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Page 4 of 8 Malcher et al. Mini-invasive Surg 2021;5:31 https://dx.doi.org/10.20517/2574-1225.2021.48

Figure 1. Identification of right-side inguinal plug before robotic mesh explantation.

Robotic mesh explantation
Most hernia repairs in the United States are performed with mesh . As more meshes are implanted, more
[31]
[32]
may need to be removed due to complications .
Mesh infection, mesh-related pain, meshoma, recurrence, chronic pain, and entrapment of the nerve are
reported as the main indications for mesh removal [33-35] .

Studies have shown that chronic pain rates after MIS inguinal repair are lower than those after open
inguinal repairs [36,37] . The main advantage of endoscopic repair on reducing chronic pain is avoiding nerve
dissection for mesh implantation and avoiding traumatic fixation.

There are different options to manage patients with chronic pain after inguinal hernia repair. In certain
situations, removing the mesh (mostly plugs) is necessary for addressing the problem [Figure 1]. Open
mesh removal is an established technique, but scarred tissue from the previous repair may alter the
anatomy, and injury to the critical structures may happen. Laparoscopic mesh removal may be incredibly
challenging due to the innate nature of straight instruments and 2-dimensional vision.

[35]
One possibility is to use the robotic platform. Truong et al. have described a step-by-step guide for
removing the pre-peritoneal mesh using the robotic platform. The robotic mesh explantation (RoME) is
feasible due to the same advantages as discussed for inguinal repairs after prostatectomies. It may be less
challenging to work on the scarred tissue using robotic articulated instruments than using classic
laparoscopic instruments.

Two concepts are essential for operating in the inflamed and fibrotic areas. The first one is starting the
dissection over virgin planes facilitates access to the area where the mesh is scarred to vital structures. The
second one is to dissect on and at the mesh while trying to free the mesh from the surrounding adhered
structures. The aim of mesh explantation is to decrease the burden of foreign body material as much as
possible without compromising vital structures. It is considered an acceptable practice to leave a small piece
of the foreign body material behind. A negative margin is not necessary as in oncologic procedures. In
inguinal mesh removal, the nerves are usually involved, and neurectomies are often necessary.