robotic Rives procedure with Transversus Abdominis Release (TAR)

A 52 years old female underwent a complex post incisional robotic ventral hernia repair.The large defect (M3 M4 M5 Rn W2 L15cm) was due to a previous open hysteroannessectomy for carcinoma of the cervix .BMI was 32 with ASA score 2.Da Vinci Xi robotic platform was employed with bilateral 3 trocars setup.After complete lysis of all visceral adhesions the retromuscolar space was dissected up to the linea semilunaris with careful identification of the neurovascular bundles.The dissection was started at the level of the umbilicus towards the subxiphoid space and the pubis.The insufficient medial advancement of the posterior rectus sheath imposed a posterior component separation with TAR.The pre peritoneal plane was entered from within the rectus sheath incised about 0.5 cm medial to the linea semilunaris and the underlying transverses adbominis muscle was divided along its entire medial edge.The retromuscolar space was bluntly developed laterally and extended superiorly and inferiorly from the xifoid to the pubis.Once release was performed on both sides the anterior defect was reapproximated in the midline with a running barbed suture.A 20×25 Parietex mesh was employed for fenestrations in the trasversalis fascia fixed with 4 transfascial sutures and tacs in the retromuscolar space.The posterior rectus sheaths were reapproximated in the midline with a running barbed suture.Interrupted sutures were used.Closed suction drain was placed ventral to the mesh.The patient was discharged on postoperative day 4.

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