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Page 16 of 20 Siegal et al. Plast Aesthet Res 2019;6:25 I http://dx.doi.org/10.20517/2347-9264.2019.35

placed through a small incision through the hernia. Briefly, this procedure starts with an incision centered
over the hernia defect and exposure of the hernia sac. Transhernia laparoscopy is set up and adhesiolysis is
performed to expose the hernia defect ring. The peritoneum is detached from the abdominal wall and the
posterior sheath is entered. An assistant elevates the abdominal wall and the retrorectus space is developed
laparoscopically or with direct visualization with a 10-mm light tube (Endo-torch, Wolf TM, Knittlingen,
Germany). After 8 cm of extraperitoneal space is achieved circumferentially, the peritoneum is closed and
the operation is converted to a laparoscopic extraperitoneal repair [extended total extraperitoneal repair
(eTEP)]. The posterior sheath is closed under low gas insufflation and the mesh is rolled, inserted into the
field, and then unfolded.

[36]
In 2019, this group reported their results after 615 MILOS repairs . There was a statistically significant
reduction in postoperative complications, recurrences, and chronic pain compared to laparoscopic
intraperitoneal onlay mesh (IPOM) technique.

Extended total extraperitoneal repair TAR
eTEP of ventral hernias was created as an extension of total extraperitoneal (TEP) repair of inguinal
hernias. The major advantage of this approach is a lack of entry into the abdominal cavity, obviating bowel
manipulation, peritoneal defect closure, and intra-abdominal adhesion formation. Classic TEP repairs are
limited by their minimal dissection space, thus space for mesh overlap as well as restricted port placement.
[37]
Daes popularized the “extended view” of TEP inguinal hernia repair to allow for easy creation of the
extraperitoneal space in a large surgical field to facilitate mastery of the repair and utility in complex cases.
[38]
Subsequently, Belyanksy et al. and an international group of hernia specialists reported on expanding
this technique to laparoscopic ventral hernia repairs (eTEP). Their technique is described briefly.

The patient is placed supine on the operating table in a flexed position to widen the space between the
costal margin and anterior superior iliac spine. Port location depends on the location of the defect, but the
guiding principles of eTEP rely on initiating the dissection in the retrorectus space of one side and “crossing
over” to the contralateral retrorectus space in the fat pads of the falciform ligament of the space or Retzius.
The dissection is carried out along the length of the RA muscles and the bilateral posterior sheaths are
released to connect the contralateral spaces in the midline by mobilizing the hernia sac out of the defect,
keeping it in continuity with the posterior rectus sheath. For larger defects, TAR can be added on either
side (or both) to permit further posterior and anterior sheath mobilization. Posterior sheath defects are
closed with absorbable suture, and the anterior fascial defect is closed with a running barbed suture under
low-pressure pneumoperitoneum. Mesh is then placed to fill the retromuscular pocket and fixated as
desired. Early results eTEP posterior component releases have shown promising results. Of the 79 patients
reported by this group, there was a 3% wound complication rate, no 30-day readmissions, and only one
[39]
hernia recurrence with 11 months of follow-up .

ROBOTIC TAR
Further advancement in surgical technology leads to the development of robotics, which have the added
benefit of finer instrument movements, greater range of freedom, and elimination of tremor. An essential
first consideration is paid to trocar placement and robot docking. Patients are placed in the supine position.
The arms are extended at 90 degrees to allow lateral robot arm placement for more working space and
a full range of motion. An 8-mm robotic trocar is placed in the lower lateral abdomen as well as the upper
abdomen on the ipsilateral side, while a 12-mm trocar is placed half way between the two as far lateral as
possible. Future mesh placement can be through the camera’s 12-mm port, or a fourth accessory port (12 mm)
can be utilized and placed in a subxiphoid or suprapubic location. In general, a grasping instrument with
bipolar energy and scissors with monopolar energy are used.