrence were recorded.

Results The mean operating time was 131 min. There

were no conversions to open or standard laparoscopic

techniques. There were no postoperative deaths. The overall

morbidity rate was 13%. One patient remained in hospital

for pain control, and another experienced urinary retention

that required a Foley catheter. The mean hospital stay was

2.4 days. During a median follow-up period of 23 months,

one of the patients experienced a recurrent hernia. None

experienced chronic suture site pain or discomfort.

Conclusions This is a retrospective series review of

robot-assisted ventral hernia repair using intracorporeal

primary closure followed by continuous running, circum-

ferential fixation. The findings show that this technique is

feasible and may not be associated with chronic postop-

erative pain. Further evaluation is needed, and long-term

data are lacking to assess the benefit to the patient, but this

series can be the basis for future studies.

Introduction

Ventral abdominal hernia (primary or incisional) repair is a

common surgical procedure. About 90,000–100,000 repairs

are performed every year in the United States. There is a

reported incidence of 3% to 20% during the 5-year period

after laparotomy [1, 2]. The traditional ventral hernia repair,

using an open technique with a simple suture closure, was

associated with a high rate of wound complications second-

ary to large flaps in the abdominal wall layers, as well as

recurrence rates between 25% and 63% [3, 4]. The open

ventral hernia repair with prosthetic mesh using a tension-

free technique has lowered the recurrence rate to 10% to 40%

[4, 5], but it also increased the incidence of significant wound

complications, including mesh infections [6, 7]. Laparo-

scopic repair of incisional hernias was introduced in 1992

[8, 9], leading to improved recovery time, hospital stay,

complication rates, and cost. Published recurrence rates have

been reduced to 0% to 9% [10–13]. These recurrences have

been attributed primarily to improper positioning of the mesh

(with \3 cm overlap of mesh and fascia) and to the use of

tacking or stapling devices for fixation rather than abdominal

wall suturing using suture passers [13, 14].

The primary complications of laparoscopic ventral her-

nia repair are seroma formation, wound infection, ileus,

N. Allison � K. Tieu � B. Snyder (&) � E. Wilson

Department of Surgery, Health Sciences Center at Houston,

University of Texas, 6431 Fannin Street, Suite 4.294,

Houston, TX 77030, USA

e-mail: brad.snyder@uth.tmc.edu

A. Pigazzi

Division of Colon and Rectal Surgery, University of California

at Irvine, Irvine, CA, USA

123

World J Surg (2012) 36:447–452

DOI 10.1007/s00268-011-1389-8

and hematoma [10–13]. Although laparoscopic repair has

been associated with faster recovery, fewer complications,

and a lower recurrence rate compared to the open tech-

nique, there continues to be a significant incidence of

postoperative pain associated with the transabdominal wall

sutures. Several authors [2, 12, 15–17] have reported a 2%

incidence of significant postoperative pain lasting more

than 2–8 weeks after repair. Significant postoperative pain

has also been described in association with helicoid staples

and tackers. In three such cases, exploratory laparotomies

were required [2, 18]. Additionally, a randomized con-

trolled study showed a significantly higher pain level with

suture placement compared to tackers for mesh fixation

[19]. The pain is described by patients as a single point of

constant, sharp, burning in a dermatome pattern at the

points of transabdominal sutures or tackers; the pain has

been attributed to tissue and nerve entrapment. These

suture sites require a prolonged hospital stay, local injec-

tions, and occasionally readmission for pain control. In

addition, mesh fixation with tacking alone without trans-

abdominal sutures has been associated with higher recur-

rence rates [14, 20]. Nonetheless, with published data

showing recurrence rates equal to or less than the open

mesh repair, fewer complications, shorter operating times,

and decreased lengths of stay [16, 21, 22], it has become a

readily used tool in the general surgeon’s arsenal.

The da Vinci robot (Intuitive Surgical, Sunnyvale, CA,

USA) offers numerous advantages, including 6� of motion,

three-dimensional (3D) imaging, and superior ergonomics

that enable easy, precise intracorporeal suturing. Previous

reports have demonstrate the ease of intracorporeal sutur-

ing of the mesh to the abdominal wall [2]. We report a

novel technique in which the da Vinci robot is used to

suture the fascial defect closed primarily followed by cir-

cumferential fixation of the mesh. Two other reports of

robotic ventral hernia repair did not close the ventral hernia

primarily, nor did they employ a continuous running

suture; instead, they used interrupted sutures to secure the

mesh [23, 24]. We believe that closing the defect primarily

could significantly increase the overlap of the mesh, and

continuously running the suture increases the surface area

of the suture to the fascia. Together, these changes may

eliminate the need for transabdominal sutures or helicoid

tackers, which can cause significant postoperative pain

while maintaining, if not improving, the strength of the

repair.

Materials and methods

Between 2009 and 2011, we performed a retrospective

review of 13 patients who underwent robot-assisted ventral

hernia repair with intracorporeal, primary closure of fascial

defects with a running 0-absorbable suture, followed by

underlay mesh fixation using a continuous running, cir-

cumferential, nonabsorbable suture. Standard laparoscopic

ventral hernias were also performed during this time, but

were not directly compared in a prospective fashion. We

recorded the following data: age, sex, body mass index

(BMI), American Society of Anesthesiologists (ASA)

score, previous abdominal operations, size and number of

defects, type of suture used, size and type of prosthetic

mesh implanted including suture used for circumferential

suturing, operating time, length of hospital stay, hernia

recurrence, and duration of follow-up. An ASA score [3

and/or fascial defects [15 cm in any one dimension

assessed by clinical, radiologic, or diagnostic laparoscopy

were not repaired using the robotic technique, and therefore

are not reported here. Demographics and hernia details are

reported in Table 1.

The procedure is performed under general anesthesia;

and preoperative antibiotic is given less than 1 h prior to

the incision. In all cases, the bladder and stomach are

decompressed with catheters. An adhesive drape is used to

cover the patient’s abdomen; it also facilitates marking the

size, shape, and location of the fascial defect. The

abdominal cavity is accessed via an Optiview trocar

(Ethicon Endosurgery, Cincinnati, OH, USA) technique

typically in the right or left upper abdomen via a 5-mm

subcostal incision; the trocar is later exchanged for a

robotic 5-mm trocar. A 12-mm trocar is placed for the

camera and a final 5- or 8-mm robotic trocar is placed in

the lower abdomen (Fig. 1). These are placed in the lateral

abdomen under direct visualization as far lateral as possible

to maximize distance away from the fascial defect. Adhe-

sions are lysed via traditional handheld laparoscopic

instruments and camera if the adhesions are too close to the

camera and/or the trocars. At least 2 cm of space is

required for robotic instrumentation to be placed in the

abdominal cavity. This was done in six cases, adding and

average of 14 ± 9 min to these cases. That is, little

adhesiolysis was done using the laparoscope and traditional

laparoscopic instruments because it is our opinion that

adhesiolysis with robotics is technically superior. The robot

is docked to the patient immediately if adhesions are

nonexistent or a sufficient distance away to safely visualize

and move within the peritoneal cavity. All of the hernias

were repaired totally robotic.

A 10-mm Intuitive robotic camera positioned 30� up is

used. The adhesions are lysed with sharp and blunt dis-

section using limited electrocautery or ultrasonic devices.

Robotic instrumentation used for the adhesiolysis is typi-

cally 8-mm surgical shears. After reduction of hernia

contents, the peritoneal sac is generally left in place. The

hernia defect is measured, and an appropriately sized

prosthetic mesh designed for intraabdominal use is

448 World J Surg (2012) 36:447–452

123

prepared to overlap all margins of the defect or defects by

5 cm prior to primary closure of the fascial defect. Most

often, expanded polytetrafluoroethylene (ePTFE) mesh

(Gore-Tex DualMesh Biomaterial; W.L. Gore Flagstaff,

AZ, USA), Proceed mesh (Ethicon Endosurgery), or

recently Physiomesh (Ethicon Endosurgery) were used for

the repairs in this series.

The robotic arms are undocked from the trocars, and the

abdomen is desufflated completely. The outline of the mesh

is marked on the adhesive covering over the abdominal

wall. Superior (12 o’clock) and inferior (6 o’clock) are

marked for orientation on both the abdominal wall and the

mesh. A 0-Gore-Tex suture on a cardiovascular needle

(CV-0) needle is then tied to each of the points marked

superior and inferior to be used later for circumferential

suturing. The length of each suture is the full circumfer-

ence of the mesh. Pneumoperitoneum is then reestablished

and the 0-absorbable suture on a short half circle (SH)

needle and the mesh with the attached suture are then

placed in the abdomen via the 12-mm trocar.

The robot is then docked and the fascial defect closed

using the running 0-absorbable suture. Typically, this

suture is run from one end of the defect to the other and

then back again in a continuous fashion. The suture is

tightened periodically to remove any slack and afford

fascial approximation. Absorbable sutures are used so as to

not leave any unneeded permanent material in the fascia

that could cause chronic postoperative pain. We believe

that approximating the fascial edges allows us greater

overlap for the mesh and its fixation. Once the mesh is

fixated underneath the defect, there is little to no tension on

the primary repair and it should not open up. Nonetheless,

it is not our main concern if the primary closure does not

hold completely because there is an underlay of mesh to

prevent hernia recurrence. Simply put, the primary repair is

to allow greater overlap and additional security to the

repair.

Once the fascial defect is closed, the mesh is positioned

superiorly and inferiorly as it was outside the abdomen, and

a spinal needle is inserted at each marked point through the

abdominal wall for verification of correct placement.

A Gore-Tex suture already sutured to the 12 o’clock and 6

o’clock positions of the mesh is then used to circumfer-

entially suture the mesh to the abdominal wall taking care

to take bites of the posterior fascia with each pass. These

bites are full thickness through the posterior fascia and into

the abdominal wall musculature. While the musculature

does not add to the overall strength of the fixation, it is

Table 1 Demographics for the patients and operative characteristics

Age (years) Sex BMI(kg/m2) ASA Defect size (cm)a Mesh size (cm) Suture/mesh used

35 F 28.9 2 2 9 2 (12.56) 7.5 9 10 Gore-Tex dual mesh, Gore-Tex suture

61 F 27.3 3 6 9 8 (37.68) 10 9 12 Veritas, 0-Vicryl suture

59 F 29.8 2 5 9 5, 1 9 1 (22.98) 10 9 15 Gore-Tex dual mesh, Gore-Tex suture

53 F 33.27 3 15 9 8 (94.2) 25 9 12 Gore-Tex dual mesh, Gore-Tex suture

48 F 29.68 2 Multiple 10 9 30 Gore-Tex dual mesh, Gore-Tex suture

39 M 41.65 3 8 9 10 (62.8) 12 9 16 Gore-Tex dual mesh, Gore-Tex suture

54 M 33.7 3 5 9 5 (19.625) 10 9 15 Physiomesh, Gore-Tex suture

43 F 36.5 3 2 9 3, 1 9 2 (6.28) 10 9 15 Physiomesh, Gore-Tex suture

72 M 28.3 3 10 9 15 (117.75) 20 9 25 Physiomesh, Gore-Tex suture

57 M 29.9 3 5 9 2, 2 9 2, 1 9 1 (23.55) 15 9 20 Physiomesh, Gore-Tex suture

52 F 27 3 5 9 5 (19.625) 15 9 15 Parietex, O-Ethibond

51 F 36 3 6 9 4 (18.84) 15 9 15 Parietex, O-Ethibond

41 M 28 3 4 9 4 (12.56) 15 9 15 Parietex, O-Ethibond

BMI Body mass index; ASA American Anesthesiologists Association (score)a Numbers in parentheses are the measurement in square centimeters

Fig. 1 Ideal trocar placement for a robot-assisted ventral hernia

repair

World J Surg (2012) 36:447–452 449

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important to know that we are getting full-thickness bites

of the fascia. Care was taken not to take too big of a bite

through the muscle because it could cause undue pain with

little gain in repair strength. If the defect is below the

arcuate line, we obtained transversalis fascia with each

bite. The suture is then run circumferentially around the

entire mesh to secure it in place.

No transfascial or transabdominal sutures are placed. No

drain is used. The 12-mm trocar site is then closed with

absorbable suture using a Carter-Thomasson suture passer.

The pneumoperitoneum is released, and the skin is closed.

It is important to be familiar with the setup of the da

Vinci robot and to approximate the ideal placement of the

trocars to obtain the optimal range of motion for repair of

the largest ventral hernias. Depending on the location of

the ventral hernia, we try to position the robotic camera and

trocars as far away from the fascial defect as possible.

Considerations for port placement must be made to

accommodate the 3- to 5-cm overlap of mesh and fascia. In

general, a 10- to 15-cm circumferential circle can be drawn

around the edge of the fascial defect. The robotic trocars

can then be placed anywhere along the semicircle outline

so long as they are 8 cm apart from one another (Fig. 1).

As the external arms of the robot typically articulate down

with this repair, we find a docking approach over the head

or pelvis inadequate for arm movement. Optimally, we

keep the side of the bed elevated where the trocars insert to

ensure proper movement of the robotic arms. The cart

comes directly in line with the defect and the camera port

(Fig. 2). In addition, the trocars should be placed at the

most extreme lateral, cranial, and caudal positions that still

allow anterior work without interfering with the bed,

anesthesiologist, or bony prominences. The most lateral

possible position of the two instrument arms allow the most

range of motion and anterior abdominal wall suturing.

Results

All data are expressed as the mean ± SD unless otherwise

stated. All 13 patients underwent robotic-assisted ventral

hernia repair and were available for follow-up. All but one

of the fascial defects were closed primarily before the mesh

repair. All 13 patients were followed up in the clinic and

underwent a physical examination. Median follow-up time

was 23 months (range 2–33 months). Five had a BMI

[30 kg/m2, and the total population had a mean BMI of

31.5 ± 4.4 kg/m2. The median ASA score was 3 (range

2–3). All but two patients (86%) had had previous surgery,

but none had had previous attempts at hernia repair. Most

hernias were in or near the midline. Multiple defects were

found in five of the patients (33%). The mean fascial defect

size was 37.39 ± 35.6 cm2. Table 1 shows the maximum

horizontal and vertical dimensions of the defects. The

mean operating time was 131 ± 57 min, and console time

was 74 ± 36 min (range 42–143 min).

The mean length of hospital stay was 2.4 ± 1.1 days

(range 0.25–10.0). None of the patients required conversion

to an open or traditional handheld laparoscopic technique

after the initial trocar insertion. There were no mortalities.

One patient required a prolonged hospital stay (6 days) for

pain control, and one patient had both prolonged hospital

stay (10 days) for pain control and postoperative urinary

retention. As there was no comparative laparoscopic arm,

subjective patient pain scales and narcotic usage were not

measured specifically within the retrospectively reviewed

group. There were no seromas, prolonged ileus, or infec-

tions of the mesh or wound reported in this series. There was

one recurrence diagnosed by physical examination. It was in

the patient with a lumbar hernia that presented many diffi-

cult challenges with regard to port placement, patient

positioning, mesh placement, and fascial closure.

Discussion

With our technique for ventral hernia repair, we adopted

standard robotic port placement to develop the techniques

necessary to safely and successfully perform intracorporeal

suturing of the fascial defect and mesh fixation with cir-

cumferential fascial fixation. The da Vinci robot has

advantages over standard laparoscopy, including 6� of

freedom with the endowrist utilizing intraabdominal

articulations and true 3D imaging. Thus, this device is an

ideal tool for intracorporeal suturing of mesh to the pos-

terior fascia of the anterior abdominal wall for ventral

hernia repair. There is less abdominal wall trauma and

postoperative pain at the working trocars ports as the ful-

crum is not entirely at the abdominal wall but the endowrist

of the instruments.Fig. 2 Robot is docked directly across from the camera and in line

with the center of the hernial defect

450 World J Surg (2012) 36:447–452

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Whereas previous reports have confirmed the need to

suture the mesh at 2- to 5-cm intervals [12–14] as a means

of reducing the recurrence rates associated with laparo-

scopic hernia repairs, we believe that continuous circum-

ferential suturing applies those principles while evenly

distributing the tension throughout the mesh. Our technique

places the approximated fascial defect edges in the middle

of the mesh, maximizing the overlap of the mesh.

Transabdominal sutures and tackers have been directly

related to severe postoperative pain that lasts for months

[11–13, 18, 25]. In our experience, the major source of pain

has not been tackers as much as transabdominal sutures.

Our technique for the robot-assisted laparoscopic repair of

ventral hernia using intracorporeal suturing allows stable

suture fixation under direct visualization and eliminates the

need for tackers because a running suture is used for cir-

cumferential fixation. The entire repair is performed under

direct visualization, with precise placement and confirma-

tion of depth into the posterior fascia for all sutures placed.

The fascial sutures encompass 1-cm bites of fascia, mini-

mizing trauma to the abdominal wall.

Intracorporeal suturing of the fascia allows the midline to

be reapproximated, allowing possible primary repair, more

physiologic abdominal wall movement, and greater overlap

of the mesh to the defect’s fascial edges. Robot-assisted

laparoscopic ventral hernia repair offers yet another

advantage by providing the suturing option under excellent

visualization for the repair of difficult hernias with bony or

muscular margins, such as lumbar, suprapubic, and sub-

costal hernias. Several of our patients had hernias on or near

lateral borders of the abdomen, making mesh fixation with

tackers difficult. This allows the surgeon to take precise

bites of tissue to anchor the mesh repair.

Limitations of this robot-assisted technique are obvious.

Large ventral hernias as they approach the working ports

and camera, make this technique technically challenging.

In addition, obese patients pose a challenge preoperatively

because it may be difficult to determine the ideal trocar

placement.

Conclusions

We report robot-assisted laparoscopic incisional hernia repair

with exclusive intracorporeal closure of the fascial defect and

continuous circumferential suturing for mesh fixation. The

findings show that this technique is feasible and may reduce

postoperative pain by eliminating transfascial sutures. Fur-

ther evaluation is needed, and long-term data are lacking to

assess the benefit to the patient, but this series can be the

basis for future studies. We will conduct a randomized pro-

spective trial to compare robotic versus laparoscopic ventral

hernia repair where operating time, hospital stay, objective

measurements of postoperative pain, chronic pain, and hernia

recurrence are measured. A study such as this would be more

appropriately poised to answer the question: Is a robotic

ventral hernia repair any better than a laparoscopic repair? In

addition, the added cost of robotics is a serious concern in our

current health care environment. Any future comparative trial

must make a sincere effort to obtain the cost comparison of

these techniques and should define a justification for using

the more expensive equipment.

Conflict of interest Drs. Erik Wilson and Brad Snyder have

agreements with Intuitive Surgical for contract fees when giving

national and international robotic lectures or proctoring other sur-

geons for credentialing of robotic privileges. In addition, the mini-

mally invasive fellowship at the University of Texas is partially

funded by Intuitive Surgical, Ethicon Endosurgery, and Gore. This

work is independent of any of these industries, and no endowments

were provided for this manuscript.

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