Robotic Transversus Abdominis Release Research Articles

Limitations of Transversus Abdominis Release (TAR)-Additional Bridging of the Posterior Layer And/Or Anterior Fascia Is the Preferred Solution in Our Clinical Routine If Primary Closure is Not Possible.

Background: By separating the abdominal wall, transversus abdominis release (TAR) permits reconstruction of the abdominal wall and the placement of large mesh for many types of hernias. However, in borderline cases, the mobility of the layers is inadequate, and additional bridging techniques may be required for tension-free closure. We now present our own data in this regard. Patients and Methods: In 2023, we performed transversus abdominis release on 50 patients as part of hernia repair. The procedures were carried out using open (n = 25), robotic (n = 24), and laparoscopic (n = 1) techniques. The hernia sac was always integrated into the anterior suture and, in the case of medial hernias, was used for linea alba reconstruction. Results: For medial hernias, open TAR was performed in 22 cases. Additional posterior bridging was performed in 7 of these cases. The ratio of mesh size in the TAR plane to the defect area (median in cm) was 1200cm2/177cm2 = 6.8 in patients without bridging, and 1750cm2/452cm2 = 3.8 in those with bridging. The duration of surgery (median in min) was 139 and 222min and the hospital stay was 6 and 10 days, respectively. Robotic TAR was performed predominantly for lateral and parastomal hernias. These procedures took a median of 143 and 242min, and the hospital stay was 2 and 3 days, respectively. For robotic repair, posterior bridging was performed in 3 cases. Discussion: Using the TAR technique, even complex hernias can be safely repaired. Additional posterior bridging provides a reliable separation of the posterior plane from the intestines. Therefore, the hernia sac is always available for anterior reconstruction of the linea alba. The technique can be implemented as an open or minimally invasive procedure.

Robotic transversus abdominis release using HUGO RAS system: our initial experience.

Transversus abdominis release (TAR) is an effective technique for treating large midline and off-midline hernias. Recent studies have demonstrated that robotic TAR (rTAR) is technically feasible and associated with improved outcomes compared to open surgery. There is no published experience to date describing abdominal wall reconstruction using the novel robotic platform HUGO RAS System (Medtronic®). All consecutive patients who underwent a rTAR in our institution were included. Three of the four arm carts of the HUGO RAS System were used at any given time. Each arm configuration was defined by our team in conjunction with Medtronic® personnel. rTAR was performed as previously described. Upon completion of the TAR on one side, a redocking process with different, mirrored arms angles was performed to continue with the contralateral TAR. Operative variables and early morbidity were recorded. Ten patients were included in this study. The median BMI was 31 (21-40.6) kg/m2. The median height was 1.6m (1.5-1.89m). A trend of decreased operative time, console time, and redocking time was seen in these consecutive cases. No intraoperative events nor postoperative morbidity was reported. The median length of stay was 3 (1-6) days. Robotic TAR utilizing the HUGO RAS system is a feasible and safe procedure. The adoption of this procedure on this novel platform for the treatment of complex abdominal wall hernias has been successful for our team.

Robotic transversus abdominis release (TAR) for ventral hernia repairs is associated with low surgical site occurrence rates and length of stay despite increasing modifiable comorbidities.

Modifiable comorbidities (MCMs) have previously been shown to complicate postoperative wound healing occasionally leading to surgeon hesitancy to repair ventral hernias prior to preoperative optimization of comorbidities. This study describes the effects of MCMs on surgical site occurrences (SSOs) and hospital length of stay (LOS) following robotic transversus abdominis release (TAR) with poly-4-hydroxybutyrate (P4HB) resorbable biosynthetic mesh retromuscular sublay for ventral hernia repair in patients who had not undergone preoperative optimization. A single-surgeon retrospective review was performed for patients who underwent the robotic TAR procedure with P4HB mesh between January 2015 and May 2022. Patients were stratified by the amount of MCMs present: 0, 1, or 2 + . MCMs included obesity, diabetes, and current tobacco use. Patient data was analyzed for the first 60days following their operation. Primary outcomes included 60-day SSO rates and hospital LOS. Three hundred and thirty-four subjects met the inclusion criteria for SSO and prolonged LOS analysis. 16.8% had no MCM, 56.1% had 1 MCM, and 27% had 2 + MCMs. No significant difference in SSO was seen between the 3 groups; however, having 2 + MCMs was significantly associated with increased odds of SSO (odds ratio 3.25, P = .019). When the groups were broken down, only having a history of diabetes plus obesity was associated with significantly increased odds of SSO (odds ratio 3.54, P = .02). No group showed significantly increased odds of prolonged LOS. 2 + MCMs significantly increase the odds of SSO, specifically in patients who have a history of diabetes and obesity. However, the presence of any number of MCMs was not associated with increased odds of prolonged LOS.

Computed tomography measurements to predict need for robotic transversus abdominis release: a single institution analysis.

The radiographic rectus width to hernia width ratio (RDR) has been shown to predict ability to close fascial defect without additional myofascial release in open Rives-Stoppa abdominal wall reconstruction (AWR), but it has not been studied in robotic AWR. We aimed to examine various CT measurements to determine their usability in predicting the need for transversus abdominis release (TAR) in robotic AWR. We performed a single-center retrospective review of 137 patients with midline ventral hernias over a 5-year period who underwent elective robotic retrorectus AWR. We excluded patients with M1 or M5 hernias, lateral/flank hernias, and hybrid repairs. The CT measurements included hernia width (HW), hernia width/abdominal width ratio (HW/AW), and RDR. Univariate, multivariate and area under the curve (AUC) analyses were performed. 58/137 patients required TAR (32 unilateral, 26 bilateral). Patients undergoing TAR had a significantly higher average HW and HW/AW and lower RDR. Multivariate analysis revealed that prior hernia repair was independently associated with need for TAR (p = 0.03). ROC analysis and AUC values showed acceptable diagnostic ability of HW, HW/AW and RDR in predicting need for TAR. Cutoffs of RDR ≤ 2, HW/AW > 0.3, and HW > 10cm yielded high specificity in determining need for any TAR (97.5% vs. 96.2% vs. 92.4%) or bilateral TAR (95.5% vs. 94.6% vs. 92.8%). History of prior hernia repair was a risk factor for robotic TAR. CT measurements have some predictive value in determining need for TAR in robotic AWR. Further prospective analysis is needed in this patient population.

Five years of robot-assisted ventral hernia repair: initial experience and surgical outcome

Objective Robot-assisted ventral hernia repair (RVHR) has become a feasible alternative for open ventral hernia repair showing fewer postoperative complications and satisfying short-term results. However, long-term results are scarce in current literature. Methods All consecutive patients who underwent robot-assisted surgery for ventral hernias from June 2018 until February 2023 were included. Patient records were retrospectively reviewed for indication, need for conversion, length of stay (LOS), postoperative complications, and postoperative pain. In addition, long-term (>24 months) results (recurrence, chronic pain, and esthetic satisfaction) were assessed by phone questionnaire. Results In total, 177 patients underwent a robot-assisted ventral hernia repair. Indication for surgery was incisional hernia (N = 109) and primary hernia (N = 68), including 124 cases with abdominal rectus diastasis. A TransAbdominal Retromuscular Umbilical Prosthesis (TARUP) was performed in 138 patients. Robotic Transversus Abdominis Release (TAR) and Extended Totally Extraperitoneal Repair (eTEP) were performed in 20 (11%) and 9 (5%) cases, respectively. Median LOS was 2 days for TARUP and 3.5 days for TAR. Minor complications occurred in 22 patients (16 TARUP, 5 TAR, 1 eTEP). The average pain score on the first postoperative day was 1.8/10. No risk factors for morbidity could be identified by uni- and multivariable analysis. Hernia recurrence developed in four (2%) patients. Chronic pain was reported in two (1%) cases. Seven (4%) patients had esthetic complaints. Conclusion Robot-assisted ventral hernia repair is a safe procedure with low postoperative pain and short LOS. Long-term results including recurrence and chronic pain are satisfying.

Enhanced recovery after robotic ventral hernia repair: factors associated with overnight stay in hospital

PurposeEnhanced recovery after surgery (ERAS) protocols lead to reduced post-operative stay and improved outcomes after most types of abdominal surgery. Little is known about the optimal post-operative protocol after robotic ventral hernia repair (RVHR), including the potential limits of outpatient surgery. We report the results of an ERAS protocol after RVHR aiming to identify factors associated with overnight stay in hospital, as well as patient-reported pain levels in the immediate post-operative period.MethodsThis was a prospective cohort study of consecutive patients undergoing RVHR. Patients were included in a prospective database, registering patient characteristics, operative details, pain and fatigue during the first 3 post-operative days and pre- and 30-day post-operative hernia-related quality of life, using the EuraHS questionnaire.ResultsA total of 109 patients were included, of which 66 (61%) underwent incisional hernia repair. The most performed procedure was TARUP (robotic transabdominal retromuscular umbilical prosthetic hernia repair) (60.6%) followed by bilateral roboTAR (robotic transversus abdominis release) (19.3%). The mean horizontal fascial defect was 4.8 cm, and the mean duration of surgery was 141 min. In total, 78 (71.6%) patients were discharged on the day of surgery, and factors associated with overnight stay were increasing fascial defect area, longer duration of surgery, and transverse abdominis release. There was no association between post-operative pain and overnight hospital stay. The mean EuraHS score decreased significantly from 38.4 to 6.4 (P < 0.001).ConclusionAn ERAS protocol after RVHR was associated with a high rate of outpatient procedures with low patient-reported pain levels.

Modifiable comorbidities impact on ventral hernia recurrence following robotic abdominal wall reconstruction using resorbable biosynthetic mesh: 36-month follow-up

BackgroundThere is an ongoing debate on the role of comorbidities in hernia outcomes, particularly with minimally invasive approaches. This study evaluated the impact of modifiable comorbidities (MCMs) on 36-month hernia recurrence rates after robotic transversus abdominis release (TAR) with resorbable biosynthetic mesh underlay for primary ventral hernia repair. MethodsA review of medical records for patients who underwent the robotic TAR procedure between January 2015 and May 2022 performed by a single surgeon was conducted. Patients were separated into three groups: those with 0, 1, and 2+ MCMs, followed by a breakdown of comorbidity types and combinations of comorbidities. MCMs included obesity, diabetes, and tobacco use. The primary outcomes included hernia recurrence at 36 months and the time between surgery and recurrence. Results175 patients met the inclusion criteria, with a mean hernia diameter of 12.9 ± 5.4 cm and a mean BMI of 34 ± 8 kg/m2. 9.7 % of patients experienced hernia recurrence at 36-month follow-up. No significant difference in the recurrence rate and length of time between surgery and recurrence was observed between the groups (p = .265 and p = .283, respectively). No group, single comorbidity, or a combination of comorbidities was found to have significantly increased odds of recurrence at 36 months. ConclusionThe presence of MCMs, either alone or in combination with another, did not significantly increase the odds of hernia recurrence at 36 months following ventral hernia repair using this approach. Future studies with larger sample sizes and multiple surgeons are needed to corroborate this data. Key messageModifiable comorbidities have previously been shown to increase the risk of hernia recurrence after ventral hernia repair. Our study found relatively low rates of hernia recurrence and no significantly increased odds of recurrence among different comorbid groups at 36-month follow-up following robotic transversus abdominis release with resorbable biosynthetic mesh underlay.

OC-047 ENHANCED RECOVERY AFTER ROBOTIC VENTRAL HERNIA REPAIR

Abstract Aim Enhanced recovery after surgery (ERAS) protocols lead to reduced postoperative stay and improved outcomes after most types of abdominal surgery. Little is known about the optimal postoperative protocol after robotic ventral hernia repair (RVHR), including the potential limits of outpatient surgery. We report the results of an ERAS protocol after RVHR aiming to identify predictors of overnight stay in-hospital, as well as patient-reported pain levels in the immediate postoperative period. Material &amp; Methods This was a prospective cohort study of consecutive patients undergoing RVHR. Patients were included in a prospective database, registering patient characteristics, operative details, pain and fatigue during the first three postoperative days and pre- and 30-day postoperative hernia-related quality of life, using the EURA-HS questionnaire. Results A total of 109 patients were included, of which 66 (61%) underwent incisional hernia repair. The most performed procedure was TARUP (Robotic Transabdominal Retromuscular Umbilical Prosthetic Hernia Repair) (60.6%) followed by bilateral roboTAR (robotic Transversus Abdominis Release) (19.3%). The mean horizontal fascial defect was 4.8 cm and the mean duration of surgery was 141 minutes. In total, 78 (71.6%) patients were discharged on the day of surgery, and confounders associated with overnight stay were increasing fascial defect area, duration of surgery, and addition of TAR. There was no association between postoperative pain and overnight hospital stay. The mean EuraHS score decreased significantly from 38.4 to 6.4 (P &amp;lt; 0.001). Conclusions The application of an ERAS protocol after RVHR enabled a high rate of outpatient procedures with low patient-reported pain scores.

OC-099 ROBOTICALLY-ASSISTED ENHANCED-VIEW TOTALLY EXTRAPERITONEAL (R-ETEP) TECHNIQUE FOR ENDOSCOPIC RETROMUSCULAR HERNIA REPAIR. A RETROSPECTIVE ANALYSIS OF OUR FIRST 99 CASES

Abstract Introduction The availability of robotics has marked the beginning of a new era in hernia surgery. Due to its tiltable instruments the robot grants a dexterity which is not comparable to any conventional minimally invasive approach. In 2019 we have established r-eTEP-repair in our hospital. The objective of this analysis is to share our experience of the first ninety-nine cases. Materials and Methods A retrospective analysis was carried out of all patients who underwent a r-eTEP repair in our hospital from September 2019 to January 2023 using gathered data out of our hospital information system (ORBIS Dedalus). Results Within the study period, we operated on a total of 99 patients. In 27 patients an extraperitoneal transversus abdominis release (eTAR) was performed. Complete closure of the hernia defect was possible in all cases and an uncoated synthetic mesh was placed in the retromuscular plane. In 3 cases a partial open hybrid procedure with robotic transversus abdominis release was performed. The median defect size was 25cm2 (2,25–375 cm2). The median mesh size was 540 cm2 (260–1350 cm2). The postoperative complication rate was 6.06%. There was one intraoperative complication and no abdominal reoperations. Median length of hospital stay was 3 days (2–10). Conclusion eTEP is a safe and minimally invasive procedure for a retromuscular mesh placement. In combination with a transversus abdominis release, even complex findings can comfortably be treated endoscopically.

Long term outcomes of robotic-assisted abdominal wall reconstruction: a single surgeon experience.

Robotic abdominal wall reconstruction (RAWR) is one of the most significant advances in the management of complex abdominal wall hernias. The objective of this study was to evaluate long term outcomes in a cohort of patients that underwent complex RAWR in a single center. This was a longitudinal retrospective review of a cohort of 56 patients who underwent complex RAWR at least 24months prior by a single surgeon at a tertiary care institution. All patients underwent bilateral retro-rectus release (rRRR) with or without robotic transversus abdominis release (rTAR). Data collected include demographics, hernia details, operative and technical details. The prospective analysis included a post-procedure visit of at least 24months from the index procedure with a physical examination and quality of life survey using the Carolinas Comfort Scale (CCS). Patients with reported symptoms concerning for hernia recurrence underwent radiographic imaging. Descriptive statistics (mean ± standard deviation or median) were calculated for continuous variables. Chi-square or Fisher's exact test as deemed appropriate for categorical variables, and analysis of variance or the Kruskal-Wallis test for continuous data, were performed among the separate operative groups. A total score for the CCS was calculated and analyzed in accordance with the user guidelines. One-hundred and-forty patients met the inclusion criteria. Fifty-six patients consented to participate in the study. Mean age was 60.2years. Mean BMI was 34.0. Ninety percent of patients had at least one comorbidity and 52% of patients were scored ASA 3 or higher. Fifty-nine percent were initial incisional hernias, 19.6% were recurrent incisional hernias and 8.9% were recurrent ventral hernias. The mean defect width was 9cm for rTAR and 5cm for rRRR. The mean implanted mesh size was 945.0cm2 for rTAR and 362.5cm2 for rRRR. The mean length of follow-up was 28.1months. Fifty-seven percent of patients underwent post-op imaging at an average follow-up of 23.5months. Recurrence rate was 3.6% for all groups. There were no recurrences in patients that underwent solely bilateral rRRR. Two patients (7.7%) that underwent rTAR procedures were found with recurrence. Average time to recurrence was 23months. Quality of life survey demonstrated an overall CCS score of 6.63 ± 13.95 at 24months with 12 (21.4%) patients reporting mesh sensation, 20 (35.7%) reporting pain, and 13 (23.2%) reporting movement limitation. Our study contributes to the paucity of literature describing long term outcomes of RAWR. Robotic techniques offer durable repairs with acceptable quality of life metrics.

Analysis of Factors Associated with Same-Day Discharge After Robotic Transversus Abdominis Release for Incisional Hernia Repairs.

Background: Advancement in surgery has shifted numerous procedures to a same-day discharge (SDD) setting. In this study, we evaluated factors related to SDD after robotic transversus abdominis release (rTAR). Materials and Methods: A retrospective analysis of a prospectively maintained hernia databank was performed. Patients who underwent rTAR for incisional hernias were assigned to either the SDD group (length of stay [LOS] <1) or the inpatient group (LOS ≥1 day). Pre-, intra-, and postoperative variables were compared. Predictors of SDD were explored through a logistic regression, and a mediation analysis was performed to assess their effect on the LOS. Results: Out of the 167 patients included, 53 patients were discharged the same day. Age, American Society of Anesthesiologists score, history of coronary artery disease, and wound infection were significantly higher in the inpatient group. Overall, median LOS was 1 (0-2). Postoperative complications did not differ between SDD and inpatient groups except for Clavien-Dindo Grade-II (1 versus 14, respectively; P = .039). Thirty-day readmission rates were comparable (P = .229). A binary logistic regression to predict factors associated with SDD rTAR showed statistical significance in age, operative time, mesh area, and history of wound infection. Mediation analysis showed that mesh size indirectly affected the LOS through the operative time (a = 0.54; b = 0.46; P < .001). An age >46-year-old, an operative time beyond 217 minutes, and a mesh size >475 cm2 increased the probability of an inpatient stay (area-under-the-receiver operating characteristic curves: 0.69, 0.81, and 0.82, respectively). Conclusion: The pre- and intraoperative factors associated with SDD rTAR were age, history of wound infection, operative time, and mesh area. Further studies are needed to investigate the appropriateness of discharge decisions while balancing patients' benefits, resource utilization, and costs.

Robotic transversus abdominis release for ventral hernia repairs

Background: Robotic transversus abdominis release (roboTAR) is a minimally invasive surgical approach for ventral hernia repairs that builds on the concepts developed by Rives and Stoppa. The Rives–Stoppa procedure incorporates Rives’ retromuscular repair and Stoppa’s concept of giant prosthetic reinforcement of the visceral sac (GPRVS).[1] In an effort to mitigate the limitations of the Rives–Stoppa procedure, Novitsky et al. developed the open transversus abdominis release (TAR). The TAR approach is favorable when repairing large ventral hernia defects, as it provides myofascial advancement to reconstitute linea alba, preserves the neurovascular bundles of the medial abdominal wall, and creates a large extraperitoneal space to allow for mesh reinforcement. Methods: The three main technical components of the roboTAR include the following: bottom-up, Novitsky method, and top-down approach. An understanding of the anatomy and technique involved in the three techniques is critical for performing roboTAR. Results: Within the authors’ practice, the average hernia defect size is 115 cm2. With a n = 200, approximately 1% of our patients has had a surgical site complication. Recurrences are rare and occur in very large complex hernias. The average operative time is approximately 400 min with an average length of stay being 1.2 days. This is consistent with others. Conclusion: Utilizing a minimally invasive approach, as seen in roboTAR, provides additional advantages, including shorter length of hospital stay, reduced wound morbidity, reduced postoperative pain, and expedited return to work and activities of daily living. This article is a comprehensive review of the pertinent anatomy, preoperative evaluation, operative technique, and the postoperative course of roboTAR.

Chronological age does not predict postoperative outcomes following transversus abdominis release (TAR).

Transversus abdominis release (TAR) is an effective procedure for the repair of complex ventral hernias. However, TAR is not a low risk operation, particularly in older adults who are disproportionately affected by multiple age-related risk factors. While past studies have suggested that age alone inconsistently predicts patient outcomes, data regarding age's effect on postoperative outcomes and wound complications following a TAR are lacking. Patients who underwent either an open or robotic bilateral TAR from 1/2018 to 9/2020 were eligible for the study. Patients were stratified by age groups (≥ 60years vs. < 60years and < 60, 60-70, and ≥ 70) and by both age and operative approach. The rates of key postoperative outcomes and wound morbidity were compared between the various cohorts. A total of 300 patients were included: 165 patients were ≥ 60 and 135 patients were < 60. Cohorts stratified by age were well-matched for important hernia factors: defect size (p = 0.31), BMI ≥ 30 (p = 0.46), OR time (p = 0.25), percent open TAR (p = 0.42), diabetes (p = 0.45) and history of prior surgical site infection (p = 0.40). The older cohort had significantly higher rates of coronary artery disease, hypertension, and COPD. On univariate analysis, cohorts stratified by age had similar rates of key postoperative and wound complications including in-hospital complications (p = 0.62), length of stay (p = 0.47), readmissions (p = 0.66), and surgical site occurrences (p = 0.68). Additionally, cohorts stratified by both age and operative approach also had similar outcomes. Multivariate analysis showed that chronological age was not independently associated with surgical site occurrences (p = 0.22), readmissions (p = 0.99), in-hospital complications (p = 0.15), or severe complications (p = 0.79). Open and robotic TARs can be safely performed in older adults and chronological age alone is a poor predictor of patient morbidity following TAR. Further investigation of alternative preoperative screening tools that do not rely solely on age are needed to better optimize surgical outcomes in older adults following TAR.

Learning curve of robotic transversus abdominis release in ventral hernia repair: a cumulative sum (CUSUM) analysis

Despite heightened interest in robotic transversus abdominis release (rTAR), concerns over its steep learning curve (LC) and associated challenges may limit its adoption. This study defines the operative time and morbidity-based LC of a single surgeon's experience with rTAR. A retrospective analysis of patients undergoing rTAR over an 8-year period was conducted. Consecutive ventral and incisional hernia repairs were stratified into four sub-categories based on bilaterality and complexity, with complex hernias being defined as those > 10cm. Cumulative sum analyses (CUSUM) were used to evaluate skin-to-skin time and morbidity LCs. This study included a total of 156 rTARs with a mean skin-to-skin time of 222.8min. Mean skin-to-skin times (min) for sub-categories were as follows: unilateral non-complex (137.6), bilateral non-complex (206.8), unilateral complex (241.9), and bilateral complex (298.6). The CUSUM-LC was obtained by summing the differences between each procedure's operative time and its sub-category mean, revealing a quadratic best-fit line maximum at case 49 and a transition point between early and late phases at case 75. Although skin-to-skin times between early and late phases did not differ significantly (235.3 vs 211.2, respectively; p = 0.12), a significant difference was found in console times. Overall postoperative complications also decreased significantly from early to late phases (41.3% vs 25.9%; p = 0.041). Postoperative complications were predicted by a history of wound infection (c = 0.61). This study reveals that the rTAR LC was overcome between 49 and 75 cases, after which, console time and postoperative complications decreased significantly.

Hybrid Robotic Hernia Repair for Incisional Hernias: Perioperative and Patient-Reported Outcomes.

Background: Minimally invasive abdominal wall reconstruction, utilizing transversus abdominis release (TAR), has been described and shown to be beneficial for ventral hernia repair (VHR). Limited literature is available surrounding the hybrid robotic TAR (h-rTAR) approach, which combines robotic dissection and component separation with open fascial defect closure and mesh deployment. In this study, we describe our h-rTAR technique and present our center's postoperative and patient-reported outcomes (PROs). Methods: h-rTAR VHRs performed between 2013 and 2018 were examined. The h-rTAR technique was described. Patient characteristics and operative variables were analyzed. Perioperative results were presented according to European Hernia Society (EHS) classifications. Pre- and post-operative hernia-specific quality-of-life (QoL) assessments were conducted. Results: Twenty patients who underwent an h-rTAR were included in this study. All hernias were incisional. A bilateral TAR needed in 90% of patients. The average hospital stay was 1.8 days. Two patients experienced medical complications and 5 patients experienced surgical site events. None of the patients experienced a hernia recurrence throughout a mean postoperative follow-up period of 319 days. PROs showed improvement in all domains, especially cosmetic. Conclusion: The h-rTAR technique combines the benefits of robotic and open techniques when used for large incisional VHR with improvement in patient-reported QoL.

The current state of robotic retromuscular repairs—a qualitative review of the literature

The management of ventral incisional hernias (VIH) has undergone many iterations over the last 5years due to evolution in surgical techniques and advancement in robotic surgery. Four general principles have emerged: mesh usage, retromuscular mesh placement, primary fascial closure, and usage of minimally invasive techniques when possible. The application of robotic retromuscular repairs in VIH allow these principles to be applied simultaneously. This qualitative review attempts to answer what robotic retromuscular repairs are described, which patients are selected for these techniques, and what are current outcomes. Using the key words: "robotic retromuscular repair", "robotic Rives Stoppa", and "robotic transversus abdominis release", a PubMed search of articles written up to December 2019 was critically reviewed. 44 articles were encountered, 9 high-quality articles were analyzed for this manuscript. Level of evidence ranged from 2B to 2C. Robotic TAR patients had BMI of 33kg/m2, defect sizes ranging from 7-14cm wide to 12-19cm long, longer OR times, no difference in surgical site events, and shorter length of stay (LOS). The techniques to perform robotic Rives Stoppa (RS) were heterogeneous; however, extended totally extraperitoneal (ETEP) approach is most described. Defect width for RS repairs ranged 4-7cm and LOS was less than 1day. Complication rates were low, there is no long-term data on hernia recurrence, and information on cost is limited. In short-term follow-up, robotic retromuscular repairs show promise that VIH can be repaired with intramuscular mesh, few complications, and shorter LOS. Data on hernia recurrence, long-term complications, and rigorous cost analysis are needed to demonstrate generalizability.

Hybrid robotic transversus abdominis release versus open: propensity-matched analysis of 30-day outcomes.

To examine the hospital length of stay (LOS) and 30day outcomes of hybrid robotic transversus abdominis release (hrTAR) compared with open transversus abdominis release (oTAR). Patients receiving hrTAR were selected from the AHSQC database and propensity matched with a contemporary cohort of oTAR patients. The cohort included 95 hrTAR and 285 oTAR patients. There was a significantly shorter median LOS in the hrTAR cohort (3 vs. 5days, p < 0.001). The rate of surgical site occurrences in the hrTAR cohort was also lower than for oTAR (5% vs. 15%, p = 0.015). Readmission rates were not different between hrTAR and oTAR (6% vs. 8%, p = 0.65). hrTAR demonstrates improved LOS compared to oTAR as well as fewer surgical site related occurrences. Further studies are needed to investigate the etiology behind the improved LOS and to confirm appropriate long-term outcomes from hybrid robotic TAR.

Discussion of: Robotic and hybrid robotic transversus abdominis release may be performed with low length of stay and wound morbidity

Discussion of: Robotic and hybrid robotic transversus abdominis release may be performed with low length of stay and wound morbidity

Robotic and hybrid robotic transversus abdominis release may be performed with low length of stay and wound morbidity

The objective of our study was to compare length of stay and wound complications after hybrid robotic transversus abdominis release (hrTAR) vs. robotic transversus abdominis release (rTAR) Two cohorts of patients undergoing robotic (rTAR) and hybrid robotic (hrTAR) performed by two surgeons at a single institution were analyzed. Mean length of stay (LOS) and incidence of surgical site occurrences (SSO) were compared. 57 patients undergoing rTAR and 25 patients undergoing hrTAR were analyzed. The hrTAR group had larger mean hernia dimensions and a larger proportion of men but otherwise the patient cohorts were similar. LOS was not statistically different between rTAR and hrTAR (2.8 vs 3.7 days p = 0.06). We found no difference in incidence of surgical site occurrences between the two groups (7.0% vs 4.0% p = 0.52). Hybrid robotic assisted TAR allows for repair of complex ventral hernias with similar lengths of stay and wound morbidity to pure robotic repairs.

Robotic Transversus Abdominis Release (TAR): is it possible to offer minimally invasive surgery for abdominal wall complex defects?

We describe the preliminary national experience and the early results of the use of robotic surgery to perform the posterior separation of abdominal wall components by the Transversus Abdominis Release (TAR) technique for the correction of complex defects of the abdominal wall. We performed the procedures between 04/2/2015 and 06/15/2015 and the follow-up time was up to six months, with a minimum of two months. The mean surgical time was five hours and 40 minutes. Two patients required laparoscopic re-intervention, since one developed hernia by peritoneal migration of the mesh and one had mesh extrusion. The procedure proved to be technically feasible, with a still long surgical time. Considering the potential advantages of robotic surgery and those related to TAR and the results obtained when these two techniques are associated, we conclude that they seem to be a good option for the correction of complex abdominal wall defects.