[Ventral Hernia Repair in Endoscopically Total Extrapertoneal Technique (eTEP) - Evaluation of Postoperative Outcome and One Year Follow-up]. / Ventralhernienversorgung in endoskopischer total extraperitonealer Technik (eTEP) ­ Evaluation der postoperativen Ergebnisse und des 1-Jahres-Follow-ups.

BACKGROUND: Several recent meta-analyses have identified the retromuscular plane as the preferred mesh position in ventral hernia repair. Open surgery used to be the standard technique for these procedures. However, new minimally invasive techniques with totally extraperitoneal access and mesh positioning in the retromuscular plane have evolved. METHODS: Between September 2018 and March 2019, 18 consecutive patients with ventral hernia were treated endoscopically in the totally extraperitoneal technique. Depending on the localisation and size of the hernia, the appropriate access was chosen and an uncoated mesh was placed in the retromuscular space in all patients. Data of patients' characteristics as well as peri- and postoperative parameters were collected. One year after surgery, patients were asked about recurrence, pain and complications, using the questionnaire of the herniamed data base. RESULTS: No intraoperative complications were noted. Postoperatively, there was one retromuscular seroma that did not need treatment, one temporary paralysis of the radial nerve and one pulmonary embolism. None of these complications led to persistent problems. 17 of 18 patients were available for follow-up. One year follow-up showed no hernia recurrence. One patient had pain at rest requiring treatment. CONCLUSIONS: Totally extraperitoneal endoscopic hernia surgery is a safe and promising new technique that is also feasible in complex hernias and with satisfactory 1 year results. This technique can combine the advantages of minimally invasive surgery with those of extraperitoneal mesh placement.

[Roboticassisted incisional hernia surgery-Retromuscular techniques]. / Robotisch-assistierte Narbenhernienchirurgie ­ retromuskuläre Techniken.

The trend to minimally invasive surgery has also made its way into the surgical treatment of incisional hernias. Unlike other areas of visceral surgery, recent years have seen a resurgence of open sublay repair in incisional hernia procedures, primarily due to the recognition of the retromuscular layer as the optimal mesh placement site. Additionally, with the growing availability of robotic systems in visceral surgery, these procedures are increasingly being offered in the form of minimally invasive procedures. These methods can be categorized based on the access routes: robotic-assisted transperitoneal procedures (e.g., r­Rives, r­TARUP, r­TAR) and total extraperitoneal hernia repair (e.g., r­eTEP, r­eTAR). Notably, the introduction of transversus abdominis muscle release enables the robotic-assisted treatment of larger and more complex hernia cases with complete fascial closure. With respect to the comparison with open surgery required in retromuscular hernia treatment, the currently available literature on incisional hernia repair seems to show initial advantages of robotic-assisted surgery in the perioperative course. New technologies create new possibilities. In the context of surgical training the use of surgical robot systems with double consoles opens up completely new perspectives. Furthermore, the robot enables the implementation of models of artificial intelligence and augmented reality and could therefore open up novel dimensions in surgery.

Establishment of minimally invasive ventral hernia repair with extraperitoneal mesh placement in a primary care hospital using the robotic platform.

Background: The progressive availability of robotic surgical systems opens new perspectives in abdominal wall surgery due to excellent visibility and dexterity of instruments. While complex hernias until today were treated primarily through an open access, we evaluated if this promising technology is suitable for treating the entire spectrum of a hernia center, including complex hernias. Material/methods: In 2017, minimally invasive hernia surgery with extraperitoneal mesh placement was started in Kempten hospital. Since 2019, a Da Vinci X system has been available for this purpose. In order to observe the process of transition we retrospectively analyzed all patients who underwent ventral hernia repair in the department of general and visceral surgery at our hospital between January 2016 and December 2020 and were indicated for mesh implantation. Results: In 2016, the percentage of minimally invasive procedures was 37.3%. In all of these cases an intraperitoneal mesh was implanted into the abdominal cavity. Open surgery was performed in 62.7%, of which an a retromuscular mesh was implanted in 75.7%, an intraperitoneal mesh in 21.6%, and an onlay mesh in 2.7%. In 2020, minimally invasive surgery accounted for 87.5%, of which 85.7% were performed robotically and 14.3 laparoscopically. In 94.3% of these minimally invasively treated patients the mesh was implanted in extraperitoneal position (75.8% in retromuscular and 24.2% in preperitoneal position). The percentage of complex hernias increased from 20.3% to 35.0% during the same period. Conclusion: The majority of ventral hernia procedures can be performed safely using the robot in a minimally invasive technique with extraperitoneal mesh placement without leading to an increase in complications. Robotically-assisted hernia repair is a promising new technique that is also practical for complex hernias.

Robotically assisted enhanced-view totally extraperitoneal repair (eTEP) of a recurrent umbilical hernia in a patient with peritoneal dialysis.

Background: Abdominal wall hernias are frequent in patients with peritoneal dialysis. Guidelines recommend an open hernia repair with extraperitoneal mesh placement to avoid access to the abdominal cavity. Method: We performed a lateral docking robotically assisted enhanced-view totally extraperitoneal repair (eTEP) of a recurrent umbilical hernia with diastasis recti in a patient with peritoneal dialysis due to polycystic kidney disease. After suturing of the midline a 20 x 28 cm mesh was placed in the retrorectus space, covering the whole area of preparation while also overlapping all trocar sites. A drainage was left in the retrorectus space until the first session of PD did not sample any form of leakage. Result: Robotically assisted totally extraperitoneal hernia repair was feasible. The patient was able to continue peritoneal dialysis without intermittent hemodialysis. There was no leakage of the dialysate to the retrorectus space. Postoperative recovery was uneventful. 6 months after surgery the patient was free from pain and showed no signs of recurrence. Conclusion: Robotically assisted totally extraperitoneal hernia repair in patients with umbilical hernia and peritoneal dialysis could be a promising surgical technique to combine the advantages of minimally-invasive surgery with totally extraperitoneal mesh placement without access to the abdominal cavity.