A clinical photograph shows the preoperative abdominal surface markings for an extended totally extraperitoneal (eTEP) hernia repair. The patient is in a supine position, draped with green surgical cloths. Annotated markings on the skin indicate planned laparoscopic port placements: a 10 mm camera port is marked superiorly and slightly lateral to the midline, and two 5 mm working ports are marked in the mid-abdominal region to facilitate triangulation. The umbilicus is identified with a vertical double-headed arrow. In the lower left quadrant (patient's right), a trapezoidal area is labeled 'H' for Hernia, along with anatomical sketches indicating the inguinal region and musculature. This visual serves as a surgical planning guide for the eTEP approach, emphasizing the caudal-to-cranial port configuration used to access the preperitoneal space for inguinal hernia mesh placement without entering the peritoneal cavity.

Two-panel intraoperative clinical photograph (A, B) captured during a robotic-assisted abdominal wall hernia repair. Image A demonstrates the crossover maneuver, where the posterior rectus fascia is being incised approximately 0.5–1 cm medial to its junction with the anterior rectus sheath. Visible tissues include the reddish, striated fibers of the rectus muscle and the pale, fibrous posterior rectus sheath. Robotic instrumentation (monopolar curved scissors) is shown performing the dissection to enter the preperitoneal space. Image B highlights a rectus diastasis, indicated by a blue bracket, with visible stretching of the midline fibrous tissue. Shadowing fibers of the contralateral rectus muscle are coming into view as the dissection progresses. The visual demonstrates key surgical steps in retromuscular dissection, including the preservation of the linea alba ventrally and the peritoneum dorsally. The content is intended for surgical education, specifically illustrating the anatomy and technical steps for robotic eTEP (enhanced-view Totally Extraperitoneal) hernia repair and diastasis recti management.

This clinical photograph is an intraoperative endoscopic view from a robotic-assisted surgical procedure, specifically an extended totally extraperitoneal repair (eTEP) for a paraumbilical hernia and rectus diastasis. The image demonstrates a 'cross-over' technique used to dissect and communicate both retrorectus spaces. The surgical field displays varied tissue textures: the upper portion shows striated red muscle tissue with visible small vessels, while the central area reveals white, glistening fascial planes and globular preperitoneal fat. A robotic surgical instrument, identified as monopolar curved scissors, is positioned at the dissection plane to perform sharp and blunt dissection between the retrorectus and preperitoneal spaces. The digital interface at the bottom of the screen provides telemetry for the robotic system, confirming the use of fenestrated bipolar forceps and monopolar curved scissors. This visual highlights the precise tissue handling and clear visualization of anatomical planes required for complex abdominal wall reconstruction.

This clinical photograph displays a high-definition intraoperative view of a robotic-assisted surgical procedure, specifically an extended totally extraperitoneal (eTEP) repair for paraumbilical hernia and rectus diastasis. The visual focus is on the apposition of the rectus muscles within the retro-rectus space. The surgical field reveals deep red striated muscle tissue and white-to-translucent connective fascia. Central to the image is the active use of robotic endo-wristed instrumentation: a set of fenestrated bipolar forceps on the left and a mega suturecut needle driver on the right. The needle driver is shown manipulating a curved surgical needle threaded with a blue monofilament suture, demonstrating intracorporeal suturing technique. This image serves as an educational example of robotic hernia repair, highlighting the precision of robotic tools in reconstructing the abdominal wall by bringing the medial edges of the rectus muscles together.

Educational graphic illustrating the surgical planning and anatomy for robotic transabdominal retromuscular umbilical prosthetic hernia repair (r-Rives or r-TARUP) via a left-lateral approach. Figure A shows an infographic detailing patient positioning on the operating table and port placement lateral to the left rectus muscle. Figure B is a clinical photograph of a patient's abdomen under pneumoperitoneum; ink markings delineate the umbilical hernia (central circle) and the anticipated mesh size (outer square). Transparietal needles are inserted at the square's perimeter to guide intra-abdominal preparation. Figure C is a cross-sectional anatomical diagram of the abdominal wall layers (skin, subcutaneous fat, rectus muscles, and posterior rectus sheaths). It maps the surgical dissection path (gray arrow) through the retrorectus space. Key steps are numbered: (1) green dots mark the lateral entry into the left posterior rectus sheath; (2) red dots signify the medial reopening of the sheath near the linea alba; (3) blue dots indicate the entry into the right posterior rectus sheath; (4) identifies lateral nerve preservation zones; (5) shows the mobilized hernia sac and peritoneal bridge. This content serves as a guide for surgical residents and fellows learning complex robotic ventral hernia repair techniques.

This intraoperative clinical photograph captures a key step in a robotic-assisted ventral hernia repair using the Da Vinci surgical system. The image demonstrates the closure of the ipsilateral posterior rectus sheath (PRS) following retromuscular mesh placement. A robotic needle driver (Mega SutureCut) is seen manipulating a 3-0 absorbable barbed suture, characterized by its thin, light blue appearance and integrated barbs for knotless fixation. The suture is being used in a continuous running fashion to approximate the edges of the PRS. Significantly, the suture line incorporates the edge of a synthetic macroporous mesh, which is visible as a grid-like filament structure positioned in the retrorectus space. This technique secures the mesh at the cranial and caudal borders to prevent migration while simultaneously restoring the peritoneal barrier. The surrounding tissue shows characteristic surgical anatomy, including the vascularized surface of the posterior sheath and the edge of the rectus muscle. This visual is intended for surgical education regarding robotic abdominal wall reconstruction and mesh fixation techniques.

This composite of six laparoscopic images (A-F) illustrates the sequential steps of the Transabdominal Sublay (TAS) procedure for ventral hernia repair. Image A shows initial laparoscopic adhesiolysis using graspers to clear the surgical field. In Image B, the peritoneum and posterior rectus sheath are incised to access the retromuscular plane. Image C demonstrates further blunt dissection of the retromuscular space to create sufficient room for mesh placement. Image D visualizes the closure of the primary hernia defect using a continuous suture technique with a surgical needle. In Image E, a synthetic polypropylene mesh with a characteristic woven texture is introduced and positioned within the dissected sublay space, ensuring adequate overlap of the defect margins. Finally, Image F shows the securing of the mesh and the closure of the peritoneal flap to exclude the mesh from the intraperitoneal cavity. This clinical series serves as an educational guide for surgeons on the laparoscopic transperitoneal approach to extraperitoneal space reinforcement.

An intraoperative clinical photograph demonstrating the placement of a synthetic mesh during a retrorectus ventral hernia repair (Rives-Stoppa technique). The visual depicts a large, white, microporous polypropylene mesh laid flat in the retrorectus plane. The rectus abdominis muscles are laterally retracted, with a white arrow indicating the medial border of the retracted muscle. The mesh is positioned directly over the posterior rectus sheath, which has been approximated in the midline. A yellow arrow points to interrupted fixation sutures (2-0 Prolene) that secure the mesh to the underlying posterior sheath to prevent migration. The surgical field shows the subcutaneous fat and the margins of the abdominal wall defect. This image serves as an educational example of proper mesh orientation, tension-free placement, and surgical fixation within the submuscular space for complex abdominal wall reconstruction.

An intraoperative clinical photograph demonstrating the placement of a synthetic mesh during a retrorectus ventral hernia repair (Rives-Stoppa technique). The visual depicts a large, white, microporous polypropylene mesh laid flat in the retrorectus plane. The rectus abdominis muscles are laterally retracted, with a white arrow indicating the medial border of the retracted muscle. The mesh is positioned directly over the posterior rectus sheath, which has been approximated in the midline. A yellow arrow points to interrupted fixation sutures (2-0 Prolene) that secure the mesh to the underlying posterior sheath to prevent migration. The surgical field shows the subcutaneous fat and the margins of the abdominal wall defect. This image serves as an educational example of proper mesh orientation, tension-free placement, and surgical fixation within the submuscular space for complex abdominal wall reconstruction.

This clinical photograph captures a laparoscopic view during an e-TEP (enhanced-view Totally Extraperitoneal) Rives-Stoppa ventral hernia repair. The image demonstrates the placement and unrolling of a silver-white polypropylene mesh in the retrorectus (retromuscular) space. The mesh exhibits a characteristic woven or knitted grid-like texture with uniform micropores and visible filaments, displaying inherent flexibility as it drapes over the underlying tissues. A metallic laparoscopic grasper is visible in the lower-left foreground, manipulating the mesh. The surgical field reveals reddish, vascularized muscle tissue with a moist, glossy appearance. Shadowing at the center suggests the use of laparoscopic instrumentation within a confined preperitoneal plane. This visual illustrates a critical step in modern abdominal wall reconstruction, emphasizing the importance of proper mesh orientation and wide overlap within the retrorectal space to prevent hernia recurrence.

This intraoperative clinical photograph captures a key step in a sublay (Rives-Stoppa) incisional hernia repair. The image demonstrates the dissection of the abdominal wall layers to create a retromuscular space. A linear incision has been made through the posterior rectus sheath near the linea alba, which is held open by surgical instruments to expose the underlying posterior aspect of the rectus abdominis muscle. This specific surgical maneuver is essential for entering the retro-rectus plane, where a prosthetic mesh will eventually be placed. The anatomical structures are clearly labeled: the 'Posterior rectus sheath' is seen as the fascial layer being retracted, and the 'Rectus muscle' is visible within the developed space. The surgical field shows the use of metallic forceps and a dissecting instrument, illustrating the transition from superficial to deep abdominal wall layers. This visual is used to teach medical students and surgical residents the technique of retromuscular plane development and anatomical identification during complex ventral hernia repairs.

This clinical photograph illustrates the standard laparoscopic port placement for a Totally Extraperitoneal (TEP) inguinal hernia repair. The patient is positioned supine, with the abdomen draped in green surgical sheets. Three trocars are inserted along the midline into the preperitoneal space. The superior port is a 10-mm infraumbilical port, equipped with a valve mechanism and insufflation tubing, typically used for the 30-degree laparoscope. Positioned inferiorly in the midline are two working ports: a 5-mm port placed midway between the umbilical and pubic regions, and a 5-mm suprapubic port located approximately 2–3 cm above the pubic symphysis. The visual demonstrates the vertical triangulation required for instruments to reach the inguinal region. This configuration allows the surgeon to operate within the extraperitoneal plane without entering the peritoneal cavity, minimizing the risk of visceral injury and facilitating mesh placement over the direct, indirect, and femoral hernia sites.

A clinical photograph of a patient's abdomen prepared for a surgical procedure, specifically illustrating the port placement for a classical totally extraperitoneal (TEP) inguinal hernia repair. The image shows surgical markings on the skin within a sterile green drape field. Three primary port locations are arranged vertically along the midline of the abdomen: a 10-mm camera port located just below the umbilicus, followed inferiorly by two 5-mm working ports. On the patient's lower right side (viewer's left), an ovoid marking identifies the location of the 'Hernia'. Additional geometric and hashed markings are visible in the lower abdominal and suprapubic regions, likely representing anatomical landmarks, planned dissection boundaries, or reinforcement zones for mesh placement. This visual is designed to teach the standard midline port configuration used to access the preperitoneal space while avoiding intra-abdominal entry during laparoscopic hernia surgery.

A clinical photograph of the surgical field during a Totally Extraperitoneal (TEP) inguinal hernia repair. The image displays the abdominal region prepped with antiseptic and surrounded by blue sterile drapes. Three laparoscopic cannulas (trocars) are successfully inserted into the preperitoneal space in a triangular configuration. The primary 12-mm observation cannula is positioned superiorly at the subumbilical midline, held by a surgeon's gloved hand. Two smaller operative cannulas are positioned inferiorly and laterally to the midline; the left-sided cannula insertion point is marked with a numeral '3' on the skin. Small, clean transverse incisions are visible at the entry points. This stage of the procedure demonstrates the portal placement necessary for establishing the preperitoneal working space and subsequent endoscopic visualization of the internal inguinal ring for mesh placement or suturing.

A clinical photograph shows the preoperative abdominal surface markings for an extended totally extraperitoneal (eTEP) hernia repair. The patient is in a supine position, draped with green surgical cloths. Annotated markings on the skin indicate planned laparoscopic port placements: a 10 mm camera port is marked superiorly and slightly lateral to the midline, and two 5 mm working ports are marked in the mid-abdominal region to facilitate triangulation. The umbilicus is identified with a vertical double-headed arrow. In the lower left quadrant (patient's right), a trapezoidal area is labeled 'H' for Hernia, along with anatomical sketches indicating the inguinal region and musculature. This visual serves as a surgical planning guide for the eTEP approach, emphasizing the caudal-to-cranial port configuration used to access the preperitoneal space for inguinal hernia mesh placement without entering the peritoneal cavity.

This clinical photograph is an intraoperative endoscopic view from a robotic-assisted surgical procedure, specifically an extended totally extraperitoneal repair (eTEP) for a paraumbilical hernia and rectus diastasis. The image demonstrates a 'cross-over' technique used to dissect and communicate both retrorectus spaces. The surgical field displays varied tissue textures: the upper portion shows striated red muscle tissue with visible small vessels, while the central area reveals white, glistening fascial planes and globular preperitoneal fat. A robotic surgical instrument, identified as monopolar curved scissors, is positioned at the dissection plane to perform sharp and blunt dissection between the retrorectus and preperitoneal spaces. The digital interface at the bottom of the screen provides telemetry for the robotic system, confirming the use of fenestrated bipolar forceps and monopolar curved scissors. This visual highlights the precise tissue handling and clear visualization of anatomical planes required for complex abdominal wall reconstruction.

This clinical photograph shows an intraoperative view of a pediatric laparoscopic setup for a right congenital inguinal hernia repair. The patient's abdomen is prepped, draped in blue surgical cloth, and appears distended, indicating the presence of pneumoperitoneum. The surgical technique utilizes a two-port approach. A primary 5 mm umbilical port, featuring a white-capped ENDOPATH XCEL trocar, is seen on the left side of the frame, housing the laparoscope for visualization. A second 5 mm working port is inserted in the upper right quadrant of the abdomen. Both trocars are associated with connected fiber optic or insufflation tubing. The skin around the puncture sites shows minor erythema typical of acute surgical access. This image illustrates the minimally invasive port placement strategy used to evaluate internal rings and facilitate hernial sac neck closure in pediatric surgery.