Chapters Transcript Video Video session — Robotic TAR and eTEP - Cheguevara Afaneh, M.D. next, we're gonna move into tars and eat steps. Um, go a little bit about my approach. Um, traditionally, these are done with the double dock technique. We go in with the various needle if we're gonna go in prepared to Neil, um, and we'll put in three trow cars on one side. Those initial three trow cars are all eights on the robot. Um, and then when we dock on the contra lateral side, we'll put in our 12, and that's what we're going to need any way to get in a large piece of mesh for these types of cases? Um, the reason we put the 12 on the contra lateral side is at that point, the posterior fascia is already dropped down. So there's only a 12 millimeter incision in the anterior fashion, not the posterior fashion patients are placed supine. We do tuck the arms, and it is a double dock technique. Most of the time, the instrumentation is pretty simple. Administrative bipolar life, some adhesions with the scissors, Um, sometimes the vessel sealers needed, um, sometimes a grasshopper is needed, but more often than not, it's just too large needle drivers. So I'm pretty simple from an instrumentation standpoint. Usually it's about 44 instruments, and, um, two of them are pretty cheap. Futures are gonna be the locks. For the most part, Vike rolls to close the ports sites to avoid, um, interstitial hernias. Like Dr Goldblatt showed you earlier. And so, um, the way sort of the start is, uh, in sizing right on the edge of the defect right there. This is a patient with the other Danlos syndrome who had a small bowel resection by one of my partners three weeks post op bear down on the toilets, um, and essentially blew out her incision and really sort of opened right back up. So in size, right at the edge. There, we make sure that we maintain the rectus muscle above us. Um, and the posterior sheath is right below us. Um, this patient, um, at least in lost the way she has a history of morbid obesity. She duodenal switch, um, in the past. So, uh, from a B. M. I standpoint was pretty favorable. Um, from that standpoint, what she had just had done was a, uh She had an incarcerated Sorry. She had a internal hernia from an adhesion that led to some intestinal ischemia that was respected, sort of with a lap slash open approach. Found the bow. They delivered it through a peri umbilical incision. Um, and then they ended up extending it to a lower midline. In that sort of what blew out from that standpoint, you can already sort of tell her post your sheath on this side looks a little thin right at the edge of the actual hernia itself or fashion decent, whatever you wanna call it at this stage of healing. Um, but you want to try to maintain as much of either the hernia, sac or the edge. You really want to start and give yourself more tissue, not less. So you have no chance of not closing. So that post your layer coverage is more important. You've already sort of seen, um, some Tar videos already, but we're sort of in sizing. Here's our, uh, neurovascular bundle right here. There's that nerve that we've sort of talked about preserving or open up the paper neuroses here, and then we're gonna end up, um, taking the muscle, then sort of sweeping it. Lateral sweeping, it lateral. I find it's a lot easier to start the Maya fashion release as high as possible because it's more consistently located. Um, it's more medial. Uh, it's a little easier to get to and sort of get my bearings at that point. And then, um really sort of get in there with the scissors. We usually crank it up to about six or seven on a forced co AG on the robot. And then, um, get underneath there, as you can see, sort of like the same technique that Fisher showed you using the right angle and sort of lifting it up that way. You really could just sort of switch hands. Um, which hand you put in the scissors? Um, when you do the contra lateral side Mhm. And here we're just gonna sort of connect the planes. Um, and now we sort of got to argue it. Line at that point there, which case? It becomes really attendant. Sort of, um, as as has been said earlier today. We end up then closing the post of your sheath. We you can tell that you've done an adequate release on the robot when the post your sheath is just sitting right on top of the bow. You know, there's sort of no tension at this point. It's just all sitting tension free on top of the bow. Um, and then you can just take a 12 inch, zero Villach future and run it closed. You can see that this is going to come together. No problem whatsoever. Um, and this is just sort of run close here. Well, uh, sometimes more often than not, take a second seizure. Even if it's just six inch run it from top to bottom, Let them meet, um, somewhere. Um, not necessarily in the middle. Um, but just so that we have something to tie to. You don't necessarily need to tie the Villach future. Um, but, uh, just to be sort of conservative with it, we don't want to risk. Um, you know any of this unraveling, so we'll usually tie them together if we have so much, uh, leftover 12 inch future will run it back on itself. Um, for probably a good 345 centimeters. Then if we're not gonna end up tying it, and here, we're going to sort of finish the closure. This is a case where we did just a unilateral release. We didn't do a bilateral release, and you can see there's probably a little bit more attention, um, than the previous closure. We just sort of showed you, Um, but it seemed like as we sort of dropped the new Mo things were still coming together. Okay, you can see, uh, slightly more attention than the previous one, but it still doesn't seem like it's pretty tense. Yeah, let's if you find that it's really sort of floating a bit too high, then you know that there's probably a little bit too much attention. Um, you want to be careful and look to make sure there's, uh, no little holes that you missed. Um, usually, if it's just a couple of millimeters, you don't need to close those, Um, but anything more than three or four millimeters, you should probably close. Um, if you can just incorporate it in your post your fashion closure. That's great. Um, but if not, um, then just get a separate Future can be something absorb all if you want and just sort of close it. And that's so you don't end up with a little loop of bowel sort of stuck in those little holes. That was the neurovascular bundle. But the idea here is sort of really preserving them. Sometimes you end up needing to take one because of how the mesh is gonna sit. Um, and you don't want to mess to sort of fold up, but really take the time to sort of identify these Getting a fast forward, This one. Since we've seen a few of these, um, this is me just highlighting to try to take the tension off the interior closure. Sometimes you'll actually mobilize, um, the sub Q off of the anterior fascia. Um, what you can do is pull the trow cars. When you do the dock on the contra lateral side, you can pull the trio cars into the sub Q and start the dissection from the sub Q to mobilize some of the anterior fascia and that'll make the closure a little bit easier. Here, you can see there's a neurovascular bundle and the trans verses of Dominus is exposed there. I'm just going to fast forward a little bit here. Here. We're just sort of taking these fibers and then we're sweeping them away from us right there and come underneath with the scissors and just come up. This is the contra lateral side here. It's, um we routinely take off the hernia sac. When we do these, we will use the scissors and just sort of take it off. We'll be a little careful once we get close to the skin. Um, last thing we wanna do is have a burn at the skin. And if that's the case, we just completely excised that piece of skin putting constituents never really worked that well for us in our experience. And so we'll just sort of cut it out by removing the hernia sac. It actually makes for sort of cleaner fashion alleges for the closure of the interior fashion. And we'll take this out through the 12 millimeter trow car towards the end, and then we'll close into your sheet. You can see we have nice, clean edges here, Um, of that interior fashion, it looks like it will come together. You'll be surprised how low you can drop the new mo and still future robotically. Um, we've featured on, you know, new mo where we set it to three or four. It actually doesn't go lower than five on the actual reading, but we'll set it to be pretty low, but there's not a lot of space. This seems to come together nicely with no tension. Mhm. Yeah, yeah, This is another closure, the interior fashion. I know we are running out of time a bit and I want to get to a couple more videos. So We will fast forward two beds here And, um, important to make sure you close support sites. These are from those initial 38 Trow cars that you place. And this is typically done with a vicryl suture and just sort of put a little too, uh around that ports site to close it. All three of them. There's another ports site for another case to avoid the interstitial hernias. Finally, we measure out the space, Um, and then we end up placing a sheet of mesh based on the space size. We don't really do much in terms of fixation at this point. Um, the mesh is usually measured close to the size of the space. Um, well, usually put one or two interrupted stitches just to hold it in place. Um, in this case, I used the hernia sac as a paper weight. This is not for strength. Um, in anyway, this is simply just so it doesn't move around as we're sort of deflating. Yeah, And then we routinely put a drain. So, um, then About 125 tars at this point had pretty good results. Um, like I said, have a low threshold. If I don't like the way the interior fashion came together to, um, close as much of the interior fashion at 12 and 6:00 and then sort of right in the middle, open up the skin just to take some tension off that interior fashion closure. Decent recurrence rate of about 8%. Um, different mesh is used for these tars. Um, but I'd say about half of them, um, more cynic or And to skip this video just for the sake of time, because it is just after 2:00 PM and we'll go to e tap. Really key to success with this is to have an apply trow car. And that's because it's the only true car on the market where you can actually, um, have insulation, Pastor. The tip. It's got a hole in it. So attached to gas to it. As you get in through an optical space, We put in usually just three Trow cars for this same approach. This is sort of our initial sort of getting into the space with the optical trow car. Um and then you do a lot of this is a blunt dissection to get in. You really just sort of sweep everything out of the way. Before you know it, you've actually done one side. Um, these aren't really long cases anymore there about an hour to an hour and a half just because there's sort of less to do. This is an attempt ventral here, um, that we're doing. Typically, we do something called the crossover pretty high up. It's more forgiving. Pretty high up because of that fat pad. Um, that runs, um, right around the false reform. Uh, we keep the linea alba up. Um, and then, um, when you want to close these defects, you want to pretty much suit for the whole space from top to bottom that you create. We use the step approach for incision ALS ventures that are multiple hernias. Um, we use it when there's a diet Stasis so that we can just do a post your application. It's not the same repair as a diet status repair, but cosmetically, it can look pretty similar. Um, but higher recurrence rate when we do it on the robot than when we do it with our plastic surgery colleagues. And we'll sort of go all the way up to the Z foid. And you can tell when you sort of get to the typhoid, your assistant will end up really sort of pushing on things. And you can use this approach to do, um, some of the cardiac surgery, the sternal hernias and whatnot. You can really sort of get behind everything. There's a typhoid up there. Um well, close these from top to bottom low. New Mo is really key to success in these operations. Just keep dropping the new mo if you're having trouble. Um, if it's not coming together from above, start working from below. Sometimes put a future sort of right in the middle to bring things along. Um, and take some of the tension off. Might put an interrupted vicryl or silk, just temporary, sort of hold things together. You can see here that the rectus muscles sort of brought back to the midline will tie them together, the two that we use, and we'll sort of place a piece of mesh into the space. Mhm. Move on to the next one. This is an incision, A little e top video. Let's fast forward a little bit. There's the head of the patient is here. The feet are going that way again. Try to be systematic about it. Start from the top and sort of work our way down. Um, you can really usually see where the linear Alba is. You can see the fibers is crossing because you're essentially operating with a microscope, so to speak, Um, and just sort of maintaining it above you. But again, you really have to future that entire space. Um, the poster sheath. Um, if we're not doing, uh, Annie kept are we really won't do much except close the holes that may have happened. We're doing the dissection. If we're afraid, there may be an injury in the abdomen, and we're just gonna take a look. I'll just make a hole myself, um, somewhere safe, where there's no incision, Um, and just take a look on the inside and make sure there's nothing sort of stuck to the under surface and then close it. If when you get in, you run into trouble and, uh, you've sort of made it into a pair to Neil, Um, if you're still able to maintain a decent new mo um, in the extra peritoneal plane, then you can put a various needle on the contra lateral side to, um, offload. Whatever new mo's entering in the peritoneal cavity, I'll dissect a hernia above us here, reduce everything, and then I'll fast forward a little bit to the closure. Here again, you sort of take your time. You start from the top. Nice, clean edges. Keep the new Mo as low as possible and bring everything back together. And we just sort of measure out the space and then sort of put in a piece of mesh close to the size of the space. Same concept, nothing new here. This is a piece of cynic or pre that we're placing into the space, and this is a fairly larger piece of mesh. That's a 12 millimeter Trow car that we put it through. Yeah, they stayed late to do the case, so I came a little little, little positive message to keep them going. Yeah, no, I'm gonna move on to a another video for the sake of time. Here. The idea is to really sort of sweep things, the muscle, the rectus muscle up. And really, um, You know, make your incision. Um, probably about 2-3 mm from the edge of the linear, if you're not sure or on the side of making the incision further away, not closer. Um, but the reason to try to make it close without getting into India is it's a lot easier to close into your fashion if it's obviously not a large separation, Um, deal with a lot of things like smoke evacuation, because it's such a small space, especially in the middle. Um, there's nowhere to go. And so you just have to be a little patient with the camera, and then it gets better as it sort of moves on, get to apart, a little easier to see. Here we go. You can see here sort of brought up earlier, um, to stay close to that post you're playing to keep the epic gastric up with the rectus muscle. If you leave sort of too much fat on it. That doesn't happen if you're having trouble getting it close like this. Another thing you can do is in size a little bit on top of the interior fashion to give yourself a little lip, too. So to most of time, these things come together pretty well. But it's about good patient selection, too, I think. A couple of videos. We tried doing some things where we would do it, but we would do prepare to really tap. Um, just see if it's, uh it's feasible. It is feasible, but it's pretty painful, uh, to get into that plane. We ended up getting into the abdomen many of times when we try to do it. So, um, we were able to do it, Um, but I sort of don't really venture that way unless I think they might have like, a nice thickened peritoneum. Um, actually happened the first time by accident. We were trying to get into the retro muscular space, and, uh, we got in sort of one layer too deep. Um, but I end up working out fine, I guess is a little faster than our tap approach because we uh, we didn't end up needing the clothes to flap, but didn't save that much time. There was a lot of weight. Where are we in, sort of. What is this for? About 10 minutes or so. This is a belly button hernia here. So cleaning it off there? Yeah, Exactly. It looks like initially thought it was the stock of the belly button, but turned out not to be the case. There's a stock up there. Just end up cutting that. Um, obviously, in a case like this, you expect a lot more holes because you're dealing with peritoneum as opposed to fashion. This patient had diced Asus. We, uh this one was on purpose, so we did the pre peritoneal. So a woman who had had a two pregnancies and with pregnancy number two, she got a little pregnancy belly, belly button, hernia with a couple of centimeters diet synthesis. And in those cases, we end up just sort of plicating that post your sheath you'd see here. We sent her to her plastic surgeon, but she didn't like the price, so I don't know. New York City prices are a little more expensive than Philly, so there's no Philly discount. Maybe I should have sent her to you instead. All right, let's go to the next one. This is another. Prepare to feel a tap that we tried doing here and end up working fine. Like I said, it's a little more frustrating to get into, um, and it really only works in, um, b m s that are a little bit a little bit on the overweight or barely obese category. The peritoneum is usually a little thicker. Um, wouldn't try it on someone who I think might have a pretty thin peritoneum. Um, this patient had, uh, actually, um, coming through the er Um, just having pain we saw in the office and came into the yard sort of a day and a half later with pain. Um, probably from that fat being stuck in one of those holes. The thing about the abdominal wall is, um, as much as, um, this CT catches all the larger hernias. It misses all these little small hernias with little little pieces of fat stuck in them. Mhm. Fast forward. A little bit. Here. You 20. Yeah. This is a piece of sin, a core that we placed into this space here, too. Wasn't really a big hernia. Okay, I'm just gonna as for this last one, because we really are running out of time at this point. Yeah. This is another one. Um, this was E tep, but not a pre peritoneal, um, space dissection. It was just a standard e type. All right, I am going to open this up to questions, okay? Mhm. Okay. And yeah. So, um, you can build whatever you want. You just almost never get paid for it. Um, we have done some unlisted coding, Um, for the past year application and whatever insurance gives us, they give us probably about 10% of the time. We're getting something for it, but it's not even close to what a diet stasis repair bills for. So it's it's almost like a freebie, for the most part, for the patient. Good question, though. Mhm. Um, so I usually start medial to the semi lunar line. And so, I, uh, I'll you if I'm going to do it for a smaller hernia, pretty medial to the semi lunar line and usually see the rectus muscle at that point. Anterior fascia. The rectus muscle and then you sort of pop in. That's actually not a bad trick, even if you want to do sort of a larger dissection to start a little more medial and then you can sort of re position report later. Published December 15, 2021 Created by
