Hepatocellular carcinoma (HCC) is the most common primary liver cancer and is associated with high morbidity and mortality. In this case, the patient was incidentally found to have a segment V/VI lesion consistent with HCC and a IVb lesion indeterminate probability of malignancy. He underwent a robotic-assisted hepatectomy for a segment V/VI lesion with cholecystectomy and evaluation by ultrasound and excisional biopsy of a segment IVb lesion. His postoperative course was unremarkable, and he was discharged on postoperative day four. The pathology demonstrated well-differentiated HCC with resection margins negative for carcinoma. This video demonstrates an experienced surgeon’s technique for performing a robotic hepatectomy for a segment V/VI lesion with cholecystectomy and evaluation by ultrasound and excisional biopsy of a segment IVb lesion. It also highlights effective management of bleeding during hepatic parenchymal transection.
Robotic extraperitoneal approaches have expanded the possibilities of minimally invasive abdominal wall reconstruction. The suprapubic preperitoneal eTEP (PeTEP) technique offers an alternative for selected patients with small-to-medium midline hernias, with or without rectus diastasis, in whom preservation of the retrorectus plane is desirable. This article describes the application of PeTEP in a 58-year-old male with a 3-cm primary umbilical hernia and a 5-cm rectus diastasis, using a suprapubic robotic extraperitoneal approach to achieve functional midline reconstruction while maintaining the integrity of the retrorectus space. The procedure includes pretransversalis access, development of the preperitoneal and pretransversalis planes, midline restoration, and placement of a preperitoneal polypropylene mesh. This technique avoids posterior sheath division, neurovascular bundle manipulation, and retromuscular dissection, thereby reducing potential morbidity in selected patients. This case illustrates the feasibility of PeTEP in a carefully selected patient. The authors do not propose this approach as a replacement for open or transabdominal techniques, but rather as an additional option within a broader reconstructive spectrum.
This case describes a 58-year-old man who developed a symptomatic incisional ventral hernia following a trauma laparotomy and left nephrectomy after a motor vehicle collision. The patient presented with multiple midline hernia defects associated with bulging and discomfort. This video demonstrates a robotic transabdominal preperitoneal (rTAPP) repair with mesh. The case highlights practical strategies for managing intra-abdominal adhesions and a prior gastrostomy site, while outlining alternative operative approaches for cases in which preperitoneal flap development is technically challenging.
A 55-year-old female has a history of multiple abdominal surgeries including laparoscopic cholecystectomy, appendectomy, laparoscopic hysterectomy, tubal ligations, and multiple cesarean sections through a low transverse (Pfannensteil) incision. Cross-sectional imaging demonstrated multiple midline hernias ranging from 1–3 cm, a rectus diastasis measuring 4 cm wide, and intraparietal cesarean section (C-section) hernia (Zanellato Type II). She underwent a robotic retromuscular extended totally extraperitoneal (eTEP) repair wherein her ventral midline hernias, rectus diastasis, and intraparietal hernia were all repaired and reinforced with wide mesh overlap. This case highlights the strengths of an eTEP approach, the decision making behind considering all of a patient’s abdominal wall pathology, and the considerations with intraparietal hernias post C-section.
Excision of Suspected Chronic Infected Suture Sinus Benjamin S. C. Fung, MD, FRCSC1; Eric M. Pauli, MD, FACS, FASGE2 1North York General Hospital, University of Toronto 2Penn State Health Milton S. Hershey Medical Center
A 65-year-old female with a history of a left deep inferior epigastric perforator (DIEP) flap for breast reconstruction presented with an incisional hernia and a draining sinus tract overlying the site for her DIEP flap harvest confirmed on physical exam and cross-section imaging. She underwent a wound exploration where the entire suture sinus was excised, and it was confirmed that there was no residual foreign material left in the area. This case highlights the importance of staged abdominal wall reconstruction and addressing chronic infection before proceeding with surgery.
Excision of Infected Onlay Mesh Benjamin S. C. Fung, MD, FRCSC1; Eric M. Pauli, MD, FACS, FASGE2 1North York General Hospital, University of Toronto 2Penn State Health Milton S. Hershey Medical Center
A 73-year-old female has a history of ventral hernia repair with onlay mesh complicated by mesh infection requiring multiple debridement. She later underwent additional laparotomies for other procedures that led to her previous mesh being chronically infected and exposed to air. Multiple office debridement did not successfully remove all of the mesh. She was taken to the operating room where her onlay mesh was completely excised. This case highlights the importance of complete foreign body excision when dealing with infected prostheses of the abdominal wall.
Recurrent gallstone pancreatitis is a common and potentially morbid condition for which definitive cholecystectomy is recommended to prevent recurrent biliary complications and reduce hospital readmissions. Surgical management may be technically challenging in patients with prior pancreatic resection because of altered anatomy, adhesions, and concern for malignancy recurrence. This video demonstrates a robotic-assisted cholecystectomy performed in a 78-year-old man with recurrent gallstone pancreatitis and a history of distal pancreatectomy for pancreatic acinar cell carcinoma. Preoperative imaging demonstrated cholelithiasis without evidence of recurrent malignancy. Diagnostic laparoscopy was performed to exclude occult intra-abdominal disease before proceeding with cholecystectomy. Operative findings included chronic cholecystitis and cholelithiasis. Robotic dissection facilitated meticulous clearance of fibrofatty tissue within the hepatocystic triangle and safe dissection around the cystic structures prior to cystic duct division, consistent with established principles for preventing bile duct injury. The procedure was completed without complication. This case highlights the role of robotic-assisted cholecystectomy in patients with recurrent gallstone pancreatitis and prior pancreatic surgery, where enhanced visualization and instrument dexterity may improve operative safety in complex inflammatory and reoperative settings.
A 58-year-old patient underwent robotic bilateral transversus abdominis release (TAR) for repair of a recurrent incisional hernia following prior hernia repair complicated by mesh infection and subsequent explantation. This approach was selected based on the patient’s surgical history, the size of the hernia defect, and the extent of incarcerated small bowel. A double-docking technique was employed to facilitate bilateral TAR, and a large macroporous polypropylene mesh was placed. This case highlights the operative decision-making involved in complex hernia repair and demonstrates the technical considerations for performing a robotic bilateral TAR.
Pediatric inguinal hernias are indirect, resulting from a persistent patent processus vaginalis (PPV). These hernias will not spontaneously heal and carry a serious, persistent risk of incarceration. Consequently, surgical repair is typically advised soon after diagnosis to minimize the risk of incarceration.
This report details a 4-year-old girl with a reducible left inguinal hernia containing the greater omentum undergoing minimally invasive laparoscopic percutaneous extraperitoneal closure (LPEC). LPEC offers improved visualization, superior cosmetic results, and the ability to identify and repair contralateral PPV during the same procedure, which reduces the risk of metachronous hernia—particularly in girls, where the technique is technically straightforward.
Hereditary spherocytosis (HS) is a form of inherited hemolytic anemia seen in children. HS is characterized by anemia, jaundice, splenomegaly, and complications such as gallstone formation or growth delay. While mild cases may be managed conservatively, splenectomy remains the definitive treatment for patients with severe symptoms or complications. This case presents a 10-year-old male with HS who presented with anemia, fatigue, abdominal pain, and palpable splenomegaly. He was found to have splenomegaly with a splenic length of 19.6 cm. He ultimately underwent a laparoscopic total splenectomy after receiving appropriate preoperative vaccinations. The procedure was completed successfully without complications, and the patient was discharged on post-op day 3. At follow-up, he demonstrated improved hemoglobin levels, resolution of abdominal pain, and no early complications. This case highlights the role of laparoscopic total splenectomy as a safe and effective treatment for pediatric patients with hereditary spherocytosis and massive splenomegaly, offering durable hematologic improvement with the benefits of a minimally invasive approach.
