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Page 2 of 7 Baur et al. Mini-invasive Surg 2021;5:27 https://dx.doi.org/10.20517/2574-1225.2021.28

Both, the morphology of the hernia and the surgical technique have been shown to influence postoperative
seroma formation. In a large register-based study with more than 20,000 groin hernia patients treated by
transabdominal pre-peritoneal (TAPP) laparoscopic techniques, multivariate analysis indicated that medial
hernias and large hernias (EHS type 2 and 3) were associated with a significantly higher occurrence rate of
seroma. Further, the method of mesh fixation was shown to have an impact; meshes fixed with fibrin glue
had higher seroma rates than meshes fixed with staples. The risk of seroma was lowest if the mesh was not
fixed at all . There are some specific surgical measures intended to prevent seroma formation; an overview
[3]
[4]
of the outcome of some of these techniques is presented in the systematic review by Li et al. .
Generally, 2 areas of interest for prophylactic measures regarding seroma formation have been investigated.
First, the medial hernial orifice with the weakened transverse fascia in large hernias can be targeted. A low
rate of postoperative seroma has been achieved both by tightening the transverse fascia with an endoloop
[5]
as well as with a V-Loc suture . Secondly, in the area of the lateral hernial orifices, the application of fibrin
[6]
glue spray into the inguinal canal has been investigated, showing a reduction in size and rate of
postoperative seromas . Although the placement of surgical drains may reduce the risk of postoperative
[7]
[2]
seroma formation, its routine use is not recommended by the European Hernia Society .
The quality of all available studies on the management of hernia orifices during endoscopic inguinal hernia
repair is limited due to the small number of patients examined. It can therefore be assumed that the
techniques presented here have not yet been widely adopted. The recent introduction of robotics into
endoscopic inguinal hernia repair promises large advantages, mainly the easiness to suture, the
unprecedented accuracy and precision of the instruments use and the advantages of immersion view. First
results pointing in this direction have recently been presented in a study where a suture retraction of the
transverse fascia was performed in a total of 67 robotic TAPP (rTAPP) procedures, with no seroma nor
other complication being recorded in the 30-day follow-up .
[8]
The use of DaVinci technology makes it possible to perform not only precise, nerve-sparing tissue
dissection and mesh placement, but allows also easy and efficient treatment of the hernial orifices for
seroma prophylaxis as part of robotic inguinal hernia treatment. In the following, the authors’ standardised
approach for the treatment of hernial orifices in robotic inguinal hernia treatment is described in more
detail.

Tailored approach
In the authors’ hospital, robotic inguinal hernia repair by rTAPP is the standard procedure; since May 2018,
we have performed more than 600 rTAPP procedures. Complementary to the usual surgical steps, we make
an additional effort to optimize the treatment of the hernial orifices in selected cases. In doing so, the
hernias are classified intraoperatively in line with the EHS classification, according to the anatomic location
(L = lateral; M = medial; F = femoral) of the hernia and the size of the hernial orifices (1 = ≤ 1 finger; 2 = 1-2
fingers; 3 = ≥ 3 fingers) . We focus on large medial orifices (EHS type M2 and M3) and lateral hernias with
[9]
large hernia sac or large lipoma (EHS type L2 and 3) as well as inguinoscrotal hernias. Although waiving of
mesh fixation has been shown to result in lower rates of postoperative seroma in the literature , it is also
[3]
associated with an increased risk of recurrence, especially in large hernias. Therefore, in the author’s series,
mesh fixation is performed in all patients, although neither with glue nor with tacks, but with sutures. The
robotic technology enables to perform mesh fixation with precise, superficially stitched, and loosely knotted
absorbable sutures, without the risk of nerve damage.