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Siegal et al. Plast Aesthet Res 2019;6:25 I http://dx.doi.org/10.20517/2347-9264.2019.35 Page 17 of 20

Initial steps in robotic TAR parallel those in open surgery. With the camera in a 30-degree-up
configuration, extensive adhesiolysis is performed to free bowel from the abdominal wall. The contralateral
edge of the rectus muscle is identified and grasped and the retrorectus space is entered with the scissors.
This space is developed both inferiorly and superiorly staying parallel to the fibers of the rectus muscle.
Once the retrorectus space is developed, the camera is changed to 30 degrees down to begin the TAR
dissection, either in a top-down or bottom-up fashion (as discussed above). Below the arcuate line, the
space of Bogros is developed. Staying medial to the linea semilunaris and the neurovascular bundles, the
posterior lamina of the IO aponeurosis is incised exposing the TA muscle. The fibers are separated from the
underlying transversalis fascia/peritoneum, extending laterally towards the psoas muscle. The dissection
can be extended as laterally, inferiorly, and superiorly as previously described.

Once enough sublay space is developed for adequate mesh overlap and holes in the posterior sheath are
closed, the posterior sheath is reapproximated with a running 2-0 absorbable barbed suture. Next, the
hernia defect and linea alba are closed with a running #1 permanent barbed suture. Pneumoperitoneum
can be lowered to reduce the tension on the closure. Mesh is introduced and unrolled to fill the sublay
space. Fixation of the mesh is a debated topic, though many experts use fibrin sealant spray to achieve
fixation and hemostasis. A surgical drain may then be introduced.

[39]
Outcome data of robotic repairs are promising. In a two-institution study, Martin-Del-Campo et al.
reported reduced blood loss and systemic complications. The patients undergoing robotic repair also
benefited from shorter length of stay and reduced readmissions compared to a matched group of open TAR
patients. There is ongoing study of this new approach, and long-term data are approaching.

OUTCOMES
[11]
Hernia repair utilizing TAR is safe and effective in published series. Novitsky et al. described their
experience in 428 consecutive cases in 2016. With a minimum of one-year follow-up, they demonstrated
a 3% recurrence rate and a SSI rate of only 9%. No mesh prosthetics required explantation, although 3
patients required debridement. The most common reason for recurrence was central mesh failure followed
by lateral, suprapubic, and subxiphoid recurrence.

Studies compared PCS with ACS to determine which release yields better outcomes. With regard to
myofascial advancement, anatomic study in 13 human cadavers evaluated PCS, ACS, and the Rives-
[40]
Stoppa repair . The authors found that ACS provided marginally more medialization of the anterior
sheath compared to PCS. On the contrary, PCS advanced the posterior sheath more. A subsequent study
of 10 cadavers revealed that each subsequent step of TAR (rectus sheath release, IO lamella release, TA
muscle division, and lateral retromuscular dissection) permits increasing myofascial advancement up to
[41]
approximately 10 cm per side .
Clinical outcomes between these methods have similarly been evaluated. A retrospective comparison of
56 ACS cases to 55 PCS cases found significantly more wound complications in the ACS group (48.2%
[42]
vs. 25.5%, P = 0.01) and a higher hernia recurrence rate (14.3% vs. 3.6%, P = 0.09) . To reduce wound
healing complications associated with ACS, several minimally invasive techniques (MI-ACS) have been
[43]
developed . However, even though a 2017 study comparing MIS-ACS to TAR found equivalent rates
of SSI/SSO, there was a non-significant, albeit double, recurrence rate in the MIS-ACS group. A recent
meta-analysis compared mesh location in the abdominal wall and reported reduced recurrence and SSIs
with preperitoneal mesh (as performed in TAR) compared to intraperitoneal and onlay (in most ACS
[44]
approaches) .
Most comparative data are retrospective and heterogeneous. No randomized controlled, prospective trial
comparing ACS to PCS has been completed at this time. However, data do support improvement in quality