Robotically Assisted Totally Extraperitoneal Midline Incisional Hernia Repair After Open Cystectomy

Abstract Introduction This case report describes a 72-year-old male patient who underwent robotically-assisted total extraperitoneal hernia repair. The patient had a history of complete cystectomy with orthotopic neobladder reconstruction and temporary colon diversion via transversostomy through midline laparotomy four years prior. The transversostomy was relocated six months before the current operation, when the patient presented in our outpatient department with a midline incisional hernia. A CT scan revealed a E2, M2, M3, M4 hernia, with an orifice measuring 6 × 20 cm. This case illustrates the feasibility of robotically-assisted total extraperitoneal repair even after open cystectomy with resection of the ligamentum umbilicale. Methods The initial entry into the retroperitoneal space was achieved through the right upper rectus sheath. The initial phase of the operation was conducted endoscopically. Following the creation of the left retro rectus space, three 8 mm robotic ports were strategically placed along the left semilunar line, and the robotic system was docked. The retzius space was completely developed extraperitoneally using the robotic system, irrespective of the previous surgical procedure. Subsequently, a cross-over maneuvre was executed through an incision of the posterior rectus sheath on the contralateral side. After developing the retrorectus space on the contralateral side, the former stomasite reached the lateral border of the right posterior rectus sheath. To fully overlap the hernia site, a partial right-sided transversus abdominis release was performed. Following this, an uncoated synthetic mesh (18 × 32 cm) was placed, ensuring sufficient overlap of the hernia site. Results The postoperative phase was uneventful and the patient was discharged on the second postoperative day. No complications occurred. Conclusion Robotic assisted totally extraperitoneal hernia repair is offers a suitable approach for treatment of midline hernias even following partial resection of the peritoneum and the ligamentum umbicale.