Robotic-Assisted Repair of a Left Lower Quadrant Spigelian-Type Hernia

CHAPTER 1

My name is Eric Pauli. I'm a professor of surgery at Penn State Hershey Medical Center, where I serve as the division chief for minimally invasive and bariatric surgery. I'm also the director of the Abdominal Wall Surgery Program here. Today's case that we're gonna do is a left-sided Spigelian hernia. This is a patient who previously had part of her rectus harvested for a breast reconstruction. She subsequently had an abdominoplasty and developed a bulge in the left lower quadrant. Because it is a Spigelian hernia, you can't feel it on physical examination. So she's been examined by multiple people who don't feel a hernia. And when I examined her I didn't feel a hernia either. But if you watch her cough or Valsalva, there's a clear area of bulging. And if you look at her CT scan, you can see that there's disruption of the internal oblique and the transversus abdominis and that the external oblique is intact over the top. And those are the hallmark findings of a Spigelian hernia. So the plan for the day is a preperitoneal repair and we're gonna do it robotically just because creating preperitoneal pockets robotically is much easier than laparoscopic. We'll obtain abdominal access remote from the area. We'll do a brief peritoneoscopy and look around. We'll put additional ports in and dock the robot. And we're gonna do this probably with a three-port configuration. We'll create a very large preperitoneal space that goes above, below, medial, lateral to the actual hernia itself and reduce the sac out of this partial-thickness hernia. Once we're sure that we have a big enough pocket for mesh, we'll close the defect in the hernia. We'll make sure there are no holes in the peritoneal flap that we've created. We'll measure and install a piece of permanent synthetic mesh and then we'll close the pocket that we created. And in an effort to reduce the amount of pain that she has, in addition to the usual multimodal pain pathways that we do, we'll do a transversus abdominis plane block utilizing a long-acting liposomal bupivacaine.

CHAPTER 2

So this is the CT scan on the patient who we're gonna operate on today. And her biggest issue is down here in the left lower quadrant where she has a Spigelian hernia. She's previously had an abdominoplasty and you can see that there is an onlay mesh right here. And she's got a previous history of mesh infection with that as well, which is now healed. But over here is where she has a bulge and it's difficult to feel any defect on physical exam, primarily because the external oblique and probably some of the old mesh are intact covering the top of this. But the internal oblique and the transversus abdominis are disconnected. And there are some subtle radiographic signs of this, like right here. Here's the internal oblique with bowel anterior to the internal oblique. And that is a hallmark sign of a Spigelian hernia. The other nice part about humans is that they are symmetrical. And if you compare the right side semilunar line, there's a difference between the right semilunar line and the left semilunar line. So our goal is to repair this hernia but to stay outside the area where all of this mesh and old mesh infection is located. And so we're gonna do that by getting in in the upper midline here and then docking with ports here and a port out lateral and then triangulating those down toward the left lower quadrant to make a preperitoneal pocket to cover all of this. The other area we're gonna look at, because as we come down and do the bottom part of this dissection, we are going to encounter the inguinal canals. We wanna make sure there's no inguinal hernias here. This is her round ligament of her uterus right here. Here's the round ligament coming up. And so there is some quantity of fat here extending outward with the round ligament. So we'll be on the lookout for a fat plug in that area that may represent a small indirect left inguinal hernia.

CHAPTER 3

So I typically use Ioban just to kind of keep the drapes in place. There's no evidence that Ioban prevents infection, but it does - if you use a non-iodine impregnated dressing, those promote infection by keeping moisture under the skin. And so these neither increase nor decrease the risk of wound infection. I'm just doing it so that stuff doesn't slip under the drapes and go off field. So, I also prep really wide and I drape really widely. I've never once had anybody say we prepped too widely. We're ready to start. You guys okay, Wilson? Yes. Wonderful.

CHAPTER 4

So lots of ways to access the abdominal cavity for these operations. Certainly many people would do an optical access entry. I prefer a Hasson. And a couple advantages to doing a Hasson in terms of robot cases, which is just the ability to pass most of your stuff down through without having to ski your big needles and things like that. It's not enough of an advantage that I would say I would do it every time. But you know, I generally prefer a Hasson method of entry. And so we're gonna do a Hasson today, but I'm not against optical access either. You got a knife there for us. Absolutely. Let's just get rid of these things 'cause they offend my sensibilities as always. So our hernia defect is here. We wanna make sure that we have a substantial enough of a view to stay. This patient also has had an panniculectomy and a tummy tuck. So our umbilicus has been reinserted. So we're gonna try and not operate around that to prevent any ischemia. And as you can see, she's got this big divot here as a consequence of the onlay mesh that she has in this area getting infected. So our goal is to keep our robot ports above the area where she has onlay mesh, while at the same time allowing us to kind of triangulate down here towards her lower quadrant. So xiphoid's here, I don't know Sam, somewhere in here. Supraumbilical. Sounds good. 12? Yeah, we'll do a 12 here. We can work with that. Knife. Times two. Tooth pickup times two. Oh no, sorry. Tooth pickup times two. I meant to say knife back, but Sam had already done it. You got a little Ray-Tec there for me? Let's go find some fascia there. Use your Bovie to do it. Great. Got some little retractors there for us? Little Army-Navy maybe. Would you hold this bottom one for us? I think we already, there's some fascia there. And again, you know, even though we know down below the abdominal, before you grab, I'm just gonna feel like, you know, you gotta ask, is there mesh here? Okay? We're well above where radiographically there appears to be mesh and thickening and I think that's just fascia right there. So get a good grab of that. I'll take another Cobra if you got it. Let's see, that's a pretty bad, my grab is kind of bad. Let's get another Kocher. Just elevate that up. We'll just kind of push that a little bit and I'll just regrab that corner. That's fine. Good, okay. Got a knife for Dr. Zolin there? And then we'll need an 0 Vicryl on a UR-6. There's some preperitoneal fat right there. That looks great. And then... We'll get in. Okay. Knife back. We'll take that 0 Vicryl on the UR-6, he'll take a snap as well. Do your corner first. Push that skin edge back. Get a good bite of this stuff. Her fascia's relatively thin. There you go. That's good. Yep, roll through. Good, take it. So we'll put a little 0 Vicryl in here to help us close our Hasson site when we're done. Just getting in and engage the fascia and then I'll get outta your way. Engage and then I'm outta your way. There you go. Yep. Uh, huh. There you go. Snap and scis, please. You go under the fascia though. Show yourself the edge with that hand, and I'll pull the skin edge back here. There's your bite. Yep. And then we'll go back to the usual way here. I'll go there. You go there. Engage the fascia. I'll get outta your way. Take the scis, please. He's got the snap already. Needle coming back at you. Snap that. Okay. Got the Hasson there for us. Good. Got the robo camera. There's some organs. Okay, gas on high flow. We're gonna insufflate. Pressure 15, thank you. Okay. Come on out with the camera. So her lower abdomen is not gonna insufflate, you know, normally with the onlay mesh and it's going to be a little more rigid and sometimes when folks have had big abdominoplasties where the whole mesh is covered doing any laparoscopic operation, even like a cholecystectomy is a challenge. That is the right lower quadrant. And there it is. So that is the partial-thickness hernia that we are looking at right there. That's the Spigelian hernia. And again, this is hard to feel on physical examination because there's an external oblique layer that's intact over the whole thing. There's the edge of the rectus and this is just lateral stuff, kind of disinserted. So the edge of the transversus will be there. We'll have to figure out whether we're closing this top-bottom or whether we're closing it left-right. We'll get a sense of how we're gonna do that. But you know, in terms of the preperitoneal pocket that we're gonna have to make, the good news is, even though she had the DIEP flap, it looks like the peritoneum was not horribly violated here. And there's not obviously bowel stuck in this defect. Let's take a quick look over here and let's make sure we're not missing... This is the same spot on the contralateral side. That looks totally fine. Where was that adhesion you were looking at? That's over here. That's out of the way of anywhere where we're gonna be working. So that can stay. Okay. So I think our initial description or our initial talk about where we're gonna place ports, it's probably gonna be pretty close to where we wanna be, Sam. So let's do the following maneuvers here. Let's go a little bit of head down and berg, please. And let's put the right shoulder down. Let's get that bowel well wow out of the way. And then landmarks, there's a medial umbilical ligament there. There's an epigastric stump, probably with a clip on it, right? There's a clip right there. So it's gonna be the stump of the epigastric. Watch your Mayo stand. Is it all right here, or more? You got a little more? Yep. That's good. And then raise the table up. Good. And then airplane my way, please. Lemme know when. That's good. Okay. So, well, you know, down here we're gonna have some element of scarring, but again, below that clip, I mean that's the lowest that they went. As we get down towards round ligament, which I don't obviously see yet in here and critical iliac structures, it's gonna be relatively free for us to work. Theoretically that clip may be in the retromuscular space as well. And if we stay preperitoneal at that level, we may never see it. Okay? So the question then is where do we wanna start our flap? And do we want to do just preperitoneal or do we want to go retromuscular the whole time? So let's take a quick look around while we still have the ability to do that. That's the wrong direction. Let's do it like that. So, how much preperitoneal fat does she have? Here's the umbilicus here. There's a bit of preperitoneal fat around that. That's potentially doable preperitoneal. That's a little bit thin, but potentially doable. We'll also have to mark out from the edge of the defect there, at least 5 cm of mesh overlap before we start. But I think we can do it as just preperitoneal. Okay? So your flap will come across the midline there, across and down, okay? Let's make sure this arm is then outside any flap that we might want to create. And you don't need to be quite so far lateral 'cause as you're making that flap, you gotta be able to reach in, right? So probably somewhere a little more within the body of the rectus. We don't want to be through the semilunar line. Hands breadth there. Somewhere like right there. Knife and then an eight port. Beautiful. That's good. Let's take a look back here. Do you guys have the, oh nevermind we'll do it later. This can back out a little more then, get a little bit more working room visualization. You can do this, like in an ideal world, you can flip this. The problem is they've designed it so that the port is, it's opposite, right? So you would want it that way to have the port outta your way. But that's gonna put the... It's the exact opposite way you'd want it most of the time. So we'll go sideways with it. That'll keep it outta the way. That'll give you enough room to kind of sit there and work up. Let's go back to that port then and figure out where we want to go here. So again, that's gonna let you reach across, it's outside where that mesh should be located, 'cause that stopped just above the umbilicus. I could theoretically cheat it a little bit higher, but, this is gonna be outside, this is gonna be lateral to the rectus. So that's outside the (indistinct). I'll take a knife, and then I'll take an eight port as well. I didn't go through anything. There was nothing there. So we're just trying to feel, you know, we know that she's got mesh in the lower abdomen. My goal was to stay outside of that mesh and I think we did that appropriately. Okay, cool. We can probably dock a robot. Do you have a long... No, the short should work. We'll take the short eight. We're just gonna nest that in here and we'll dock. What we can eventually do, Sam, if we need to, is once we start the flap, if we need more distance on the camera, we can just push that port in and then when it's time to sew, we'll just back it back out as we sew. Okay?

CHAPTER 5

Come on in. You're targeting towards the Hasson port here in the midline, in the middle. Great, right there. Straight in. We will run that through the middle between arms at three and four. 30. Fenestrated bipolar to Dr. Zolin. Okay, leave it there. I'm gonna burp this port up a little bit then. Let's give it a shot.

CHAPTER 6

All right Sam, so bottom of hernia is there. That's seven above. It's five above right there. The patient has been re-paralyzed, is that correct? Yeah. Okay. It didn't take. So if we start here, number one, that's enough distance on the coverage. Number two, as I back out, plenty of room to sew there. If we want to come even another centimeter above that spot, we can. So let's go six above. Edge of defect is right there. Can we work there? Yeah, that's not too close Guys, ruler's gonna stay in for a few minutes. Okay? I'm gonna wait until she's paralyzed. Okay? So we're gonna try and do a preperitoneal repair here. If the peritoneum is too thin, there's two options. We can jump retromuscular, that's gonna get a little more sticky down where she had the DIEP flap done. Option two is to do an intra-abdominal repair and actually make the preperitoneal flap only out here. And then put an IPOM mesh in to cover. So we have at least two backup plans for what our current plan is. Let's see if we can get this going though as a preperitoneal flap. So we'll try and make this flap straight across. There's the preperitoneal space here and we'll work on going straight across. There's the retromuscular, the posterior rectus sheath there. If it just goes retromuscular, we can just jump retromuscular, Sam. We'll have to do sort of a semi-TAR in order to get across, but we'll see. So the peritoneum can be thin and so we're gonna go slowly as we get the flap started. As we're working, we're gonna be cautious about tension and accidentally making holes in areas where we don't want to make 'em. And again, the easiest remedy to having some holes is to simply switch planes and go one plane up into the retromuscular plane and do just a straight up retromuscular repair. The hardest part about these preperitoneal operations is kind of currently where we're working, which is in an area of the abdominal wall where there is generally not a lot of preperitoneal fat. Where the hernia is located and lateral to the hernia, those are very easy areas to work preperitoneal. That's why we do our inguinal hernia repairs in the preperitoneal space out there. You don't need a robot to do a lot of that deconstruction, but this is where robotic technology is very helpful. This dissection, I'm sure that someone can and does do this laparoscopically, I'm just not that good. And I would say that most people don't have the ability to make a straight up preperitoneal pocket here without having a lot of holes. But this is the area we're gonna be most concerned is where it's gonna be the thinnest and where we're gonna have to struggle a little bit to get that flap going. The goal is obviously a very wide flap. The wider the flap, the bigger the mesh overlap. That's good reason number one to make the flap big. But number two, as we're working, we don't want any tension on the edges of the flap. And if you have a small flap and your arms are reaching in, even if they're reaching in off screen, you may wind up with some holes that are really not even visible to you, you know, as you're working. So I'm trying to make this flap go straight across. And then we'll take the, you know, there is some transversalis fascia. Some of this is not just preperitoneal. Some of these little bands are bands of transversalis fascia that are coming down with us. And so we'll figure out if we're preperitoneal or pretransversalis in a minute. The bottom line is we are not yet intentionally retromuscular, but we'll see. So a little hole starting to form there. Sam, did you see that? So we'll leave that for a moment and we'll go back across the midline here a bit. As we go toward the midline, there's a little bit more fat, there's some preperitoneal fat. So as we come this direction, we should be in a little bit better shape doing the preperitoneal dissection alone. And again, I'm looking at this arm coming in and asking when I'm in here and I'm reaching down here to do the dissection, you know, how wide does this have to be for me to safely do the dissection in this corner? I don't wanna be pushing here and have the flap tearing up top. So I'd rather make this a little wider at the beginning than have it tear, you know, while I'm working. So I'll make this a little wider now into the preperitoneal space. That's all preperitoneal fat. Again, that's gonna be easier areas to dissect. And then as we come directly behind the rectus, it's gonna be a little harder to dissect. And then as we get a little lower, it may be even harder in the areas where the rectus was, you know, harvested. So we'll see, if it starts to rip a bunch, we'll jump retromuscular straight away. Well just like her skin was very oozy, her preperitoneal space here is also nicely oozy. Her IV was oozy too. So we got that going for us today, which is nice. Okay, so is this wide enough? I think this arm can get in here and can kind of work down this direction. So I think that's okay. This is the rectus muscle right here with the posterior rectus sheath still attached to it. And so again, if this starts to rip, our next maneuver is to simply jump upward and drop the posterior rectus sheath down with us. So we'll get this going a little more before we decide which plane we're continuing in. I do have this small hole out here lateral in the beginning of the flap that I want to very carefully look at as we go. Lateral to the rectus. Out here, making a preperitoneal pocket, as I said earlier, it's a bit easier. The easiest area is out there where all of that fat is located. It comes down relatively easily. Just looking for all these spots where these little bits of ooze are coming from. I'm actually colorblind and I don't like blood in the field 'cause it makes it hard for me to see planes. And so I try to keep this relatively blood free if we can. Not always possible, but we try. Okay, so hernia border starts straight ahead there. That could get a little bit tricky as we get into the hernia. But let's keep extending this corner pocket here where this should hopefully be a little bit easier. We're gonna do the Conrad Ballecer buzz buzz, push, up against the abdominal wall. Buzz, buzz, push to get that pocket going and we'll work back. As they say, it is easier to continue a plane than to start it. And so once you get into this plane and it's kind of opening up with a little bit of ease, you work your way back to areas where it was maybe a little more fused. Now I'm not gonna cut this edge anymore, Sam. I'm gonna leave that alone because I think that, there's my hole. I think that we'll be okay if we work from that area. Let's work around this hole as best we can. And we'll decide what plane we're gonna work in. Where's she oozing from? Okay, so that's getting pretty thin, okay? And we've already got one hole there and one hole here. So I'm gonna propose that we jump retromuscular to do the next steps. Okay, now the problem with going retromuscular is when we do, this'll be okay. This is just retrorectus dissection down to here. We're gonna have to do some element of a transversus release, but at some point it's not gonna work very well because we know that there's a Spigelian here and there's been disinsertion. So here it's gonna have to jump back preperitoneal to get this down with us, okay? But let's go back up here and see if that's what we gotta do. We'll give it one more shot here and see if we can get this going. Whoa, something's very bright. There we go. What was going on there guys? So the good news about where we're currently doing this part of the dissection is there's really nothing, there are no critical structures in this area. We're below and at least one layer where the epigastrics would be. So that's okay. Here in the middle part of the dissection there's still a fair bit of preperitoneal fat here. And so we have that going for us as well. There's the posterior rectus sheath there. I'd like to get to a spot where I can get my left hand in like it is now to provide some downward tension without making an obvious hole in the flap. And I didn't think that I could do that lateral yet. It seems too thin. So I'm gonna try and do that here, a little more medial, where there's some preperitoneal fat coming down with us in the area where I'm working. And I'm gonna work this edge back. So again, it's easier to continue a plane than to start it. And so I'm gonna start it medial and I'm gonna try and continue it extending lateral into the retromuscular space. Remembering that our backup is to just jump planes up one level and go into the retromuscular space. Theoretically you can plane hop here. There is an extra layer of stuff that is the transversalis fascia behind all of this. So we can jump pretransversalis by intentionally trying to peel the transversalis fascia off of the abdominal wall. And that's easier to do out lateral behind the transversus abdominis. Right now we're still very likely just behind the rectus abdominis. just looking to see if she was breathing again there. She's not. Thank you to our anesthesia team for doing what you do. You'll get production credits in the cut scene. There's a bonus scene at the end. What do you think, Sam? Keep going preperitoneal? It looks like it's giving it to you. It's trying, right? It's trying. Again, the idea of making this, you and I both know that as we get that flap farther down, any small holes we have up top, just like when we do a TAPP, we'll be able to kind of cover by just pulling a little bit, right? We just pull up a little bit. And so those small holes that we have should theoretically kind of come down. I'm trying to buzz only into the back of the muscle in the rectus sheath and not directly burn the peritoneum. And again, I'm trying to keep my hand and downward tension where I know it's a little bit thicker and I'm just watching as I come across here. So all of those fibrous bands, those little fibers there and there and there, that's all transversalis stuff that I should be able to bring down with me. Would you guys be kind enough to clean my scissor tip? I think we're almost to freedom, Sam. I think once we get to some, I mean you can see preperitoneal fat in the distance. In the distance here. This is all lateral. I mean this is all lateral to semilunar lines even though there's no fat, that should slide off. You can see it wants slide right there. So I think we're close to being able to say preperitoneal is the way to go. I'm gonna go up until that point and then I'm gonna turn you loose a little bit to work lateral and medial to the hernia. And then we'll have to see. Again, I hope that the hernia sac comes out relatively easily. I think it will. Again, that grab that I did makes you think that it will. Yeah, I was gonna ask if you were thinking kind of like circle the enemy and lateral. I would certainly start that way. Yeah. Are you guys able to reparalyze the patient? Thank you so much. So this technique again is the Conrad Ballecer buzz, buzz, push. For those of you who don't know Dr. Ballecer, he is a robot surgeon from the Phoenix area who is sort of a pioneer in robotic retromuscular hernia repair. He's an all around good guy as well. Shout out to Dr. Ballecer for teaching everybody buzz, buzz, push. He also sings a lot of Disney musical stuff. "Aladdin." I will spare everybody those parts of the operation today. So I'm also trying to decide, Sam, am I wide enough up top? Do I need to open this more to have this drop down additionally? Okay? Is it too narrow one direction or the other? Again, it's not tearing. We seem to be mindful as we're working that it doesn't, you know, start to tear. Yeah, I think right now you're good. Again, the easiest side to open would be going more lateral. You know, just cut this 'cause the flap is already made out there, so it's not like you would be at a bad angle restarting the flap. I'd also like to find what's been oozing in here the whole time and just make it stop. So as I mentioned earlier, there's two layers here and you can see the second layer is the transversalis fascia that's coming down. It's approaching the beginning of the hernia, but we're not quite at it yet. We also may need to switch camera views at some point. I'm still 30 up. I would normally be a little more rough in the areas where it's clear that we're preperitoneal and it's coming down easily. I'm not. Mostly, because she's super oozy, which is shockingly annoying. Now Sam, I think I actually entered the medial part of the hernia. Did you see that? This appears to be the medial edge of the hernia right there. So I'm just gonna, I was trying to get the flap to come across the middle here, but if I'm to the level of the hernia on the front end, then I'm just gonna work this to that level and then maybe you and I can swap. Okay? Yep. That's clearly going up in the hernia there. This operation probably could have been done as an eTEP operation, although admittedly because of the DIEP flap, your retromuscular dissection to go from middle to lateral probably would've been a little challenging to do from within the retromuscular plane. Not impossible. Certainly somebody out there would be able to do that. I just don't know that that person is me. Your port position though, probably would've put you somewhere near the mesh. Yeah? Yeah. The lower one, The lower one would've definitely gone through the area of that old onlay mesh and old mesh infection. So that might've been challenging. Again, not impossible, but certainly a little more challenging. So we're picking our poison here of doing a more challenging preperitoneal dissection, but also at the same time we're able to avoid the mesh. Alright, since we're making a movie, let's clean the camera there, please. Okay, we are now approaching the area of epigastric territory. We're lateral to it right now, but we gotta start thinking about where it is as we're working on some of the medial, I'm working on some of the medial elements of this. So I'm trying to intentionally jump, as I said earlier, pretransversalis right here and leave, this is the back of the transversus abdominis muscle that you're looking at right there. I'm not doing a TAR though. If we jumped retromuscular in order to do these maneuvers, we would've had to release the transversus abdominis insertion on the posterior sheath to get lateral. So we're avoiding a component separation by staying preperitoneal, but also the layers are a little thicker, and so we're struggling a little bit to stay preperitoneal. This is trying to divide into it. See, it's trying to divide there in the wrong plane. Let's figure out what's bleeding down here and let's stop it. It's just everything. So that's cool. Very, very oozy. So trying to plane hop there and I don't like that. So I'm gonna try and get back under this guy right here. Always good to zoom out every once in a while. Take a look at where you're working, look at where the tension is, right? So as I'm pushing here, when I'm focusing here, there is a little bit of tension out here, but it's not bad. The flap stretches and it's not pulling the other side. So I think that we've got enough stretch in what we've created of a flap that we don't need to open it anymore to continue on with the dissection. I am gonna grab this a little bit now that I can get a good grab on it and try and stay above. It's a little scarred here near the top lateral edge of the actual hernia defect. That's a little bit of the scarring that we're running into. The transversalis fascia is kind of fused to the transversus abdominis. It's possible that one of the stitches from the outside kind of caught through this area, or that they did some sort of a suture repair that's not in their, you know, not necessarily in their note. But I think shortly past that area, we should be okay. That's gonna be freedom for Sam. The top edge of the hernia is right there. All right, Sam, let's swap. Okay? Come on over. So that lateral part I want you to work on next. Okay? So Sam, I would work kind of from that direction over, 'cause this is the hernia top edge. Okay. So gentle grab on that stuff and then when you buzz, you're gonna buzz on the ceiling. Try to bring that stuff down with you. It's transversalis fascia. Yep, little buzz, little sweep, little push. Okay? These are all gonna be pretty gentle motions. The good news is the peritoneum in the area where you're working is just now substantially more stretchy. And so it's got a little more forgiving in terms of your instrument push on it as well as the degree to which it separates from the transversalis fascia. Yeah. Yep. And I would work that edge and I would work cephalad. Yep. Yeah, keep going up toward the head. Yep. Buzz, buzz, push. Yep, good. Very nice. Uh-huh, good. Yep. Keep working this direction as best you can, 'cause again, pause for a second. Here's your hernia here. This is all your kind of superior lateral pocket. So you need that for mesh overlap for sure. Okay. And because that's... Because that's... Because it's all in the retroperitoneal fat now it's gonna separate, you know, a little bit easier. Yep. I would buzz those guys a little bit. You can see it's kind of oozy there. She's gonna ooze. So I would just buzz near the muscle. Yep. And then sweep that down. We'll spend a minute before we start putting mesh in, making sure the ceiling is as dry as possible. Yep. Good. Uh-huh. Yeah. Keep working cephalad, Sam. That tension is perfect. Yep, just buzz the ceiling. Buzz, buzz, sweep. There you go. Sweep upward now. You got one hand down. You got one hand up. I love it. Yep, beautiful. Uh-huh. Good. Keep working out. So keep coming... Wow. My hands are both lost. Yeah, that's great. Uh-huh, I like it. Uh-huh. Good. Yep. For those of you watching this video at home, Sam, how many robot cases have you done? 25 to 30. This is within Sam's first 30 robot cases here. And so... Yep, good. Now, before you go too much farther, pause for a moment and look back at your hernia defect and ask yourself, is that enough coverage above the defect? Okay? If you're not sure, you got a ruler. I mean, I'm gonna tell you that I think you have well more than five superior. Okay? So the only reason to keep going cephalad is if you feel that that dissection is going to help you in terms of continuing dissection some other direction. I don't think that's the case at all. Okay. So I would just start going more lateral now. So, what that means is for you, let me get these hands. Give me one second, Sam. Let me put these back there. Okay, good. So for you it means going that direction. So lift the flap up for a second and just look on the inside and say, "Hey, where am I gonna go?" So look, you're going down here, right? You're gonna go all that direction and you can start working back lateral to the defect. Okay? At some point you might wanna switch 30 down as well. Yeah. I'm gonna... You're pretty close to that point, you're not quite there yet. So here's what I would do. Let's change the plan. Come back out and let's have you work across the hernia from lateral to medial. You got the lateral spot open. So start working this way. Okay? Get a good grab of that. Go right to this edge here and work it backwards that way. Yep. Yep. Good. Uh-huh. You can sweep, sweep upward. Go right to where the tension is, the tension's in that little corner right there. Okay? Yep. Also center yourself on the screen. There you go, good. Uh-huh. Yep. Okay, so then you can take all that stuff, all this right here can go. Yeah. Take all that nonsense. All that. Yep. Yep. Okay. Good. Uh-huh. Alright then work back up in here. Yep. There you go. Yep. Sweep a little bit, see what you get. Uh-huh. Good. So the tension is again, the tension's at this apex right here. So come back to that apex right there. Yep. So, Sam, things you can do, let go of your hand on the floor for a second and see if grabbing that little ridge, see if grabbing that little ridge right there helps you at all. Can you lift that up? Nope. Maybe not. But grab a little more medial or just push downward. Go farther across. Put your hand farther in, farther into the plane in this direction. And then push down. That's where you want to be. Okay? Now you got all of that stuff that you can cut. Yep. This is the very tippy top edge of the defect. It's why it's so scarred. And once you're around that corner it's gonna be a little bit easier. Yep, that's fine. Yeah, do that little wiggle. Yep. Cut it right there. Perfect. I like it. Do it again. Yep. Good. Even if you're off plane with that motion because you're lateral, the worst case scenario is you injure the transversus abdominis muscle a little bit. You're not cutting any nerves, there's no structures of any value there that you're gonna damage. You're below and behind the semilunar line. Yeah. That little band can go. Yep. Good. And then I would pause and I would go back. I would go back here. Okay? Hand in across and down. Good. Yep. And then sweep all that stuff up. Little vessel there. Okay, I don't know what that vessel is. You can see it. The question is, which direction does it need to go? It goes down to the fat. I don't think it matters. I think so long as you manage it appropriately you're gonna be fine. So give it a buzz before you cut through it. Yep. Yeah. Be a little more dynamic with that left hand. Can you change your angle or your push a little bit? Uh-huh. Push down, push up, sweep up. Yep. Flick that wrist up. Flick it upward. There you go. Cut through that band right there. Cut that band. You see where you gotta go, right there. Yep. Take that. Good. Sweep that upward now. There's your plane right there, my friend. Yep. Yep. Okay, keep taking that edge now. That's where your tension is. Uh-huh. Yep. Yeah, take that stuff. Uh-huh. Yep. So Sam, don't keep going into the abdominal wall. You want to plane hop back. So you want to go from - yeah, yeah, yeah, yeah, yeah. Yep. Figure that out right there. That's where you need to go. Yep. Do it. Good. Okay. Yep. Sweep there a little bit. Yep, go lateral. If you got room and you can go lateral. Go lateral. Yep, give those a little bit of buzz on the upper stuff there. Above your arm. Work above your arm. And work superior to your left hand. So work out here, push down, buzz all that off the abdominal wall. Buzz, buzz, push. So this was an area that minutes ago you couldn't really see very well and we thought we had to go camera down. And now that you've opened the pocket more, it's still in the field of view, yeah? So... Yep, nice. Good. Yep. Good. Get your hand out there. Get your left hand into that pocket now. Yep. Good. Wonderful, Sam. Get this little ooze from that little thing right there. Back all the way out. Let's reassess where you're going. Let's go back to the hernia now, let's see how we're doing. Go all the way medial. Keep coming medial. More, more more. I would go above that little band right there. Yep. And just work in there. There you go. Work straight down the middle. So from that point Sam start working more medial. Okay. So sweep this all up medial. Yep, and again, a lot of that because she's so oozy, I would give that some energy, okay? I feel like I'm being held a little bit here. So then that - so, stay there where your instrument tip is, leave the instrument there but back your camera out and show yourself the issue that you're having. Leave the instrument where you're trying to work. Back your camera out and ask yourself, "Am I doing anything bad?" And so you are being limited by that flap, but also, if you - in a moment you're gonna be free enough, I don't think you need to extend the flap to do what you're doing. Okay? So I would just plan the following. I would regrab with my hand the fat just underneath your instrument tip there and pull it down to the floor and then work right there. Okay? I think you'll be able to make this flap without a ton of issue. The other thing you could do is switch hands, right? You could work as a left-handed surgeon and work medial. It's a little more challenging 'cause you're a right-handed person and so am I, but I think you can make this work without tearing anything and without you know, having to extend the pocket. Okay. So take that there. That's the medial umbilical ligament you're working under. You can see it in the distance. Look in the intraperitoneal view. You can see it down there, right? It's straight ahead. So that's where you're working. Okay? Yep. Yep. Push down, sweep up. Yep. Okay. And do you think I can start working across that? I think so. Yep. Stay high on the abdominal wall side. Bring all the transversalis fibers down with you as best you can. A little muscle jump there. That's okay. Yep. Right there is the spot. You got it right there, Sam. Do it. Yep. Sweep, sweep, buzz, buzz. Push, push. Cut, cut. Just keep switching motions. It's very thin there so be mindful of that. Uh-huh. Let's switch out for 30 seconds. That's getting super thin, and I think there's probably some element of transversus abdominis fibers up against the abdominal wall. It looks like it's sort of been partly disrupted. So some of those fibers that you and I both thought needed to come down may not need to come down. They may need to stay. So like this, right? Like you were gonna leave that up and I'm gonna say, "Hey is that actually what I wanna do? Do I actually want to plane hop here a little bit?" I don't know. Right, these fibers were lateral to the rectus. Here's the edge of the rectus right here. There's bare rectus muscle there. So again we always have the option of hopping one plane up if we really feel like it's gonna be necessary. I'm gonna ask for a camera clean, please. Nice job, Sam. That's a real nice pocket you got going there. So I'm gonna actually go up here, Sam, and I'm gonna try and address the problem that you were having, before I have the same problem which is I'm gonna make this pocket just a little bit more bigger in the midline. A little fat there around the umbilical stalk right there. So there's the ligament right there. See it when I pull. So I'm looking from the edge of the defect, you know medial, do we have enough, do we have to go more? And I think we have to go a little more. This is all preperitoneal fat coming down and off the abdominal wall. I'm gonna plane hop somewhere in here. There's my plane right there. And again, the preperitoneal fat in the midline here is usually very, very stretchy and comes down very nicely. I'm gonna go a little slower 'cause you can see how thin it is. It's paper thin right there. So I don't wanna get a big hole medial, but also we should be okay. Now here's the difference. preperitoneal, here's pretransversalis, right? So we kind of plane hopped here a little bit. That's okay. I'll take the plane hop where it's easy. And I'll jump back, you know, where I need to.

CHAPTER 7

Okay, that's okay for now. We might need to gild that lily a little bit once we get going. I'm gonna go after some of the hernia now 'cause I think that's mostly what's holding us up. When I'm pulling over here, it's all up here in the hernia. That's the problem. So, I'm gonna go after the hernia now. So we'll try and sweep all of this up. Little scoops, just like you were doing. Removing the sac from an incisional hernia in the middle, or any kind of hernia in the middle, can often be challenging. Laterally, while it's not super duper easy, it's also a little bit easier because the peritoneum, as I said earlier, is very stretchy out here. That muscle going up, that is the transversus abdominis muscle, potentially. Or it could be the external oblique. If I'm pulling the ceiling down, we know that the external oblique is intact over top of all Spigelian-type hernias. There's a defect in the posterior muscles of the abdominal wall, transversus abdominis and the internal oblique. The external oblique is intact and that's true in this patient as well. So this is very likely as I'm bringing it out of the hernia, it's very likely the very bulgy but intact external oblique. And that's why this patient has a bulge. You can see it on examination and when she coughs, but when you go to palpate that area, you don't feel the hernia defect. It's 'cause there's a layer of muscle intact over the top of her hernia. So while she feels it and you can see it, when you examine her it's not readily obvious that there's a hernia. So you have to rely on the fact that she has a bulge. On imaging when you look even, you know again, hernias are commonly missed on imaging reports. And this lady's report does not really mention the fact that the transversus and the internal oblique are missing at this location. But you can see it if you look and there appears to be on the imaging, some bowel not trapped 'cause the hernia is not incarcerated. But there's bowel in between the layers of the abdominal wall. So there's an intramuscular hernia or what we might call an intraparietal hernia on the imaging and that's what this Spigelian is. I'm doing that motion that you were doing earlier, Sam, which is to kind of hook under the near edge. And if I buzz the external oblique a little bit, I'm not gonna lose too much sleep over that. But hopefully that comes up in an area where it's just a little more stuck than the other places. Gonna make my life a little bit easier and take a break from the hard stuff and go to something a little easier here. And now as we start to get lateral, we're gonna begin to do an inguinal. These are the lateral parts of an inguinal hernia dissection out here. Above, it's kind of the lateral dissection. If we had done a TAR, it's the same plane we'd be in if we had done a TAR, even though we did this preperitoneal, it comes apart as if we did a TAR. Unfortunately, she's oozy. And so while I might normally just push, I'm gonna be a little more patient today, and we will do a little bit of buzzing action as we get that all to come down. So here's your edge of the hernia. So again, your upper overlap here, from here to there is great. This is kind of the lateral stuff. I'm gonna leave that for you 'cause it looks a little bit more friendly. I'm gonna keep going after this. This is obviously still stuck. Let's back up for one moment and let's ask how much more do we have to go? So I'm probably 50% of the way. We'll have a edge on the other side to get that down. And then below that, nobody's been there before doing anything bad. So we should have a little more freedom when we get to that area. We also still haven't changed our camera angle and we can certainly do that at some point. The sac also has a lot of redundancy. So if I have a hole, large or small, we should be able to sew it. I'm plane hopping here a little bit. There's clearly two planes, here and there. It doesn't matter which one I'm in 'cause all of this stuff that's coming down is kind of nonsense. I'm gonna try and pick the plane that I can continue without having to hop back and forth repeatedly. Let's go to a camera clean, please. So things we'll need. A couple 2-0 Vicryl's cut to six inch. We'll need several of them, maybe four or five available. We'll need a six inch 2-0 V-Loc and we'll need a number one Stratafix on a CT-1. And then you got some - ten of Tisseel. So here's the plane hopping between preperitoneal and probably what's left of the transversalis fascia and/or the posterior sheet. So I'm gonna - this gets pretty thin - I'm gonna stay in this plane for a moment. And see if I can't work in this pretransversalis plane for just a minute here. Bring an extra little layer down with me. And then plane hop back preperitoneal at the bottom edge of this all. That appears to be sort of working there. And then here's the medial inferior edge of the defect right here. Medial inferior edge. So if I can go from here to there, that whole medial side of the hernia defect edge will be down. So I'm gonna now intentionally drop this down with me. I can see the back of the rectus there. So I plane hopped. I'll just plane hop back on the other side. Again, there's no epigastrics here 'cause the muscle was harvested from this area. All right, so now we hopped back. This is the transversalis fascia staying up as an element of the posterior sheath. And now we're back to just preperitoneal in this whole area right here. This is just preperitoneal dissection now. I don't wanna get too far in there. There's that clip we were looking at earlier. There's a clip, so someone's been in that area before. Alright, so now to go after the rest of the hernia here. This is hernia sac coming out of the kind of medial inferior edge of this defect. That's the bulgy, external oblique going up, going up. Here's the bottom of the true defect right there where the transversus abdominis is back inserted normally. This is very much if you were doing a direct inguinal hernia, this is what the pseudo sac would look like. This layer up here has the same appearance as the pseudo sac of an indirect, I'm sorry, of a direct inguinal hernia. So we have a little bit of a volcano sign here. We did the left side, we did right side. You can see where this is tethered up there. And we're just gonna work on the top and the bottom to kind of connect these guys back together. You can see the individual red blood cells there in that little vessel. You gotta love it. That's where I want to go. There to there. So we also need to remember not only the abdominal wall structures, where are the epigastrics? Where are nerves? We need to think about inguinal structures. This is a female patient, but if this were a male patient, we'd be thinking about the vas and the vessels laterally. We will come across and find a round ligament and very likely need to mobilize and potentially transect it in a few moments, so that we can have adequate inferior overlap going that direction. But as you come around the corner going this direction, you have to realize that you're gonna be retro-colic. And in some patients, if the colon inserts a little higher on the abdominal wall, you're gonna find the colon. Now her colon is nowhere to be seen, right? And so if the defect ends, the defect ends up here, all of this is retroperitoneal dissection, but the colon is not in jeopardy. You just want to at least ask yourself or say where, you know, where is the colon as I'm working and do we need to do anything differently to get around it? I think we're okay in terms of working behind the colon and not using energy when we do those parts of the dissection. We can use energy for most of this as we get down in that direction. External oblique going up. Hernia sac and portions of the transversalis fascia that may remain coming down. Lateral edge of the defect is right there. This is the transversus abdominis muscle right here ending. That should be inserted all the way over here. So, that edge of muscle began its life over here and needs to get kind of reinserted at that location. So we're gonna reinsert here to here, here to here, here to here as we come across. If we can't reinsert because it's too big of a stretch, it's okay because this is intact fascia over the top. The external oblique is intact over the top here. And so we don't need to worry about there being a bridged mesh reconstruction. There will be a reconstruction. We don't have to worry about a bridged mesh reconstruction because the the external oblique will cover. In that circumstance, we might plicate the external oblique with some sutures so that it's not as bulgy, being mindful that above that level is her skin and also an onlay piece of mesh. So it may not plicate very well, but you could do that. And then you just need to widely cover this area with mesh. This patient was cautioned preoperatively that she is always gonna have some element of a bulge here because of the loss of muscle for her DIEP flap. And if you look at patients who had muscle utilized for reconstruction somewhere else, a lot of them have regret about the decision to use autologous tissue to do that because of this issue. You know, we commonly meet people who have bulges that are not hernias, but are uncomfortable and interfere with activities or are actually, as in this case, a true hernia. You know, in this case a Spigelian hernia, that have resulted in ongoing symptoms and some element of pain and disability. And so a lot of them have regret about their choice to have the surgery that they had. I was trying to get from point A to point B here and not have a hole at the lateral edge of this. And then I'm gonna turn it back over to Dr. Zolin 'cause we're gonna be lateral and at that point it's just more of the lateral elements of a TAR and the inferior elements of an inguinal hernia repair. If you were the plane, where would you be? This is all okay, this is just abdominal wall. It's like the disininserted edge of the transversus that it's all stuck to. Ah, I know why it looks so funky. And I'm gonna show you this. The bottom edge of the defect is right here. This rolls out and then rolls back over. So watch. See, it goes over and around a corner. So we have to... We gotta come around a bend. I gotta go around that little corner and then hop into this plane, okay? So that's why it looks like that. This sac is actually kind of stuck inside the layers of the abdominal wall. So I gotta roll around the edge. Now I got it. Okay. There we go. So this is just peritoneum, very thin. This is transversalis fascia here, and I can pick either of these planes to continue to work in. Okay? I'm gonna probably come across the transversalis fascia here. Just until I get out to this corner and then I'll stay pretransversalis above that level to get this going. And that's gonna be the transversus abdominis staying up. So here, I'm peeling the transversalis fascia off of the back of the transversus abdominis right there, so that I don't get a big hole where this flap is. Once again, very, very thin. This is another area where she's just exceptionally thin. So plane hopping from preperitoneal to pretransversalis right here. And I'm gonna carry this back up to where the dissection was already on. So I just need to get from here to here. And then all of the peritoneum is out of the hernia and we're just doing our normal lateral dissection. And it should be, I hope, substantially less scarified as we're working there. If she wants to be mean to us today, she'll still be stuck. That's the transversus right there. This is the preperitoneal and/or pretransversalis plane. And then this is scar and nonsense keeping us from victory. Okay. This is preperitoneal. This is pretransversalis, okay? We can kind of plane hop and come up this direction as we work. This is all preperitoneal going this way though, and this is gonna be down towards the inguinal region, okay? So why don't you - where should we have you go, first? Here, let's stop this hemorrhage. So it looks like, Sam, we need to, this is still stuck to the edge of the transversus. Do you see that? Yep. So you've got this plane going, that's a nice plane down there that you started. And down here it's gonna be a little bit easier. I think you gotta do a little bit of work on the backside here. Okay? And then probably figure out how to take this off without making holes down below. So I would kind of work in here first and I would come back and very carefully divide this. Okay? Okay. Come on over. One second. Yeah, that's okay. Yep. Yep. Use your bipolar, grab it. Yep. So Sam, see if you can't sweep that up a little bit more. So make a little more, well dry it up first. See what's bleeding. Yeah, right there. It's right there. So see if you can't work, maybe work this pocket open a little bit more. Yeah. So sweep down and sweep up. Yep. Sweep that down right there. Drop all that down. Good. And lift all that stuff up. You might be actually working at the disinserted edge of the transversus, meaning this stuff that you are working through that may be transversus abdominis that's gonna eventually need to come up. Nice. Okay. So then take a moment and work cephalad. Make that pocket more. Get yourself some additional room. Yep. Sweep up. Yep. Yep. Huh? Okay, good. Back up then. Yeah, so this thing you're holding in your hand is probably, that's probably part of the transversus abdominis muscle that's disinserted. So you're, you know, that will eventually come back to the middle. If you look, that attaches to the lateral abdominal wall right there. And probably the reason it's bleeding right there is it's probably some muscle, some transversus muscle belly. Okay? So you are gonna eventually wanna divide that, probably somewhere closer to here at the medial insertion point. Can we check the level of paralysis, please? Let's go back down below. Go inferior to that. Okay. And why don't you just do some of your regular old inguinal dissection down here.

CHAPTER 8

Okay. Goes in a little bit easier there, yep. Yeah, bring all that down with you. You can sweep all that down. You can center yourself on the screen as well. And if you want to, you can also potentially change camera views at some point here. Where's that clip that we found earlier? Can you identify that clip? Okay, fine. I would just take all that nonsense. All this flim-flam here can go with you. Yep. Yep. Good. There's the clip. Okay. So it's a landmark. If that's your epigastric stump, you now know where medial and lateral to the epigastric are. Okay? So let's work the medial stuff from the epigastric now. And again, I need you to ask yourself, how much of this do I have to do to get coverage? Okay, so look, your edge of the hernia is here. So all of that is still necessary to get coverage. Okay? But I would say if that's your epigastric there, I wouldn't go any more medial, or I'm sorry, lateral on it. I would work all this medial stuff. Why don't you change your camera to go 30 down there and see if you can get all the way down to kind of the pubis. Nice. I love it. Okay. You gotta be pretty close. Yep. Okay. So then work the medial aspect of that edge back up. That's lateral, work medial. Yep. Up in there. And then just work out of that corner. So keep scooting your way back out. Yep. Work that edge up. Uh-huh. There you go. Perfect. Wonderful. Yep, back out a little bit. Keep working. Just bring that whole edge back to yourself. Your camera's rotated a bit. There you go. Okay, so again, that corner's kind of tough to get to and so we might need to fiddle with that in a minute. Again, pause from there. Look back from there. From that spot look back to your hernia. Where's the hernia? You have at least five overlap from that edge right there. Okay? Yep. So ignore the most medial aspect now and let's work this step down here. So you're gonna have to plane hop. This is preperitoneal, this is pretransversalis. These eventually have to kind of find their way back together. Look over here and see what's going on down there. Yeah, so stay in pretransversalis there is fine. So you're gonna go preperitoneal here. Gonna be pretransversalis here. And this is the transversus abdominis off the abdominal wall. So you're gonna have to find a plane that goes kind of behind there. Okay? But I would say work this step down here first. How are we doing on the re-paralysis? Is she doing okay? Yes. Oh, thank you. You're gonna have to take some of that with you. You're gonna plane hop preperitoneal to pretransversalis. Yep. Go right here? Yeah, I would stay a little, find the clear areas where it's a little more clear. Yeah, that's fine. Go there to there. Yep, there you go. That's fine. Take that. Better pull, stay higher. Better pull. Right there. Yep, right there. Good. Yep. Then sweep. Yep. Yep, then regrab a little lower. Yep. Yep, buzz then sweep. Zoom out for one second. Something's bleeding somewhere. Oh. Nothing exciting. Sorry, I thought I saw something more. Keep going. So again, pause for one second. Ask yourself, where am I? There's a stump of epigastric there. It's beating away. This is the indirect space here. This is the direct space over here. So you're near the bottom of your inguinal dissection right now. Okay? So you can go ahead and grab that right there and work that across, thinking about where the round ligament's gonna be as you work, okay? Cut the clear stuff though. Yep. Yep, get that right there. Good. Get a better grab of this stuff. Pull it out. Sweep. Good. Sweep. Good. Good. Yep. Okay. So that's over femoral space now is where this stuff is there. Hold on, pause right here. Let's take a look. Vascular structures. Yeah, I mean you got vascular structures here. You got some stuff here. So let's ignore this for a moment then and let's come back and let's work up here now, okay? Try and find a space behind that thing. Figure out where that pocket goes back there. Yeah, this is just all really, really stuck in here. Yep. That's what you gotta do. Yeah. Okay. That's gotta come down. Yep. Make the space, grab a little closer to yourself. Yep. Divide it. Yep. Make the space. Yep. Okay. Yep. Sweep. See if you can separate them. It's gonna be right in there somewhere. Yep. There we go. Okay. Yep, grab that there. Sweep. Okay, back your camera out for a little bit. Lift your flap up. Okay. So a ways to go in some corners there. Is she still moving? She's paralyzed, right? Yeah, I mean her abdominal wall muscles are contracting there on the outside and on the inside. So I think she's still breathing a little bit. Sweep, sweep, sweep. Yeah, definitely she's not paralyzed. Yep. There you go, Sam, sweep that all that over. There you go. Good. Yep. There's your plane right there. Nice. Cool. Okay, let's swap again for a moment. Let's gild this lily lower down. Good job. And let's see where we wanna go here. Alright, so... There's the urinary bladder right there. That's good coverage there. So come in this direction now. So I was looking for what's left of the round ligament. There's a clip on what would presumably be epigastric. This is epigastric, again, this is the direct space, this is the indirect space, this is the femoral space, you know, is this the round ligament here? And the answer is, I don't know. The way to do this safely is to just grab the peritoneum and just sweep the peritoneum down and off. So all of that stuff is gonna go over. And we'll work in the near ground, not in the background where those vessels are gonna be. We also wanna back up and ask ourselves, hey, how far do we have to be? Here's the bottom edge of the defect here. Okay? So from there down to there is currently our coverage. That's pretty substantial coverage, alright? Obviously the more coverage, in general, the better. There's gonna be a balance point in which we say, hey, that's as low as we're gonna get without having a problem. So let's be careful. But right now we don't need to say that. Almost certainly the round ligament right there. Round ligament right there going through the indirect space, up through the abdominal wall, right there. A little bit of fat going out there with it. But again - do we have to take that? From there to there for overlap. That's plenty of overlap. Okay? This is very high above. When the Spigelian is lower down and is here, and it's on the - or it's basically over the inguinal hernia space, you definitely wind up having to do a little bit more to free that up. Gonna be a cord lipoma here. That appears to keep going, doesn't it? So that's gonna be an indirect inguinal hernia. I'm gonna look at the scan real quick and just get a sense of how big that lipoma is.

CHAPTER 9

So there is, you know, we're seeing what we're seeing. It is real. And again that that gives you a good view of the iliacs in the background, right next to the round ligament. This is the blood supply that it's on. Okay, so that's lipoma for sure. This other little section, I'm just trying to figure out if that's true lipoma, or I'm just pulling some abdominal wall fat out with me. Don't quite know. This is the round ligament here. There's some of the nerves, neuro - lateral femoral cutaneous nerve of the thigh. Ilioinguinal, iliohypogastric are gonna start showing up in that pocket right there. And again, this is just the lateral kind of superior most extent of the pocket that Sam started to work on here. So we're plane hopping a little. And the question is, you know, how much do we need to plane hop to get the coverage that we need? Edge of the hernia's up here. So this is the kind of lateral inferior edge of what we're working on. So we're gonna keep rolling this edge out as best we can. Push everything over and we'll work our way up and down. This is just transversalis fascia. And so I'm gonna just come through this and plane hop. And now the pocket is all kind of maximally filled out there. Edge of defect is there. You're down at least to here. Right, pocket's way down to there. So this is the peritoneum here. There's the edge of the peritoneum there. This is approaching the myopectineal orifice again. So we just wanna separate what is the peritoneum from the structures of the myopectineal orifice. We'll find the proper plane, which is the true preperitoneal plane here. I'm gonna work that back just a little bit more. That leaves all of the fat, all of the nerves, all of the structures that we don't wanna divide or put a tack into or sew onto up against the abdominal wall. She's got a very fatty retroperitoneum here, which is convenient for us. But here we haven't gotten this all the way down. So this needs to come down. That's gonna be the backside of the round ligament right there. There it is. And so we've gotta work this then off. This needs to work down and off the round ligament. Okay? And so, if we can find the round ligament up top here, we can divide that and then just drop it down with us. Okay, this is what we thought was some fat from the abdominal wall. And so I think there's a clear space right there and I'm gonna divide that then right here. There's the round ligament showing up on the backside there. Round ligament. Round ligament right there. Guys, we will need then some clips in just a moment to divide the round ligament, okay? Round ligament. This is our second really beefy round ligament on a Spigelian this year, huh? If I clip there, that can flip down. This can come down. Okay, so let's get a clip. We're gonna do clip, clip, clip, and then back to scissors, okay? And that will go on scissor arm. So then we're close to being able to measure and then construct some mesh.

CHAPTER 10

Yep, please advance the instrument. One clip on the round ligament. You don't wanna be too crazy high in the canal. So you know, if you wanna hold distal and put two clips kind of proximal, that'll work, okay? You don't wanna clip too far into the canal 'cause you'll grab the genital branch of the genitofemoral nerve. So get in, go around, slide downward. Fire it there. Yep. Good. You got plenty of room to get another clip there and cut. Yep, come on out. Bring it all the way back out so you can see it's in the flap. Back out, back out. Move it more medial. That's great right there. Good. Take the clip applier, get us the next clip, please. Next clip. Near the first one there, Sam. Yep. Roll your instrument around. Close it the other way. Yep, like that. Slide upward. Upward. Yep. There you go. Leave yourself some room to cut in between. Yep, good. Do it. Great. One more clip, please. All right, Sam, so you'll clip that cord lipoma up against the abdominal wall. So you know, clip it somewhere like, I dunno like somewhere like there, so you can cut this off. Yep. That's fine. Yeah I would - okay, that's fine. You got one more clip for him? Yep. So, Sam, clip the lipoma then on the abdominal wall side. Okay? Yep, great. Clip. All right, good. Let's get that instrument into a safe location. Let's get that out and we'll go back, we'll put the scissors in, we'll clean the camera. Okay? Alright. Divide those guys. Great. Good. Grab above, pull it out, cut it. Okay, let's swap for a moment. Let's get this pocket finished so we can start closing.

CHAPTER 11

Alright, lipoma here. Where's that coming from? That little thing right there. Okay. I don't wanna go too much more crazy on this 'cause we're over the iliacs and this is our inferior coverage from that hernia here down to here. This is femoral space here. Corona mortis there. True iliacs there. Direct space here. Mesh will sit out there. Mesh will sit out here. Okay that coverage is all okay. Let's go back here now and let's look medial. Would you guys get me a robotic sucker? Just so I can mop this up a little bit. Yes, please. Thank you. Medial edge of defect to here. We're definitely, we're past the midline. Thank you so much. This is the linea alba here. So we have crossed the midline with our dissection for coverage. Seven to the edge. You okay with that? Alright, well let's do some measurements here now. Would you guys write some numbers down? 15, you wanna call it 17? Let's call it 18. So medial edge is 18. I'm gonna just draw this. 15. We can make 18 work there too probably. Okay, so we got 18 by 18 and that's at a right angle and then we'll just make this a triangle. And so our bottom edge then... It was 15 to there and it's like five to there. So it's like 25. Sam go 30 up and measure the defect. Okay? Hey for the record I just did 18 and 18 and put it into the little Pythagorean theorem there and it came out to 25.46. So we've developed... Not bad. Like a perfect triangle. Somewhere a Greek man is happy. In order to make this work we're gonna need a 30 by 30 barred soft mesh, okay? So get the edge here and get it to - go back. You're fine. You put that edge there. Alright, you're gonna call it seven from there to there, and six. So six by seven. Okay. We gotta close the defect on the ceiling first. We gotta close the holes in the floor next and we're gonna put the mesh in. Let's put the barbed suture in, the number one Stratafix, and then let's close the ceiling with the needle driver, okay? All right, let's drop the insufflation pressure, please. Let's go to eight to start. Open a port and bleed some pressure off.

CHAPTER 12

All right, Sam, I would sew distal to proximal, okay? So let's find - you wanna find the bottom apex of this thing. Bottom apex is probably like somewhere like that. Okay? Yep. Get a good bite through there. That's great. I would get a little farther over here. I would go there to there. There you go. Yep, roll through. Yep. We'll watch your skin. Once you get this anchored, on your next bite, I'm gonna have you plicate the external oblique down. Okay? You wanna go - nope, come back out. You wanna go there to there. Yep, that's good. Take it. Your needle rolled. Yep. Okay, pull through and then back stitch over the tab. So one of the things that I think is important when you're using barbed suture is you've gotta understand how to secure it appropriately. And some of the barbed sutures that are out there have a little loop on the end and they just obviously put it through the loop. This one has a little tab on the end. The problem is that tab is not designed to keep the suture from pulling through the abdominal wall. I'm gonna drop your pressure to five, Sam. It is there to allow it to be held in place, but you have to back stitch the suture over the top of it. And if you don't really back stitch over the top, it could theoretically pull through, so we make sure to back stitch over the top half of it here. Yep. Left, right, left right. Pull, pull, pull. Pull it more. Pull till the tab is flush. Yep. Good. Got - Tab's there, good. Alright, now back stitch. Go in here and come out there, right through the apex of the incision. Right here? Yeah, I usually go in to out but that's fine too. As long as you're back stitching over, it's fine. Great. All right, pull it up and let's sew. You can see on the lateral edge you can see the shelving edge there, that is the internal oblique and the transversus, it's gonna try to come back to the midline. So even though this defect is big, those muscles are pretty stretchy, they'll come back to the middle and the reduced insufflation pressure is probably, you know, reduce the size of the defect. It was artificially stretched as you were doing it. I just measured on the CT scan and with her kind of laying flat in supine, it's only about five centimeters. So those extra two that you measured left, right lateral are probably just from the insufflation, okay. And so you'll do basically three bites. You're gonna do the internal oblique and transversus, you'll do a bit of the ceiling to plicate, and then the transversus and oblique on the other side. Okay. Get all that suture outta the way. Make your life easy. Stuff it somewhere else. That's good. Alright, yep. Get a bite. Yep. You can stay right there. Dunk the ceiling down. That's the oblique. I'm watching to make sure you're not getting any skin. Looks good. Take a bite. Good. Now regrab your needle. Roll through. Take the medial edge. After this bite we're gonna camera clean, and then Sam, we'll switch out. I'm gonna close the rest of this. Okay. Your last bite went in somewhere over here. Pull, pull. Like you just jumped way up to here. That's way, way, way too much progress. Okay? You're making a circle into a line and so you gotta, there you go. Right in there is where you want to be. Yep. That stuff, take that. Yep. Roll through. Easy. Hold on. Hold on. You gotta be really easy on the downside 'cause your iliacs are down here, okay? So... Uh-huh, follow the curve of the needle through. Good. Alright. Pull that through. Get your, you know, get some of the suture tensioned appropriately. Don't pull it all the way through obviously, you wanna have some loops, and then let's - pull a little more through, yep - let's camera clean. Okay, leave it right there. We'll probably need a 2-0 Vicryl to close - there's one small hole in the right corner of the pocket that we definitely have to close. I would say we don't close - the only other holes we have, Sam, are near the very top of the pocket and I don't think we need to do anything with those 'cause they might be able to just be closed when we close the flap. Yep. Wonderful. Okay, thank you. Okay, so here's your first bite there. There's your tab there. Okay. Fine. First loop here. This is the downside of barbed suture sticking to things that we did not want it to stick to. So we got that going for us. Okay. This is your first bite here. That's the back stitch through the top. Fine. I'm not gonna make a lot of progress on the second bite here. I'm gonna go right next to that first bite. All right, so there's this loop here. That's that one there. That second bite. This is first bite. So first bite gets pulled through, second bite gets pulled through, third bite gets pulled through. So we're trying to keep some suture in the loops just so that we are managing the length of this. Again, we could have used a smaller suture. We didn't. Edge of rectus here. Number one, number two, number three, number four. No skin on these bites, guys. No. Thank you. This is the bulgy oblique over the top. It's where the hernia sac used to be. This is the lateral edge of the defect there. Loop one, loop two, loop three, loop four. A little bit of bleeding from the muscle there 'cause we took a bite of actual muscle and not fascia 'cause we're closing a defect where you have to take bites of the muscle. Generally as you pull these through and start to cinch them that goes away and it's less of a concern, but sometimes it keeps oozing. You gotta put an extra figure-of-eight in and around it. We're gonna just work under the assumption that it will slowly start to stop oozing in a minute. One, two, three, four, bite five. And we're almost there. So by closing the posterior elements of the abdominal wall, that's the transversus and the internal oblique. And by taking these little plicating bites here of the external oblique bulgy fascia over the top, we're doing a few things. We're reducing the dead space. We're putting the muscles back where they actually belong in midline apposition, and then hopefully preventing her from experiencing any further bulging by plicating that oblique a little bit. One more bite here we're probably gonna be done. And we'll do our little back stitching. Okay that's back to native abdominal wall there. Above the defect. We've got a lymphatic leak here somewhere, don't we? Let's take a look at that in a minute. One. Two, three, four. Five. You guys, we have the sucker available. Is that right? Yeah. Okay, cool. All right, we'll back stitch once. We'll cut this. We'll get this out, then we're gonna have to spend a moment and see if there is a lymphatic leak or not. Okay? It may have happened at some other point during the case, not late, but because we reduced the insufflation pressure, we're just noticing it now. So we'll need to spend a moment and figure that out. How's the skin looking on the outside? There are no bites? That's better. Looks pretty good. You okay with that? Yeah. Because this is in the preperitoneal space, you can leave it longer. Alright team, let's get our suture out, the leftover tail here. I'd like to go, before we do anything, let's go up on the insufflation pressure, please. Go back to 15. We'll take the suture out and then I'm gonna ask you to give me the sucker. And then Sam, what we'll do is how about once we find or don't find a lymphatic leak and assure ourselves that nothing needs to be done, why don't you close the one hole in the preperitoneal space. Bring the sucker on in. It's like right there. That hole right there. You'll close that guy with a Vicryl. And then while you're doing that I'll go and cut the mesh. Okay, so again, the amount of stuff here is now substantially less concerning. So I mean major lymphatics would be here. Whatever this was, we clipped on both sides and left it in. So that ain't it. There's nothing exciting going down here in the midline. That's okay. No rundown, nothing from here. I think we're okay, Sam. I think it just looked bad because it's a big pocket and all that stuff had accumulated. Okay, so we know we gotta close that one hole. Now what else do we have? Where are the other holes? You know, they were like right up here, you know, and I think that as we're closing this flap, I think they're gonna be, I think that's just gonna close as one big flap. I don't think you're have to worry about any other holes. Okay? So why don't you then, why don't you close that hole right there with a Vicryl and I'll make you a mesh. Okay, let's take the sucker out. We'll put a six-inch Vicryl 2-0 in. Sam will take a needle driver, and then I'm gonna go scrub to cut the mesh.

CHAPTER 13

And then we're gonna want to sew the mesh up against the abdominal wall. Probably like three six inch. Well we'll need three bites total. So we need probably two six-inch Vicryls. Okay. So this is a 30-centimeter mesh. I'm just gonna take off five 'cause I want it to be 25. So there's five right there. Boom. And we'll do this, I'll take another snap. And we'll snap right there. Boom. And then we will trim. Okay. So that's our 25 centimeter long axis. 25 that way. Do you have another ruler? Yeah, do you want one? It's all mushy. That one that was inside? Yeah, I'll take another one if you got it. Could I see the mushy one? So I'm cheating to make the triangle 'cause these need to meet up. There's only one way that these can meet and be 18. Okay. And then you can take that off. That's fine. Okay. 25 by 18 by 18. We're gonna install this and it's gonna sit up against the abdominal wall. I'm gonna be able to unroll the ceiling. So I'm going to roll this like this, so that when we install it, the long ends will go in along the floor and we will unroll it along the ceiling. Cut a snap. Actually let me see the Vicryl for a second. So we will put a little stitch in to keep this from unrolling. Put your other hand right there. And then we'll do our little magic carpet trick and just kind of unroll it once we're on the inside. So that's the hold-it-together stitch. You doing okay, Sam? Two, three. You're gonna leave that long enough that Sam can see it and cut it. Honestly it doesn't truly matter, but I'll put one here just for orientation purposes there. And so when I dunk this in this, I'll grab that side. That's the inside corner. You ready, Sam?

CHAPTER 14

Okay, so, Sam, the way I did this is I've rolled the mesh. You're gonna put the bottom end in first. There's a stitch in the middle. You're gonna cut the stitch in the middle, then you're gonna unroll it along the ceiling. Okay? Got a needle for me? Do you have another six inch for me? See I'm gonna give you another six inch. You can park this somewhere safe. I wouldn't put it in the flap 'cause you're about to put the mesh in there. I would stow it maybe in the abdominal wall where you had that other one. Leave it somewhere down there. When I give you the mesh I'm gonna give you the retro-pubic corner, okay? Coming at you. Okay. That corner goes to the pubis. Okay, don't take it yet, 'cause when I come in I'm gonna grab the other end here so I can help. Okay, let's go together. You go in. Yep, take that in. Take it in, take it in. Drop that into that corner there. Good. Okay, leave that there. I'll let go here. Grab this end here. Make sure it doesn't drag your suture. Yep. Tuck that in the far corner then. And again, let's get this suture kind of outta the way. Okay great. The needle driver again. Here comes your other arm back, Sam. Let's get the mesh positioned. So get your inside corner in. Put the mesh flat against the entire bottom edge of the pocket we created. Hey buzz that bleeding thing on the abdominal wall there. Just figure out where that's coming from before you get too far here, 'cause you're about to cover that with mesh. Yep, flap your hand a little bit. Beautiful. Okay, so this is the opposite of the magic carpet trick. Just go all the way into that corner there. There's the far corner edge there. Want this to sit all the way flat all the way down here and all the way into here. Now it's not perfect and it's again it's a little bit oversized at the moment. What we'll do is we'll come down in here and we'll say hey we gotta resize this pocket just a little bit out here. Just a little bit. Not much. Okay. Before I buzz I'm just making sure I know where I am. There's the inguinal space right there, right? So I'm not in or around or near anything that I'd be concerned about in terms of inguinal stuff or we'll goof around long enough that it clots on its own. There's the bottom edge there. Bottom edge there, bottom medial corner there. Bottom edge flat, bottom edge flat, bottom edge flat. Flat. It's still bleeding. It's probably a little bit of that. This is probably still from that muscle edge where we sutured. Okay, so here's the suture I put in to hold this closed. Suture is now cut. We're gonna hold here and we're gonna unroll. What do you think, Sam? I think we've got pretty good overlap, we've got good coverage, you know, down or got coverage for the inguinal. I think it looks pretty good. I'm debating if I cut it a little too short. This overlap from here to here I don't like 'cause it could come up much more. Yeah? Yeah. Yeah. And if I shift it we're gonna lose our inferior coverage. Guys, can you guys get me another 25-centimeter, or 30 by 30 Bard Soft Mesh. So I'm not happy with that. Okay? This is all perfect. This is all great. Okay? So that's fine. And even this is fine. This is perfect. 18 is fine here. 25 is fine here. I don't think it's enough coverage from there to here. The one thing I can do before we take this out and recut mesh is shift it up, 'cause our inferior coverage is too much. Inferior, like dead center midline. Okay? So if I can pull the whole thing kind of out of the flap a little bit without compromising this inferior edge, that would work. Two, four, five. You okay with that? Mesh is getting soft 'cause it's been in the patient. It's a little better with it shifted upward. You know we're not all the way as directly far retro-pubic as we were a minute ago. I think it's much better. This is one stitch past. So defect ends about there. Two, four, six. I think it's okay. And then that sits fine. Okay. Guys don't open that other mesh. Okay? Thank you. So we're gonna put some sutures in here, guys, just so that the mesh doesn't grossly shift. This is not really much more than that. As soon as we close the peritoneal flap and because we have the sucker irrigator available, probably what we'll do is stick the sucker in the flap and as we are desufflating the abdomen, we will kind of laparoscopically with the handheld sucker, we'll glue the bottom edge of the mesh and then we're going to close the top flap. She is starting to contract her abdominal wall muscles again. What arm is it easier to get the glue in through? So let's come out with the needle driver. Open, close, take it. Needle driver back. Okay, let's put the gluer in now. Yep. Yep, advance it in a little bit there. Is this the rigid one? Yeah. I would just undock the arm. Okay. Advance it in there for me. Alright, go ahead and start. Oops, go ahead and start spraying. So we're gonna put some glue in here on the bottom edge to keep that from moving a bit. Yep, up and down. Up and down. Yep, up and down. Good. Let's come back this way. Come back toward me. Yep. Advance in a little bit with that. Yep. Good, good. Yeah, yeah, yeah, yeah. Nice. So this is Tisseel fibrin sealant. Good. One more layer up. Go back this direction. Yep, that way. Let's go right down here. Beautiful. How much we got left? Keep going. Uh-huh, spray right up there. Yep. There you go. Beautiful. Yep. Good. Yeah, good. Let's come back this way. Uh-huh. Okay, good. Take it out and then let's take a, we'll take a 2-0 V-Loc.

CHAPTER 15

Got it. This is a six inch? Nine inch. Perfect. Sam, you should just need this one to close then. Okay? Alright Sam, which way you want to go? That way or this way? It might actually be easier to start from patient's left. Okay. There, there. Work toward yourself. Okay. All yours, go for it. So we'll close this flap up. We'll take one last look with the laparoscope. For skin, we'll need just some 4-0 Monocryl and some Dermabond. I'll drop your insufflation pressure here. Put you down to eight. We will Exparel when we go lap. So we'll go lap, we'll suction out, we'll take a brief look for that clip. If we can find it, great. If not, I'm not super concerned. They're meant to stay on the inside. And then we will TAP block and we'll take our ports out. Okay, so let's do this. Can you gimme 60 total? So 20 of Exparel, 40 of saline and we'll do injections of 20. Three injections of 20. Two on the left. One on the right. Yeah, so usually, you take that bite. Usually I do two bites and then pull it tight. Okay? This one you don't - the tail is not particularly long, and you're not tensioning this the way you are the fascia. Okay, so get a second bite there and then pull it - pull it all the way through. Yep, good. Yep. Then pulley, pulley, pulley. And pull the thing all the way up tight, and it will close as you go. You're looped through yourself. That loop has to go back through. There you go. Stuff it in there. Okay. Keep going. Two bites, pull through, two bites, pull through. Okay? So we'll close this preperitoneal flap here that will put the mesh in an extra peritoneal position. That's what allowed us to use an uncoated piece of mesh. Just roll. You can just take both bites, Sam. Just, you know, get yourself set up to take both bites simultaneously, right? You know, reloading the needle there - not necessary. Yep. So grab it with your other hand. Get the needle set up so you can take a good bite. Floor, ceiling. Roll through. Give yourself a little extra slack. Good. Yep. Floor, ceiling, roll through. You're holding halfway through the needle, right? I would hold farther back. Hold it farther back. Yep, good. Take a float bite of the floor. Roll through. Good. Bite of the ceiling. Roll through. Pull the ceiling down to you. Take the bite, grab the needle. Roll through. Great. Yep. Now pull it through. Pull the second one. Yep. Pull, pull, pull. Pull, pull, pull. This allows us to use an uncoated piece of mesh that's a reduced-weight macroporous mesh. These are inexpensive. We don't like to use the word cheap. Cheap implies quality. We're talking about the actual cost of the mesh. So lift that floor up to yourself as you pull it tight so it doesn't rip through. Yep. Pull, pull, pull. Pull, pull, pull. Yep. If it starts to rip, you can also take these as Connell stitches. You have to back stitch through that a little bit. Okay? Pressure's down to five. Yep. Roll through. Take it in two if it's gonna rip. Good. Take your bite. Yeah. That's just blocking your view is not super helpful. Yep. Get a good bite. Yep. Roll through. Good. Yep. Pull it up. That'll close your hole. Pull, pull, pull. All right, I'm gonna, sew for a few. What's the abdominal pressure reading currently? I said up to five. Is it five yet? Okay. All right, we'll take a look at those tiny little holes there before we finish, Sam. If they need like a single Vicryl, we'll put it in. Okay? So the main thing that I did to get past that and ignore the hole was just take a bigger bite of the healthier peritoneum. You were in a very thin area. So I took a bigger bite of this healthier stuff and then I aggressively pulled everything tight to kind of roll that edge back inside itself. Okay. So because we reduced the pressure, the mesh - the abdominal wall is stretched less and the mesh now totally fills the flap. Okay? And so that's part of the issue is if you measure at a reduced pressure, it's a little bit smaller. So the mesh is now I think appropriately filling the pocket. And very likely as we start to close this, it should flatten out - when we suction, we'll stick a little sucker in there and we'll suction this flap out and that should really handle - all of that redundancy should go away and we should actually watch the flap kind of stick up. Now there's a hole there. That will need an individual stitch in it very likely. Because I don't think - I can't get down here. So we'll need another Vicryl suture in a moment. This is a little bit of Vicryl sticking out. I'm not concerned about that. If that was barbed suture, we would be concerned 'cause those barbs like to get stuck to the bowel and then you get a little bowel obstruction there. So as we're pulling this tight, trying to make sure that really no barbs are sticking out and remain in the abdominal cavity, the barbed suture that we use to close the fascia, I would not use that suture if it was gonna be exposed to the abdominal cavity, because those barbs on that number one Stratafix suture are very big and they like - you saw it early on when Dr. Zolin was suturing that it really wanted to get stuck to all of the things that were nearby. It stuck to the fat, it stuck to the abdominal wall. Well if it sticks to the bowel like that, then you get a bowel obstruction and that's a problem. Like that. That's what I'm talking about. Okay. So even these barbs when they get exposed to stuff like to stick and that's how you get a bowel obstruction. And so when we back stitch this at the very end, which I'm about to do, we wanna make sure that we really vary it in the abdominal wall. That's a terrible bite I'm trying to take there. That's better. We'll do some wrong-handed suturing here. Okay. Looks pretty closed to me, except for the one little hole there, which you're gonna take care of in just a moment. Alright, we'll back stitch this one time. And then what we'll do, guys, why don't we exchange a 2-0 V-Loc out for a 2-0 Vicryl in, okay. V-Loc out. Let's put the insufflation pressure back up before we take anything out. Okay, you can come out with the instrument. And then I'd like you to give me the sucker after we do the instrument exchange. Close. Take it. Okay. Take the sucker. Mesh looks flat. Yeah? Okay. Where's the hole? Look at that. I made it go away. How about that? I'm a genius. Okay, I'll take the needle driver back. Oh man, it's not working. It must be leaking from some other spot. Could be a little leaky. Yeah, it could be leaking back in through there. It's okay. We're gonna suction it up there with - okay, give me the needle driver. We'll stick a little end. Can I have an angiocath for the end of the case, guys? The old figure-of-eighty-eight, also known as the Dale Earnhardt Jr. stitch, for those of you who celebrate. So again, we're closing these little holes just to make sure that there's no spots where the mesh is exposed to abdominal content to form an adhesion. But probably more importantly, we don't wanna loop a bowel to get up and into this pocket. That's just thin there, man. Nothing you could have done differently I don't think, other than, you know, you could have considered if it was super thin we could have considered doing a Connell stitch there and run it that way. But... This should do the trick. And then after this we're probably ready to undock, yeah? That should be it. We'll do our TAPs lap. We'll suction it out lap. We'll make sure our ports are okay and we'll get outta Dodge. Alright guys, let's take this needle out and then we can undock. Do we have anything else in that needs to come out?

CHAPTER 16

Alright, so up next we're gonna do some TAP blocks. We're gonna use a mixture of liposomal bupivacaine and we're gonna inject that into the plane between the transversus and the internal oblique muscle. The intramuscular plane, which is where all of the nerves that supply the central abdomen run. The medication we're gonna use, it's a long-acting liposomal formation of bupivacaine. Get a little camera clean for me.

CHAPTER 17

Alright, so let's just take a quick look around there for - if we can find the clip. There it is. Give Dr. Zolin a bullet, please. Clip is out. Now let's take a look. So it hasn't bled the entire case, right? Let's do our TAP blocks so we can get that done. Give Sam the Exparel, please. I would do a two-point TAP. I would do one there. Let me go 30.

Oh. You have a 60 per side. So this is 30. We have two 30s. Two 30s. So you're gonna do 40 on that side. So do 30, you know, do 20, 20, and I'll do 20. Okay? There you go. So there's the transversus abdominis muscle. Back it out a little more, then inject there. That's it. Widely spreading in the transversus abdominis plane, and as he's injecting, probably not a lot of tension there as he's injecting. You can put 20 in there. Oh, I'm sorry. That's okay. Went to the 20 mark. Go to the 10 mark. We got Pythagoras going today. We got all the math going today. Alright, good. And then, I would scoot down then. Probably... Right about there is gonna work for you. Just stay right at the edge of that. Yep. That's above the flap. It's outside where we did the suturing. Yep. Go in till you see yourself. Yep. And then back out a little. Yep. Right there, inject. Good. You're in the right spot. He'll take the next of the Exparel. So you'll do 10 now. Yep. You're there. There you go. Back it up a little bit. Good. Inject. Good. Perfect. Alright, your turn. There's my port there so I'm just gonna do 10 above and 10 below the port. Okay. There's above the port. Advancing in, needle back it into the plane. That goes easy. Come down here. Again, I'm gonna try and stay. I'm gonna go lateral a little bit. I wanna stay outside where that mesh is located. I don't wanna deal with the old mesh. There I am there. 10. Okay, cool. Now let's take a look at this port site next, 'cause that's super annoying that it wants to ooze. It looks better now, huh? Okay, take the angiocath. Ignore that for now. Flap starts there, there, there. That's inside the flap. So let's advanced the angiocath in. Yeah. Give him the whole thing. Yep. Go until you're through the abdominal wall. You'll be inside the flap there. Good. You're probably inside there. You think you're in? No, probably not. The old mesh? Is it? Yeah, it might be the old mesh. Yeah. You're just under the skin. Can I have, can I have, can I have... Let's go with the lap sucker. Let's take this port out. Make sure it's not bleeding. I'm gonna have you stick a finger in it. The robot one is fine. Okay, that's fine. Okay. We'll try it once. If not, it's gonna stay the way it is. Nope. Not getting the flap very well, am I? Sorta, sorta. Little bit. That's what we want, dude. Gas off, please. Okay, let's watch this port come out. So we sucked that flap up. That looks okay too. Gas off, camera off. You can stay in. Stay in, stay in. Just gonna watch, make sure nothing's bleeding here as we take that all the way out. Let me look back over this way at your flap. You're dry. Okay, so most of the air's outta that flap. It's leaking right through there. Come on. Okay. Coming out. Room lights on. Laparoscope off. We'll tie these together to make a little U-stitch and that'll close the midline fascia of that Hasson port. Monocryl to each of us, please. So we don't close the eight-millimeter ports because they went through enough muscle, they don't need to be closed. The Hasson port is a 12-millimeter port. We would always close that regardless of where it goes through the abdominal wall. That happened to go through the midline. And so we definitely want to close a 12-millimeter port through the midline to prevent or reduce the risk of her getting a hernia at that port site in the middle. These lateral ports can cause hernias as the robot arms torque through the abdominal wall. They sometimes put a little bit of extra torque in a way that you're not aware of. We're gonna put a binder on her at the end of the procedure here. Alright, got some glue there for us now. Can we dry that? Okay.

CHAPTER 18

As you saw, creating a large preperitoneal pocket there was somewhat difficult because we tried to stay just preperitoneal. It was thin, and we had a couple holes that we had to fix. And it was slow going for parts of that. You can simply jump planes, as I mentioned several times. If you are having a hard time, if those planes aren't coming, you can hop upward, one layer in the abdominal wall and stay purely retromuscular and bring the posterior rectus sheath down and then do a formal transversus abdominis release. I elected not to do that because we were making slow, steady progress and none of the holes that we had in that preperitoneal pocket were substantial. It took one or two stitches to close them all. I think the other thing you saw is that we did find some fat plug in the indirect inguinal space. And so officially we removed that fat plug, we divided the round ligament and our mesh covers the entire left myopectineal orifice. So we did a left-sided inguinal repair as well. On the scan, pre-op, wasn't 100% sure we were gonna do that, on the scan post-op we did. Even if we hadn't have found fat in that area, we would've covered the myopectineal orifice just because of its proximity to where the hernia was. But now that hernia there is also fixed, and so it was kind of a two for one deal. Our primary goals today were to do the hernia repair and avoid disrupting her old onlay mesh to avoid the entire lower, you know, roughly 50% of her abdominal cavity, where the tummy tuck was done, where the mesh was placed, where she had a previous mesh infection. And so a minimally-invasive approach, either done laparoscopically, pure lap, or robotic-assisted in this case, allowed us to actually do that without having to divide or deal with any of that old mesh. That was very helpful in terms of the choice of the technique that we made.