Robot-assisted repair of incisional hernia of the abdominal wall: Which access is better—endoscopic totally extraperitoneal preperitoneal plasty (eTEP) or mini- or less-open sublay (e)(MILOS), some first considerations

Abstract

Numerous metanalyses have shown that the retromuscular mesh placement is superior to other positions in terms of recurrence and complication rate. As a result, there has been a surge in novel minimally invasive retromuscular surgical techniques. We compared total extraperitoneal plasty (eTEP) and hybrid Mini/Less-open-Sublay [(e)MILOS] with respect to their adaptability to a surgical robotic system. Unfortunately, there is little to no literature regarding robotic adaptation of the (e)MILOS procedure, which made it rather difficult to juxtapose, but then again also implies that it is not commonly performed. As many benefits as the robot brings to endoscopic surgery, however, there is one major constraint when it comes to directionality. In eTEP dissection is performed in one direction and the trocars are positioned at the edge of the dissection field. The centripetal preparation of the (e)MILOS procedure is less suitable for the currently available systems and would naturally require multiple un- and re-dockings of the robot. Alternatively, the robot could only be used for a minor part of the operation. Looking at the published data concerning laparoendoscopic (e)MILOS and eTEP, there appears to be no significant difference in terms of major complications as well as reoperation and infection rates. However, a comparison to a robot-assisted eTEP cannot be done due to lack of publications. Judging from our own experience, we believe the eTEP technique to harness the advantages of the robot in addition to those of minimally invasive surgery more effectively. Within the last two decades, we have been experiencing a constant increment of endoscopic procedures in hernia surgery. This surge is nonetheless thanks to the availability of robotics in a continuously increasing number of hospitals in Europe and the United States. The combination of the advantages of minimally invasive surgery and robotic systems has been discussed and elaborated on many occasions and platforms. Hence, the goal of this analysis is to compare two broadly established minimally invasive (or less open) retromuscular methods in hernia repair surgery with regard to their adaptability to a surgical robot.