What are the differences between ETEP (Extraperitoneal) Rives-Stoppa and ETEP (Extraperitoneal) Robotic Mesh surgery steps?

Differences Between ETEP Rives-Stoppa and ETEP Robotic Mesh Surgery Steps

The main difference between ETEP Rives-Stoppa and ETEP Robotic Mesh surgery is that the robotic approach offers improved visualization, dexterity, and precision during the retromuscular dissection and mesh placement, while following the same anatomical principles of the traditional Rives-Stoppa repair.

Anatomical Approach

Both techniques utilize the extraperitoneal space for mesh placement, specifically the retromuscular (retrorectus) space:

• Common Goal: Place mesh in the retromuscular space between the rectus muscle and posterior rectus sheath
• Advantage: Avoids intraperitoneal placement, reducing risk of adhesions and bowel complications

ETEP Rives-Stoppa Procedure Steps

1. Port Placement:

   • Initial port placed in lateral rectus sheath
   • Additional working ports placed under direct vision
   • Typically requires 3-4 ports total

2. Space Creation:

   • Dissection begins in the retrorectus space
   • CO2 insufflation helps maintain working space
   • Crossover to contralateral retrorectus space by dissecting behind the linea alba

3. Hernia Reduction:

   • Peritoneal sac is reduced
   • Contents returned to peritoneal cavity
   • Peritoneum preserved intact when possible

4. Defect Closure:

   • Posterior rectus sheath closed with sutures
   • Anterior fascial defect closed to restore linea alba
   • May require component separation (TAR) for larger defects in 30% of cases 1

5. Mesh Placement:

   • Polypropylene mesh placed in retromuscular space
   • Mesh fixation with sutures or tacks
   • Average mesh size around 486 cm² 2

6. Closure:

   • Drain placement optional
   • Port site fascial closure for ports ≥10mm 3

ETEP Robotic Mesh Surgery Steps

1. Port Placement:

   • Camera port typically placed at lateral border of rectus
   • Additional robotic arm ports placed under direct vision
   • Assistant port for retraction/suction

2. Robotic Docking:

   • Patient positioning in supine position
   • Robot docked from lateral or cranial approach
   • Specific positioning of robotic arms to optimize workspace

3. Space Creation:

   • Enhanced visualization allows more precise dissection
   • Robotic instruments facilitate crossing midline
   • Extended dissection possible with robotic articulation

4. Hernia Reduction:

   • Similar to laparoscopic approach but with improved dexterity
   • Robotic instruments allow for more precise handling of hernia contents

5. Defect Closure:

   • Robotic suturing allows for more precise posterior sheath closure
   • Fascial closure with barbed sutures common
   • Potential for more complex reconstruction techniques

6. Mesh Placement:

   • Precise positioning of larger mesh possible
   • More secure fixation with robotic suturing
   • Better distribution and flattening of mesh

7. Closure:

   • Similar to laparoscopic approach
   • Fascial closure for all port sites ≥10mm 3

Key Differences

1. Operative Time:

   • ETEP Rives-Stoppa: Average 204 minutes 2
   • Robotic approach: Initial learning curve with longer times, decreasing to average 63.8 minutes after 29 cases 4

2. Technical Complexity:

   • ETEP Rives-Stoppa: Technically demanding with standard laparoscopic instruments
   • Robotic approach: Enhanced dexterity and visualization, but requires specific training

3. Learning Curve:

   • ETEP Rives-Stoppa: Steep learning curve requiring advanced laparoscopic skills
   • Robotic approach: Learning curve of approximately 29 cases for operative efficiency and 51 cases for minimizing adverse outcomes 4

4. Dissection Precision:

   • ETEP Rives-Stoppa: Limited by standard laparoscopic instruments
   • Robotic approach: Enhanced by 3D visualization and articulating instruments

5. Suturing Capability:

   • ETEP Rives-Stoppa: More challenging intracorporeal suturing
   • Robotic approach: Facilitates complex suturing for posterior and anterior fascial closure

Clinical Outcomes

Both approaches demonstrate:

• Low recurrence rates
• Short hospital stays (1-4 days)
• Low complication rates (10.5% for ETEP Rives-Stoppa) 5
• Excellent cosmetic results

Practical Considerations

• Patient Selection: Both techniques are suitable for ventral and incisional hernias with defects between 4-8 cm 2
• Contraindications: Hemodynamic instability, anticipated bowel resection (open approach preferred) 6
• Mesh Selection: Both techniques allow for non-absorbable synthetic mesh placement in clean fields 3
• Component Separation: TAR (transversus abdominis release) can be incorporated into both approaches for larger defects 1, 5

Pitfalls and Caveats

1. Avoid midline trocar placement to reduce risk of trocar-site hernias 3
2. Close fascial defects for trocars ≥10mm to prevent port-site hernias 3
3. Ensure adequate mesh overlap (minimum 5cm beyond defect edges)
4. Be prepared to convert to open approach if complications arise
5. Consider surgeon experience - both techniques require specific training and experience

The choice between ETEP Rives-Stoppa and robotic approach should be based on surgeon expertise, available resources, and specific patient factors, with both approaches offering the benefits of retromuscular mesh placement while minimizing peritoneal entry.