Robotic Repair of Non-Midline Hernias

Robotic Repair of Non-Midline Hernias | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Robotic Repair of Non-Midline Hernias Alyssa Guo, Dillon Isaac, Liliana Jaraczewski, William Cobb, Alfredo Carbonell, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2046306/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Non-midline abdominal wall hernias present unique anatomic challenges, making repair more complex. The constraints of the peritoneal cavity, pelvis, and costal margin limit the utility of intraperitoneal mesh repair, and extraperitoneal repairs have traditionally been performed using open techniques, often resulting in higher wound morbidity. Advances in minimally invasive surgery make visualization and dissection of such complex cases feasible, with all the attendant benefits of a minimally invasive over an open approach. In this study we examined the use of the robotic platform to repair non-midline hernias. Methods Retrospective review of all non-midline abdominal wall hernias performed robotically at Prisma Health, excluding parastomal hernias. Study conducted and outcomes reported according to STROBE statement. Results Repair was performed in the retromuscular space (n=42), preperitoneal (n=22), and intraperitoneal (n=1). Mean hernia width was 9.4cm, permanent synthetic mesh used for all repairs. Mean LOS was 1.5 days. Surgical site occurrence (SSO) occurred in 49.2%, 78% of which were simple seroma. Three patients (4.6%) developed surgical site infection (SSI). Two recurrences were identified with a mean follow-up of 11 mos. Conclusion The robotic platform facilitates complex dissection to allow minimally invasive, extraperitoneal repair of complex non-midline hernias. This approach overcomes the anatomic constraints of intraperitoneal mesh repair and the wound morbidity of open repair. Lateral hernias robotic hernia repair non-midline hernias transversus abdominis release hernia recurrences Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Lateral abdominal wall hernias may develop as primary lumbar hernias, but more commonly derive from prior subcostal or flank incisions, ostomy sites, traumatic abdominal wall injury, or trocar sites. [ 1 – 3 ]. Non-midline hernias are often complex and may be larger and more symptomatic than midline defects. Repair is technically demanding due to anatomic boundaries of the bony pelvis, retroperitoneum, and costal margin, often resulting in higher risk of intraoperative and perioperative complications [ 4 – 5 ]. Achieving defect closure and adequate mesh reinforcement requires utilizing sometimes unfamiliar tissue planes in the lateral abdominal wall and retroperitoneum. Physiologically, the ratio of muscle to aponeurotic tissue in the lateral abdominal wall is higher, resulting in a lower effective tensile strength, which affects both defect closure integrity and the strength and durability of mesh fixation. Furthermore, lateral hernias are subjected to asymmetric forces that may result in higher risk of recurrence [ 6 ]. The European Hernia Society (EHS) classification system defines lateral hernias as below the costal margin, above the iliac crest, and lateral to the semilunar line. Midline hernias occur between the xiphoid and pubic symphysis and bounded by the semilunar line laterally [ 3 ]. While this is system is a useful standard for reporting, it does not necessarily correlate with surgical technique required for repair. Most notably, when using a retromuscular (RM) approach to ventral hernia repair (VHR), the linea semilunaris limits the lateral dissection and therefore mesh overlap of the hernia. For hernias occurring through the linea alba, this is typically adequate. However, for hernias occurring through the rectus sheath but not directly through the linea alba, such as prior stoma sites, repair technique likely includes additional lateral dissection with a transversus abdominis release (TAR), which increases the complexity and may account for different outcomes compared to RM repair alone. For this reason, we define hernias for this study as non-midline rather than simply lateral. We previously reported outcomes for open preperitoneal and retromuscular repair of lateral abdominal wall hernias, resulting in 13% risk of surgical site infection (SSI) and 11.5% recurrence rate [ 7 ]. More recently, we have adopted a robotic approach for many of these hernia defects. The robotic platform provides excellent visualization, enhances the ability to dissect abdominal wall layers, close the hernia defect, and widely reinforce the repair with mesh [ 8 ]. This study evaluates our surgical approach and clinical outcomes of robotic repair of non-midline abdominal wall hernias. Methods We retrospectively identified all patients undergoing repair of non-midline ventral / incisional hernias between August 2013 and March 2020. All surgeries were performed at Prisma Health Upstate by senior authors JAW and AMC. Patient demographics, hernia characteristics, technical details, and clinical outcomes were maintained prospectively in the Abdominal Core Health Quality Collaborative (AHSQC), a prospectively maintained national hernia registry. Any patient with a non-midline hernia was included, including those with a concurrent midline hernia defect (n = 26). Patients with parastomal hernias were excluded. Outcome measures were selected to determine the safety and efficacy of the robotic surgical approach. Primary outcomes were Surgical Site Occurrence (SSO) and infection (SSI). Secondary outcomes were operative time, hernia recurrence, conversion to open repair, and other complications associated with repair. Study design and outcomes reporting was performed according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [ 9 ]. This study was approved by the Prisma Health Institutional Review Board. Surgical Technique Technique varied according to the location of the hernia defect and presence or absence of a concurrent midline hernia. The single patient repaired with intraperitoneal mesh followed standard surgical approach that is well described elsewhere. Selection of the optimal approach is key, and preoperative computed tomography (CT) imaging is essential (Fig. 1 ). The eTEP technique involves laparoscopic entry directly into the retromuscular space without immediate entry into the peritoneal cavity (Fig. 2 ). The retromuscular space is developed to accommodate additional trocar placement. Depending on the location of the hernia, this may be a unilateral or bilateral retromuscular dissection and trocar placement varies according to the technique required for repair. For hernias without concurrent midline defect that are true lateral hernias, a unilateral dissection is often adequate, with placement of trocars along the medial rectus sheath with dissection progressing medial-to-lateral, a transversus abdominis release (TAR), and lateral dissection continuing in the preperitoneal / retroperitoneal space (Fig. 3 A). For hernias off-midline but within the confines of the rectus sheath, such as prior ostomy sites, or patients with a concurrent midline hernia, a bilateral retromuscular dissection is needed to ensure adequate mesh overlap in all directions (Fig. 3 B and C). Transabdominal repair begins with intraperitoneal placement of trocars with incision of the posterior rectus sheath (for retromuscular repair) or peritoneum (for preperitoneal repair) to enter the extraperitoneal plane for repair and mesh placement (Fig. 3 D). Results We identified 65 patients who underwent robotic repair of non-midline hernias. Mean age was 62 years (range 21–91) and included 27 female and 38 female patients. Mean body mass index (BMI) was 33.8 kg/m 2 (21.9–59.3). Comorbidities include hypertension (53.8%), diabetes (29.2%), chronic obstructive pulmonary disease (6.2%), and active smokers (16.9%). Patient characteristics are detailed in Table 1 . Table 1 Patient Characteristics Characteristics Values Male 27 (41.5%) Female 38 (58.5%) Mean Age (year) 62 (range 21–91) Mean body mass index 33.8 (range 21.9–59.3) ASA classification 1 2 1 (1.5%) 2 18 (27.7%) 3 44 (67.7%) 4 2 (3.1%) Race White, not-Hispanic origin 53 (81.5%) Black/African American 8 (12.3%) Hispanic 4 (6.2%) Comorbidities Hypertension 35 (53.8%) Diabetes mellitus 19 (29.2%) Chronic obstructive pulmonary disease 4 (6.2%) Hepatic failure 1 (1.5%) Nicotine use Current, within 1 month 11 (16.9%) Former, within 1 year 3 (4.6%) Distant former, more than 1 year 15 (23.1%) Never 34 (52.3%) Hernias were located subcostal (L1; n = 7), flank (L2; n = 20), iliac (L3; n = 20), lumbar (L4; n = 13), or multiple sites ( n = 5). Concurrent midline hernias were present in 26 patients. Hernia types included primary lumbar hernias ( n = 2), traumatic flank hernias ( n = 6), and incisional hernias ( n = 57). Incisional hernias occurred after urologic procedures ( n = 9), spine procedures ( n = 3), prior ostomy site ( n = 16), cholecystectomy ( n = 5), appendectomy ( n = 4), trocar sites ( n = 8), or other incisional ( n = 12). Robotic repairs were performed using a transabdominal retromuscular approach (rRM) in 27 patients (41.5%), transabdominal preperitoneal (rTAPP) ( n = 22; 33.8%), extended view totally extraperitoneal (eTEP) ( n = 15; 23.1%), or intraperitoneal onlay of mesh (IPOM) ( n = 1; 1.5%). The mean hernia defect size was 111 cm 2 (9.1 cm mean length; 9.4 cm mean width). Permanent synthetic mesh was used for repair in all cases. Conversion to open approach was required in 9 cases (13.8%) due to development of hypercarbia (n = 3), poor visualization (n = 5), and concern bowel injury during adhesiolysis (n = 1). Five of these cases occurred during eTEP repair and 4 during transabdominal retromuscular repair. Surgical details are shown in Table 2 . Table 2 Surgical Details Characteristics Value Hernia Etiology Incisional 57 (87.7%) Urologic procedure 9 (15.8%) Spinal procedure 3 (5.3%) Prior ostomy site 16 (28.1%) Cholecystectomy 5 (8.8%) Appendectomy 4 (7.0%) Trocar sites 8 (14.0%) Other incisional 12 (21.1%) Traumatic flank 6 (9.2%) Lumbar (primary hernia) 2 (3.1%) Hernia classification L1: subcostal 7 (10.8%) L2: flank 20 (30.8%) L3: iliac 20 (30.8%) L4: lumbar 13 (20.0%) Multiple sites 5 (7.7%) Concurrent midline defect 26 (40.0%) Surgical approach Transabdominal retromuscular 2 (3.1%) Transabdominal retromuscular + TAR 25 (38.5%) Transabdominal preperitoneal 22 (33.8%) eTEP 1 (1.5%) eTEP + TAR 14 (21.5%) IPOM 1 (1.5%) Converted to open 9 (13.8%) Mean defect area (cm 2 ) 111 (range 4-575) Length (cm) 9.1 (range 2–30) Width (cm) 9.4 (range 2–25) Mesh used Barrier-coated polypropylene 1 (1.3%) Multifilament polyester 3 (4.0%) Heavy-weight polypropylene 4 (6.1%) Mid-weight polypropylene 57 (87.7%) Mean mesh area (cm 2 ) 517 (range 81-1710) Length (cm) 22.5 (9–45) Width (cm) 20.9 (8–38) Mean operative time was 220.4 min (range 80 to 484 min). Fascial closure was achieved in 63 cases (96.9%). No bowel injuries occurred. Mean length of stay (LOS) was 1.5 days (median 1 day). SSI occurred in 3 patients (4.6%), 2 superficial and 1 deep space infection. All SSIs were treated with antibiotics and 1 required wound opening. No mesh infections occurred, and no mesh removal was needed. SSOs developed in 32 patients (49.2%), 25 of which were seromas. Wound debridement was required in 1 case, percutaneous drainage in 3, and antibiotics in 4 patients (2 due to concurrent SSI, 2 empiric). One patient developed an enterocutaneous fistula that ultimately closed spontaneously after percutaneous drainage and did not require mesh removal. Two hernias recurred (3.1%), and 1 patient developed a trocar site hernia. Mean follow-up was 11 months (range 0.5–60.9 months). Surgical outcomes are shown in Table 3 . Table 3 Outcomes Outcome N (%) n 65 Mean length of stay (days) 1.5 (range 0–8) Median length of stay (days) 1 (IQR 0,2) SSO* 32 (49.2%) Seroma 25 (78.1%) Hematoma 3 (9.4%) Enterocutaneous fistula 1 (3.1%) Skin/soft tissue necrosis 1 (3.1%) Wound serous drainage 1 (3.1%) Other 3 (9.4%) SSOPI** 7 (10.8%) Antibiotics 4 (57.1%) Percutaneous drainage 3 (42.9%) Wound opening 1 (14.3%) Wound debridement 1 (14.3%) SSI 3 (4.6%) Superficial 2 (66.7%) Deep 1 (33.3%) SSIPI 3 (4.6%) Antibiotics 3 (100%) Wound opening 1 (33.3%) Recurrence*** 3 (4.6%) Complications 4 (6.2%) Bowel Injury 1 (12.5%) Pain requiring intervention 1 (12.5%) Urinary tract infection 1 (12.5%) Enterocutaneous fistula 1 (12.5%) * 32 patients had a total of 34 SSOs ** 7 patients had a total of 9 SSOPIs *** 2 recurrence, 1 trocar site hernia SSO, Surgical Site Occurrence; SSI, Surgical Site Infection; SSOPI, SSO Requiring Procedural Intervention; SSIPI, SSI Requiring Procedural Intervention; IQR, Interquartile Range. Discussion While primary non-midline hernias, Spigelian or lumbar hernias, are rare, non-midline secondary hernias can result from a variety of surgical procedures or trauma. Etiology of the hernia will certainly play a role in complexity of repair, and the heterogeneity of surgical techniques and hernia morphology should be taken into account when analyzing clinical trials data [ 9 ]. Non-midline abdominal wall hernias present with unique anatomic challenges during repair. Hernias occurring lateral to the anterior axillary line (EHS classification L4) may not be well visualized from an intraabdominal approach due to the lateral peritoneal attachments of the colon, and lateral mesh overlap is limited for the same reason. Dissection into the retroperitoneal space is required for mesh placement, or an alternative approach such as an onlay is required. When dissecting into this space, it is critical to consider the course of the ureter, gonadal and iliac vessels, and retroperitoneal neural anatomy, all of which may be distorted due to the hernia. Intimate knowledge of these structures is needed to perform a safe and efficacious repair. In particular, the iliohypogastric, ilioinguinal, and lateral femoral cutaneous nerves are at risk of injury for hernias in this location, particularly if found more caudal near the iliac crest. Posterior dissection should allow for at least 5cm of mesh overlap and typically will extend over the psoas and/or quadratus lumborum. Inferior dissection will typically extend to the iliac fossa, where the inguinal nerves are particularly at risk, as are the spermatic structures. Superiorly, dissection of the peritoneum from the diaphragm may be needed to allow adequate mesh overlap under the costal margin. Interestingly, many lateral abdominal wall hernias will present as partial thickness defects with the external oblique layer still intact (Fig. 1 D, Fig. 4 ). This feature actually adds benefit to a robotic approach, as the defect can be difficulty to locate with an open approach. Hernias in the lateral aspects of the rectus sheath, such as parastomal or prior ostomy site hernias, are still defined by the EHS as midline hernias [ 3 ]. However, if repaired with a retromuscular Rives-Stoppa approach, lateral mesh overlap is limited by the linea semilunaris, and additional lateral myofascial release is required. This is accomplished using the transversus abdominis release (TAR). The posterior rectus sheath is incised medial to the intercostal neurovascular bundles along the semilunar line, dividing the posterior lamella of the internal oblique and the transversus abdominis muscle / aponeurosis to enter the preperitoneal or pretransversalis plane. Dissection is then extended laterally in the extraperitoneal plane below the transversus abdominis muscle to allow for adequate mesh overlap and myofascial mobilization for hernia defect closure. For this reason, hernias technically classified as midline (M1-5) by the EHS are included in this report, as the addition of a TAR adds significant complexity to the repair and is necessary for most hernias that occur lateral to the linea alba. Selection of the optimal surgical approach depends on the location and size of the hernia relative to these anatomic limitations. Strong consideration should be given to preoperative computed tomography imaging to delineate the extent of the hernia. Current published series of lateral abdominal wall hernia repair are limited, and there is no current consensus on optimal repair owing to this limited data and the heterogeneity of these hernias. We previously reported outcomes of 61 non-midline hernias repaired in an open extraperitoneal fashion [ 7 ]. Patients developed SSO in 49.2% of cases with SSI in 13.1% and hernia recurrence of 11.5% with a mean of 15.4 months. Others have reported similar outcomes for open flank hernia repair. Moreno-Egea, et al reported similar SSO and recurrences in 20 patients with lumbar hernias, with 40% and 15%, respectively [ 10 ]. Their group also reported a small series of 7 patients with lumbar hernia repaired using the open technique and yielded a 42.9% recurrence [ 11 ]. Veyrie, et al reported the repair of 61 patients with non-midline incisional hernias using a retromuscular approach. Early perioperative morbidity was 18% with a recurrence rate of 4.9% with median follow-up of 47 mos [ 12 ]. Minimally invasive surgery, and hernia repair in particular, has repeatedly demonstrated lower risk of SSI compared with open surgery. There is limited data on laparoscopic repair of lateral hernias, however, due to the anatomic considerations mentioned above, which make minimally invasive repair difficult. Moreno-Egea, et al published a series of 55 patients who underwent laparoscopic (35 patients) and open (20 patients) repairs of lumbar hernias demonstrating benefit of the laparoscopic approach over open repair in terms of both wound complications (seroma 20 vs 40%) and hernia recurrence (2.9 vs 15%)[ 13 ]. A second study looking more broadly at non-midline hernias demonstrated a recurrence rate of 8.2% overall, with 25% of subcostal hernias developing a recurrence [ 14 ]. The authors do note the increased complexity of preperitoneal dissection and limitations of mesh fixation in these hernias, which likely contribute to hernia recurrence. These anatomic and technical concerns can largely be mitigated with the utilization of extraperitoneal mesh placement. This is technically difficulty to accomplish with traditional laparoscopy but is greatly facilitated by the robotic platform. The enhanced visualization and ability to perform a complex dissection with articulated instruments in an ergonomically friendly manner has enabled expansion of minimally invasive techniques to include complex abdominal wall reconstruction. The ability to achieve fascial closure, aided by lateral abdominal myofascial release and extensive extraperitoneal dissection, is key to the success of robotic repair. Others have reported similar outcomes in limited series [ 15 ]. Di Giuseppe, et al reported outcomes of robotic repair of 7 incisional flank hernias [ 16 ]. With a mean follow-up of 6 months, no seromas nor recurrences were reported, and no cases required conversion to open surgery. Another more recent smaller study reported no recurrence of non-midline hernias repaired robotically, with data presented up to 24 months post repair [ 17 ]. There are several limitations of our study. Selection bias is inherent to any retrospective analysis. Clinical perception of technical difficulty of a given hernia repair will influence the decision to pursue open versus robotic repair, and this description is not necessarily representative of non-midline hernia repair outcomes on the whole. Additionally, this study is conducted in a high-volume hernia-specific practice at a single center, which may limit generalizability. We also performed several variations in technique. Though similar in concept, there may be important differences in outcome and technique that cannot be elucidated due to the small sample size and may increase bias in the results. As there are no controls for the current study, future case-matched studies may be beneficial to compare outcomes of robotic repair with open and laparoscopic repairs. Finally, our follow-up duration is short, and long-term analysis is needed to confirm the risk of hernia recurrence. Because of the increased capability of different institutions in performing robotic surgeries in addition to the gap of knowledge in robotic repair of non-midline hernias, timely report of the safety and efficacy of the robotic approach was a main factor for reporting our current findings. The goal is to have a follow-up report of surgical outcomes of the current data set a few more years after hernia repairs. Larger studies with long-term follow-up are needed to confirm our initial experiences with robotic lateral hernia repairs. Conclusion Non-midline abdominal wall hernia repair is difficult due to anatomic and technical constraints to commonly employed techniques. The evolution of advanced myofascial release techniques and the robotic platform enables reconstruction of these complex hernia defects in a minimally invasive fashion, minimizing perioperative morbidity while adhering to well-established principles of hernia repair. Overall, it is evident from our study that the robotic platform is safe and efficacious and will become an integral tool in repairing non-midline abdominal wall hernias. Further study is needed to optimize patient selection and determine long-term outcomes. Declarations Author Contributions Study conception and design was done by Jeremy A Warren, William S Cobb, and Alfredo M Carbonell; acquisition of data by Alyssa A Guo, Dillon Isaac, and Liliana Jaraczewski; analysis and interpretation of data by Alyssa A Guo and Jeremy A Warren; drafting of manuscript by Jeremy A Warren and Alyssa A Guo; and critical revision by Alyssa A Guo, Jeremy A Warren, William S Cobb, and Alfredo M Carbonell. All authors read and approved the final manuscript. Funding No funding was received for any portion of this study. Competing Interests Drs. Warren and Carbonell have received honoraria for speaking and teaching from Intuitive Surgical. Drs. Carbonell and Cobb have received honoraria and consulting fees from W.L. Gore Ethical Approval The databased used for this study was approved by the Prisma Health Institutional Review Board. References Hope WW, Tuma F (2022) Incisional Hernia. In: StatPearls. StatPearls Publishing, Treasure Island (FL) Dennis RW, Marshall A, Deshmukh H, Bender JS, Kulvatunyou N, Lees JS, Albrecht RM (2009) Abdominal wall injuries occurring after blunt trauma: incidence and grading system. Am J Surg. doi: 10.1016/j.amjsurg.2008.11.015 Muysoms FE, Miserez M, Berrevoet F, Campanelli G, Champault GG, Chelala E, Dietz UA, Eker HH, El Nakadi I, Hauters P, Hidalgo Pascual M, Hoeferlin A, Klinge U, Montgomery A, Simmermacher RKJ, Simons MP, Smietański M, Sommeling C, Tollens T, Vierendeels T, Kingsnorth A (2009) Classification of primary and incisional abdominal wall hernias. 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World J Surg. doi: 10.1007/s00268-012-1857-9 Stabilini C, Cavallaro G, Dolce P, Capoccia Giovannini S, Corcione F, Frascio M, Sodo M, Merola G, Bracale U (2019) Pooled data analysis of primary ventral (PVH) and incisional hernia (IH) repair is no more acceptable: results of a systematic review and metanalysis of current literature. Hernia. doi: 10.1007/s10029-019-02033-4 Moreno-Egea A, Carrillo-Alcaraz A (2012) Management of non-midline incisional hernia by the laparoscopic approach: results of a long-term follow-up prospective study. Surg Endosc. doi: 10.1007/s00464-011-2001-x Kirkpatrick T, Zimmerman B, LeBlanc K (2018) Initial Experience with Robotic Hernia Repairs: A Review of 150 Cases. Surg Technol Int Di Giuseppe M, Mongelli F, Marcantonio M, La Regina D, Pini R (2020) Robotic assisted treatment of flank hernias: case series. BMC Surg. doi: 10.1186/s12893-020-00843-3 Cabrera ATG, Lima DL, Pereira X, Cavazzola LT, Malcher F (2021) Robotic transabdominal preperitoneal approach (TAPP) for lateral incisional hernias. Arq Bras Cir Dig. doi: 10.1590/0102-672020210002e1599 Additional Declarations Competing interest reported. Drs. Warren and Carbonell have received honoraria for speaking and teaching from Intuitive Surgical. Drs. Carbonell and Cobb have received honoraria and consulting fees from W.L. Gore Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 20 Nov, 2022 Reviews received at journal 17 Nov, 2022 Reviewers agreed at journal 12 Nov, 2022 Reviewers invited by journal 12 Nov, 2022 Editor assigned by journal 13 Sep, 2022 Submission checks completed at journal 09 Sep, 2022 First submitted to journal 08 Sep, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2046306","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":135396453,"identity":"46a04141-2de1-43f7-8fed-822ba74d4fc9","order_by":0,"name":"Alyssa Guo","email":"","orcid":"","institution":"University of South Carolina School of Medicine Greenville","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Alyssa","middleName":"","lastName":"Guo","suffix":""},{"id":135396455,"identity":"357884b6-d082-4e25-9d54-0c7d44c971af","order_by":1,"name":"Dillon Isaac","email":"","orcid":"","institution":"Prisma Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Dillon","middleName":"","lastName":"Isaac","suffix":""},{"id":135396456,"identity":"0c6bd41b-fc7b-465a-b0f9-02f4d01a16d8","order_by":2,"name":"Liliana Jaraczewski","email":"","orcid":"","institution":"Presbyterian College","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Liliana","middleName":"","lastName":"Jaraczewski","suffix":""},{"id":135396457,"identity":"43b44310-5768-4fe3-835f-dbdaf643686e","order_by":3,"name":"William Cobb","email":"","orcid":"","institution":"Prisma Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"William","middleName":"","lastName":"Cobb","suffix":""},{"id":135396458,"identity":"5c44aaca-4a31-4eab-b897-a982ce6e702b","order_by":4,"name":"Alfredo Carbonell","email":"","orcid":"","institution":"Prisma Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Alfredo","middleName":"","lastName":"Carbonell","suffix":""},{"id":135396459,"identity":"29ce14e7-4769-4ef1-b7e4-54e16a17d707","order_by":5,"name":"Jeremy Warren","email":"data:image/png;base64,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","orcid":"","institution":"Prisma Health","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Jeremy","middleName":"","lastName":"Warren","suffix":""}],"badges":[],"createdAt":"2022-09-08 17:29:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2046306/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2046306/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":26365549,"identity":"1a2b0b95-635a-4b69-838a-1a667877faa0","added_by":"auto","created_at":"2022-09-12 20:35:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":989453,"visible":true,"origin":"","legend":"\u003cp\u003eComputed tomography imaging of non-midline hernias\u003c/p\u003e\n\u003cp\u003eA. Concurrent midline hernia and hernia extending through the linia semilunaris; \u003cem\u003edashed arrow\u003c/em\u003e – medial edge of obliques\u003cem\u003e; solid arrow – \u003c/em\u003elateral edge of rectus abdominis. B. Lumbar hernia; \u003cem\u003edashed arrow\u003c/em\u003e – posterior iliac crest; \u003cem\u003esolid arrow\u003c/em\u003e – lateral edge of obliques. C. Non-midline hernia occurring through the rectus sheath; \u003cem\u003edashed arrow\u003c/em\u003e– linea semilunaris; \u003cem\u003esolid arrow\u003c/em\u003e – lateral portion of rectus abdominis muscle. D. Recurrent flank hernia; \u003cem\u003edashed arrow\u003c/em\u003e – prior mesh in the intraperitoneal position with posterolateral hernia recurrence; \u003cem\u003esolid arrow\u003c/em\u003e – intact aponeurotic portion of the posterolateral external oblique.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-2046306/v1/c25dd24ae0a07472cfe1638c.png"},{"id":26365547,"identity":"a4361ca1-6aea-4ade-8478-7451ebddf292","added_by":"auto","created_at":"2022-09-12 20:35:56","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":520956,"visible":true,"origin":"","legend":"\u003cp\u003eeTEP repair of lateral incisional hernia after urologic procedure\u003c/p\u003e\n\u003cp\u003eA. Hernia defect; \u003cem\u003era\u003c/em\u003e – rectus abdominis; \u003cem\u003eta\u003c/em\u003e– transversus abdominis; \u003cem\u003ehd\u003c/em\u003e – hernia defect; \u003cem\u003ep\u003c/em\u003e – peritoneum / posterior sheath. B. Completed repair with mesh lying over the peritoneal layer and closed hernia defect (\u003cem\u003earrow\u003c/em\u003e).\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-2046306/v1/9c9a1b6ada018c89558c353e.png"},{"id":26365548,"identity":"7d9a52c1-db0e-415e-8a0a-91fe26e6c546","added_by":"auto","created_at":"2022-09-12 20:35:56","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":141371,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic of extraperitoneal repair options.\u003c/p\u003e\n\u003cp\u003eA. eTEP approach with unilateral retromuscular dissection and TAR for hernias at or beyond the linea semilunaris. B. eTEP approach with bilateral retromuscular dissection across the midline and contralateral TAR for hernias within the rectus sheath. C. eTEP approach with bilateral rectromuscular dissection and unilateral TAR for concurrent midline and non-midline hernia. D. Transabdominal approach with retromuscular or preperitoneal dissection for non-midline hernias.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-2046306/v1/351ade4900837f1151dad7cf.png"},{"id":26365753,"identity":"86ae2640-5993-48f3-b778-7e182500ac86","added_by":"auto","created_at":"2022-09-12 20:40:56","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":688730,"visible":true,"origin":"","legend":"\u003cp\u003eOperative view of flank hernia\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRa\u003c/em\u003e – rectus abdominis; \u003cem\u003eta/io\u003c/em\u003e– transversus abdominis and internal oblique muscles; \u003cem\u003eeo\u003c/em\u003e – intact overlying external oblique musculoaponeurotic layer; \u003cem\u003edashed arrows\u003c/em\u003e – edges of hernia defect.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-2046306/v1/907b03ffa2377edcf26bc4a6.png"},{"id":26365766,"identity":"51119637-ca4b-41fe-886c-2be9be122e9f","added_by":"auto","created_at":"2022-09-12 20:41:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2363948,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2046306/v1/bf06411d-6464-4b67-aec4-c52972de1f83.pdf"}],"financialInterests":"Competing interest reported. Drs. Warren and Carbonell have received honoraria for speaking and teaching from Intuitive Surgical. Drs. Carbonell and Cobb have received honoraria and consulting fees from W.L. Gore","formattedTitle":"Robotic Repair of Non-Midline Hernias","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLateral abdominal wall hernias may develop as primary lumbar hernias, but more commonly derive from prior subcostal or flank incisions, ostomy sites, traumatic abdominal wall injury, or trocar sites. [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Non-midline hernias are often complex and may be larger and more symptomatic than midline defects. Repair is technically demanding due to anatomic boundaries of the bony pelvis, retroperitoneum, and costal margin, often resulting in higher risk of intraoperative and perioperative complications [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Achieving defect closure and adequate mesh reinforcement requires utilizing sometimes unfamiliar tissue planes in the lateral abdominal wall and retroperitoneum. Physiologically, the ratio of muscle to aponeurotic tissue in the lateral abdominal wall is higher, resulting in a lower effective tensile strength, which affects both defect closure integrity and the strength and durability of mesh fixation. Furthermore, lateral hernias are subjected to asymmetric forces that may result in higher risk of recurrence [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe European Hernia Society (EHS) classification system defines lateral hernias as below the costal margin, above the iliac crest, and lateral to the semilunar line. Midline hernias occur between the xiphoid and pubic symphysis and bounded by the semilunar line laterally [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. While this is system is a useful standard for reporting, it does not necessarily correlate with surgical technique required for repair. Most notably, when using a retromuscular (RM) approach to ventral hernia repair (VHR), the linea semilunaris limits the lateral dissection and therefore mesh overlap of the hernia. For hernias occurring through the linea alba, this is typically adequate. However, for hernias occurring through the rectus sheath but not directly through the linea alba, such as prior stoma sites, repair technique likely includes additional lateral dissection with a transversus abdominis release (TAR), which increases the complexity and may account for different outcomes compared to RM repair alone. For this reason, we define hernias for this study as non-midline rather than simply lateral. We previously reported outcomes for open preperitoneal and retromuscular repair of lateral abdominal wall hernias, resulting in 13% risk of surgical site infection (SSI) and 11.5% recurrence rate [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. More recently, we have adopted a robotic approach for many of these hernia defects. The robotic platform provides excellent visualization, enhances the ability to dissect abdominal wall layers, close the hernia defect, and widely reinforce the repair with mesh [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This study evaluates our surgical approach and clinical outcomes of robotic repair of non-midline abdominal wall hernias.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe retrospectively identified all patients undergoing repair of non-midline ventral / incisional hernias between August 2013 and March 2020. All surgeries were performed at Prisma Health Upstate by senior authors JAW and AMC. Patient demographics, hernia characteristics, technical details, and clinical outcomes were maintained prospectively in the Abdominal Core Health Quality Collaborative (AHSQC), a prospectively maintained national hernia registry. Any patient with a non-midline hernia was included, including those with a concurrent midline hernia defect (n\u0026thinsp;=\u0026thinsp;26). Patients with parastomal hernias were excluded. Outcome measures were selected to determine the safety and efficacy of the robotic surgical approach. Primary outcomes were Surgical Site Occurrence (SSO) and infection (SSI). Secondary outcomes were operative time, hernia recurrence, conversion to open repair, and other complications associated with repair. Study design and outcomes reporting was performed according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]. This study was approved by the Prisma Health Institutional Review Board.\u003c/p\u003e\n\u003ch2\u003eSurgical Technique\u003c/h2\u003e\n\u003cp\u003eTechnique varied according to the location of the hernia defect and presence or absence of a concurrent midline hernia. The single patient repaired with intraperitoneal mesh followed standard surgical approach that is well described elsewhere. Selection of the optimal approach is key, and preoperative computed tomography (CT) imaging is essential (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe eTEP technique involves laparoscopic entry directly into the retromuscular space without immediate entry into the peritoneal cavity (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The retromuscular space is developed to accommodate additional trocar placement. Depending on the location of the hernia, this may be a unilateral or bilateral retromuscular dissection and trocar placement varies according to the technique required for repair. For hernias without concurrent midline defect that are true lateral hernias, a unilateral dissection is often adequate, with placement of trocars along the medial rectus sheath with dissection progressing medial-to-lateral, a transversus abdominis release (TAR), and lateral dissection continuing in the preperitoneal / retroperitoneal space (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eA). For hernias off-midline but within the confines of the rectus sheath, such as prior ostomy sites, or patients with a concurrent midline hernia, a bilateral retromuscular dissection is needed to ensure adequate mesh overlap in all directions (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eB and C).\u003c/p\u003e\n\u003cp\u003eTransabdominal repair begins with intraperitoneal placement of trocars with incision of the posterior rectus sheath (for retromuscular repair) or peritoneum (for preperitoneal repair) to enter the extraperitoneal plane for repair and mesh placement (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eD).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe identified 65 patients who underwent robotic repair of non-midline hernias. Mean age was 62 years (range 21\u0026ndash;91) and included 27 female and 38 female patients. Mean body mass index (BMI) was 33.8 kg/m\u003csup\u003e2\u003c/sup\u003e (21.9\u0026ndash;59.3). Comorbidities include hypertension (53.8%), diabetes (29.2%), chronic obstructive pulmonary disease (6.2%), and active smokers (16.9%). Patient characteristics are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCharacteristics\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eValues\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (41.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (58.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean Age (year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (range 21\u0026ndash;91)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean body mass index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.8 (range 21.9\u0026ndash;59.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA classification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (27.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (67.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite, not-Hispanic origin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (81.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack/African American\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (12.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (6.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (53.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (29.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic obstructive pulmonary disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (6.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatic failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNicotine use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent, within 1 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (16.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormer, within 1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (4.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistant former, more than 1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (23.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (52.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHernias were located subcostal (L1; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7), flank (L2; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;20), iliac (L3; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;20), lumbar (L4; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;13), or multiple sites (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5). Concurrent midline hernias were present in 26 patients. Hernia types included primary lumbar hernias (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2), traumatic flank hernias (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6), and incisional hernias (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;57). Incisional hernias occurred after urologic procedures (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9), spine procedures (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3), prior ostomy site (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;16), cholecystectomy (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5), appendectomy (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4), trocar sites (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8), or other incisional (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12). Robotic repairs were performed using a transabdominal retromuscular approach (rRM) in 27 patients (41.5%), transabdominal preperitoneal (rTAPP) (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;22; 33.8%), extended view totally extraperitoneal (eTEP) (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;15; 23.1%), or intraperitoneal onlay of mesh (IPOM) (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1; 1.5%). The mean hernia defect size was 111 cm\u003csup\u003e2\u003c/sup\u003e (9.1 cm mean length; 9.4 cm mean width). Permanent synthetic mesh was used for repair in all cases. Conversion to open approach was required in 9 cases (13.8%) due to development of hypercarbia (n\u0026thinsp;=\u0026thinsp;3), poor visualization (n\u0026thinsp;=\u0026thinsp;5), and concern bowel injury during adhesiolysis (n\u0026thinsp;=\u0026thinsp;1). Five of these cases occurred during eTEP repair and 4 during transabdominal retromuscular repair. Surgical details are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgical Details\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCharacteristics\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eValue\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHernia Etiology\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57 (87.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrologic procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (15.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpinal procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (5.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior ostomy site\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (28.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCholecystectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (8.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAppendectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (7.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrocar sites\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (14.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther incisional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (21.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraumatic flank\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (9.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumbar (primary hernia)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHernia classification\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL1: subcostal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (10.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL2: flank\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (30.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL3: iliac\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (30.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL4: lumbar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiple sites\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcurrent midline defect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (40.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgical approach\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransabdominal retromuscular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransabdominal retromuscular\u0026thinsp;+\u0026thinsp;TAR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (38.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransabdominal preperitoneal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (33.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eeTEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eeTEP\u0026thinsp;+\u0026thinsp;TAR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (21.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIPOM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConverted to open\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (13.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean defect area (cm\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111 (range 4-575)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.1 (range 2\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidth (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.4 (range 2\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMesh used\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBarrier-coated polypropylene\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultifilament polyester\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (4.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeavy-weight polypropylene\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMid-weight polypropylene\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57 (87.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean mesh area (cm\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e517 (range 81-1710)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.5 (9\u0026ndash;45)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidth (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.9 (8\u0026ndash;38)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMean operative time was 220.4 min (range 80 to 484 min). Fascial closure was achieved in 63 cases (96.9%). No bowel injuries occurred. Mean length of stay (LOS) was 1.5 days (median 1 day). SSI occurred in 3 patients (4.6%), 2 superficial and 1 deep space infection. All SSIs were treated with antibiotics and 1 required wound opening. No mesh infections occurred, and no mesh removal was needed. SSOs developed in 32 patients (49.2%), 25 of which were seromas. Wound debridement was required in 1 case, percutaneous drainage in 3, and antibiotics in 4 patients (2 due to concurrent SSI, 2 empiric). One patient developed an enterocutaneous fistula that ultimately closed spontaneously after percutaneous drainage and did not require mesh removal. Two hernias recurred (3.1%), and 1 patient developed a trocar site hernia. Mean follow-up was 11 months (range 0.5\u0026ndash;60.9 months). Surgical outcomes are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOutcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOutcome\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eN (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean length of stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.5 (range 0\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian length of stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (IQR 0,2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSSO*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (49.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeroma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (78.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (9.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnterocutaneous fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkin/soft tissue necrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound serous drainage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (9.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSSOPI**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (10.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntibiotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (57.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePercutaneous drainage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (42.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound opening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (14.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound debridement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (14.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSSI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (4.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuperficial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSSIPI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (4.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntibiotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound opening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrence***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (4.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (6.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBowel Injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain requiring intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary tract infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnterocutaneous fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e* 32 patients had a total of 34 SSOs\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e** 7 patients had a total of 9 SSOPIs\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e*** 2 recurrence, 1 trocar site hernia\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eSSO, Surgical Site Occurrence; SSI, Surgical Site Infection; SSOPI, SSO Requiring Procedural Intervention; SSIPI, SSI Requiring Procedural Intervention; IQR, Interquartile Range.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWhile primary non-midline hernias, Spigelian or lumbar hernias, are rare, non-midline secondary hernias can result from a variety of surgical procedures or trauma. Etiology of the hernia will certainly play a role in complexity of repair, and the heterogeneity of surgical techniques and hernia morphology should be taken into account when analyzing clinical trials data [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Non-midline abdominal wall hernias present with unique anatomic challenges during repair. Hernias occurring lateral to the anterior axillary line (EHS classification L4) may not be well visualized from an intraabdominal approach due to the lateral peritoneal attachments of the colon, and lateral mesh overlap is limited for the same reason. Dissection into the retroperitoneal space is required for mesh placement, or an alternative approach such as an onlay is required. When dissecting into this space, it is critical to consider the course of the ureter, gonadal and iliac vessels, and retroperitoneal neural anatomy, all of which may be distorted due to the hernia. Intimate knowledge of these structures is needed to perform a safe and efficacious repair. In particular, the iliohypogastric, ilioinguinal, and lateral femoral cutaneous nerves are at risk of injury for hernias in this location, particularly if found more caudal near the iliac crest. Posterior dissection should allow for at least 5cm of mesh overlap and typically will extend over the psoas and/or quadratus lumborum. Inferior dissection will typically extend to the iliac fossa, where the inguinal nerves are particularly at risk, as are the spermatic structures. Superiorly, dissection of the peritoneum from the diaphragm may be needed to allow adequate mesh overlap under the costal margin. Interestingly, many lateral abdominal wall hernias will present as partial thickness defects with the external oblique layer still intact (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD, Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). This feature actually adds benefit to a robotic approach, as the defect can be difficulty to locate with an open approach.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eHernias in the lateral aspects of the rectus sheath, such as parastomal or prior ostomy site hernias, are still defined by the EHS as midline hernias [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, if repaired with a retromuscular Rives-Stoppa approach, lateral mesh overlap is limited by the linea semilunaris, and additional lateral myofascial release is required. This is accomplished using the transversus abdominis release (TAR). The posterior rectus sheath is incised medial to the intercostal neurovascular bundles along the semilunar line, dividing the posterior lamella of the internal oblique and the transversus abdominis muscle / aponeurosis to enter the preperitoneal or pretransversalis plane. Dissection is then extended laterally in the extraperitoneal plane below the transversus abdominis muscle to allow for adequate mesh overlap and myofascial mobilization for hernia defect closure. For this reason, hernias technically classified as midline (M1-5) by the EHS are included in this report, as the addition of a TAR adds significant complexity to the repair and is necessary for most hernias that occur lateral to the linea alba.\u003c/p\u003e \u003cp\u003eSelection of the optimal surgical approach depends on the location and size of the hernia relative to these anatomic limitations. Strong consideration should be given to preoperative computed tomography imaging to delineate the extent of the hernia. Current published series of lateral abdominal wall hernia repair are limited, and there is no current consensus on optimal repair owing to this limited data and the heterogeneity of these hernias. We previously reported outcomes of 61 non-midline hernias repaired in an open extraperitoneal fashion [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Patients developed SSO in 49.2% of cases with SSI in 13.1% and hernia recurrence of 11.5% with a mean of 15.4 months. Others have reported similar outcomes for open flank hernia repair. Moreno-Egea, et al reported similar SSO and recurrences in 20 patients with lumbar hernias, with 40% and 15%, respectively [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Their group also reported a small series of 7 patients with lumbar hernia repaired using the open technique and yielded a 42.9% recurrence [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Veyrie, et al reported the repair of 61 patients with non-midline incisional hernias using a retromuscular approach. Early perioperative morbidity was 18% with a recurrence rate of 4.9% with median follow-up of 47 mos [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMinimally invasive surgery, and hernia repair in particular, has repeatedly demonstrated lower risk of SSI compared with open surgery. There is limited data on laparoscopic repair of lateral hernias, however, due to the anatomic considerations mentioned above, which make minimally invasive repair difficult. Moreno-Egea, et al published a series of 55 patients who underwent laparoscopic (35 patients) and open (20 patients) repairs of lumbar hernias demonstrating benefit of the laparoscopic approach over open repair in terms of both wound complications (seroma 20 vs 40%) and hernia recurrence (2.9 vs 15%)[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. A second study looking more broadly at non-midline hernias demonstrated a recurrence rate of 8.2% overall, with 25% of subcostal hernias developing a recurrence [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The authors do note the increased complexity of preperitoneal dissection and limitations of mesh fixation in these hernias, which likely contribute to hernia recurrence.\u003c/p\u003e \u003cp\u003eThese anatomic and technical concerns can largely be mitigated with the utilization of extraperitoneal mesh placement. This is technically difficulty to accomplish with traditional laparoscopy but is greatly facilitated by the robotic platform. The enhanced visualization and ability to perform a complex dissection with articulated instruments in an ergonomically friendly manner has enabled expansion of minimally invasive techniques to include complex abdominal wall reconstruction. The ability to achieve fascial closure, aided by lateral abdominal myofascial release and extensive extraperitoneal dissection, is key to the success of robotic repair. Others have reported similar outcomes in limited series [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Di Giuseppe, et al reported outcomes of robotic repair of 7 incisional flank hernias [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. With a mean follow-up of 6 months, no seromas nor recurrences were reported, and no cases required conversion to open surgery. Another more recent smaller study reported no recurrence of non-midline hernias repaired robotically, with data presented up to 24 months post repair [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere are several limitations of our study. Selection bias is inherent to any retrospective analysis. Clinical perception of technical difficulty of a given hernia repair will influence the decision to pursue open versus robotic repair, and this description is not necessarily representative of non-midline hernia repair outcomes on the whole. Additionally, this study is conducted in a high-volume hernia-specific practice at a single center, which may limit generalizability. We also performed several variations in technique. Though similar in concept, there may be important differences in outcome and technique that cannot be elucidated due to the small sample size and may increase bias in the results. As there are no controls for the current study, future case-matched studies may be beneficial to compare outcomes of robotic repair with open and laparoscopic repairs. Finally, our follow-up duration is short, and long-term analysis is needed to confirm the risk of hernia recurrence. Because of the increased capability of different institutions in performing robotic surgeries in addition to the gap of knowledge in robotic repair of non-midline hernias, timely report of the safety and efficacy of the robotic approach was a main factor for reporting our current findings. The goal is to have a follow-up report of surgical outcomes of the current data set a few more years after hernia repairs. Larger studies with long-term follow-up are needed to confirm our initial experiences with robotic lateral hernia repairs.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eNon-midline abdominal wall hernia repair is difficult due to anatomic and technical constraints to commonly employed techniques. The evolution of advanced myofascial release techniques and the robotic platform enables reconstruction of these complex hernia defects in a minimally invasive fashion, minimizing perioperative morbidity while adhering to well-established principles of hernia repair. Overall, it is evident from our study that the robotic platform is safe and efficacious and will become an integral tool in repairing non-midline abdominal wall hernias. Further study is needed to optimize patient selection and determine long-term outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy conception and design was done by Jeremy A Warren, William S Cobb, and Alfredo M Carbonell; acquisition of data by Alyssa A Guo, Dillon Isaac, and Liliana Jaraczewski; analysis and interpretation of data by Alyssa A Guo and Jeremy A Warren; drafting of manuscript by Jeremy A Warren and Alyssa A Guo; and critical revision by Alyssa A Guo, Jeremy A Warren, William S Cobb, and Alfredo M Carbonell. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for any portion of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDrs. Warren and Carbonell have received honoraria for speaking and teaching from Intuitive Surgical. \u0026nbsp; Drs. Carbonell and Cobb have received honoraria and consulting fees from W.L. Gore\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe databased used for this study was approved by the Prisma Health Institutional Review Board.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eHope WW, Tuma F (2022) Incisional Hernia. In: StatPearls. StatPearls Publishing, Treasure Island (FL)\u003c/li\u003e\n \u003cli\u003eDennis RW, Marshall A, Deshmukh H, Bender JS, Kulvatunyou N, Lees JS, Albrecht RM (2009) Abdominal wall injuries occurring after blunt trauma: incidence and grading system. Am J Surg. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.amjsurg.2008.11.015\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003eMuysoms FE, Miserez M, Berrevoet F, Campanelli G, Champault GG, Chelala E, Dietz UA, Eker HH, El Nakadi I, Hauters P, Hidalgo Pascual M, Hoeferlin A, Klinge U, Montgomery A, Simmermacher RKJ, Simons MP, Smietański M, Sommeling C, Tollens T, Vierendeels T, Kingsnorth A (2009) Classification of primary and incisional abdominal wall hernias. Hernia. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10029-009-0518-x\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003eMoreno-Egea A, Carrillo A, Aguayo JL (2008) Midline versus nonmidline laparoscopic incisional hernioplasty: a comparative study. Surg Endosc. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00464-007-9480-9\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003eSlater NJ, Montgomery A, Berrevoet F, Carbonell AM, Chang A, Franklin M, Kercher KW, Lammers BJ, Parra-Davilla E, Roll S, Towfigh S, van Geffen E, Conze J, van Goor H (2014) Criteria for definition of a complex abdominal wall hernia. Hernia. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10029-013-1168-6\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003eKapur SK, Butler CE (2018) Lateral Abdominal Wall Reconstruction. Semin Plast Surg. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-0038-1666801\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003ePatel PP, Warren JA, Mansour R, Cobb WS, Carbonell AM (2016) A Large Single-Center Experience of Open Lateral Abdominal Wall Hernia Repairs. 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Surg Endosc. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00464-011-2001-x\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003eKirkpatrick T, Zimmerman B, LeBlanc K (2018) Initial Experience with Robotic Hernia Repairs: A Review of 150 Cases. Surg Technol Int\u003c/li\u003e\n \u003cli\u003eDi Giuseppe M, Mongelli F, Marcantonio M, La Regina D, Pini R (2020) Robotic assisted treatment of flank hernias: case series. BMC Surg. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12893-020-00843-3\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003eCabrera ATG, Lima DL, Pereira X, Cavazzola LT, Malcher F (2021) Robotic transabdominal preperitoneal approach (TAPP) for lateral incisional hernias. Arq Bras Cir Dig. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1590/0102-672020210002e1599\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Lateral hernias, robotic hernia repair, non-midline hernias, transversus abdominis release, hernia recurrences","lastPublishedDoi":"10.21203/rs.3.rs-2046306/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2046306/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNon-midline abdominal wall hernias present unique anatomic challenges, making repair more complex. The constraints of the peritoneal cavity, pelvis, and costal margin limit the utility of intraperitoneal mesh repair, and extraperitoneal repairs have traditionally been performed using open techniques, often resulting in higher wound morbidity. Advances in minimally invasive surgery make visualization and dissection of such complex cases feasible, with all the attendant benefits of a minimally invasive over an open approach. \u0026nbsp;In this study we examined the use of the robotic platform to repair non-midline hernias.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRetrospective review of all non-midline abdominal wall hernias performed robotically at Prisma Health, excluding parastomal hernias. Study conducted and outcomes reported according to STROBE statement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRepair was performed in the retromuscular space (n=42), preperitoneal (n=22), and intraperitoneal (n=1). Mean hernia width was 9.4cm, permanent synthetic mesh used for all repairs. Mean LOS was 1.5 days. Surgical site occurrence (SSO) occurred in 49.2%, 78% of which were simple seroma. Three patients (4.6%) developed surgical site infection (SSI). Two recurrences were identified with a mean follow-up of 11 mos.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe robotic platform facilitates complex dissection to allow minimally invasive, extraperitoneal repair of complex non-midline hernias. This approach overcomes the anatomic constraints of intraperitoneal mesh repair and the wound morbidity of open repair.\u003c/p\u003e","manuscriptTitle":"Robotic Repair of Non-Midline Hernias","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-09-12 20:35:53","doi":"10.21203/rs.3.rs-2046306/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-11-21T02:06:30+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-11-17T16:05:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9b450aa3-fcf8-49f7-a9b6-97109d202f1c","date":"2022-11-13T00:00:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-11-12T21:09:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-09-14T01:34:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-09-09T09:49:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2022-09-08T17:22:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"1a5dba33-feec-4557-b6d8-113380456943","owner":[],"postedDate":"September 12th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2022-11-25T21:59:13+00:00","versionOfRecord":[],"versionCreatedAt":"2022-09-12 20:35:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2046306","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2046306","identity":"rs-2046306","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}