Ventral hernia repair is one of the most commonly performed procedures in general surgery [1]. The approach to repair has evolved dramatically in the modern era. Hernia repair strategies have pushed towards the utilization of broad, extraperitoneal positioned mesh with a premium placed on defect closure [2, 3]. The advent of modern techniques such as transversus abdominis release (TAR), have provided safe and reproducible approaches for achieving broad mesh coverage for complex reconstruction, while simultaneously reducing wound morbidity traditionally present for advanced procedures such as anterior component separation [4–6]. Further enhancing surgeons’ ability to deliver complex repair options while minimizing morbidity has been the revolutionary robotic approaches to abdominal wall reconstruction, which have been allowed surgeons to attain comparable long term outcomes and reduce morbidity further [4, 5].

Minimally invasive abdominal wall reconstruction is in its early phase of adoption. Spurred by procedures like intraperitoneal onlay mesh repair (IPOM), transabdominal preperitoneal repair (TAPP), and enhanced totally extraperitoneal techniques (eTEP), general surgeons have expanded their armamentarium to address ventral hernia defects [7]. Expert opinion on the best technique for a given defect is diverse and dependent on a variety of factors. However, one common and emerging theme among abdominal wall specialists is the realization that hernias may be considered a chronic disease process, and that abdominal wall planes should be preserved to allow for future operations to be performed. Beyond preservation of hernia repair options for the future, many experts have noted that over utilization of advanced techniques such as TAR, can be associated with major complications [8].

We sought to develop a technique to allow for broad mesh coverage, decrease tension on fascial closure while minimizing the potential for injuries to the neurovascular elements of the abdominal wall. As such, an extended transabdominal preperitoneal dissection with concurrent rectus aponeuroplasty (TAPPRA) was developed. We share our initial experience and the development of the TAPPRA technique. Further, we describe early perioperative outcomes for patients who have had this operation. Our study aims to assess the safety, efficacy, and results of TAPPRA technique for moderate sized ventral hernia defects.

The optimal surgical approach for moderate sized ventral hernias is complex and dependents on multiple patient, surgeon, and institutional factors. We report our initial experience of a novel technique for robotic ventral hernia repair, TAPPRA, and demonstrate that short-term outcomes are appropriate with expected findings related to intraoperative reproducibility and immediate postoperative outcomes. We are encouraged by these findings which allow for yet another technique to minimally invasive hernia repair with ventral defect closure and broad mesh reinforcement.

Contemporary ventral hernia repair has evolved dramatically in the last two decades. Many of the principles of hernia repair have been derived from retromuscular techniques proposed by Rives and Stoppa—namely prosthetic reinforcement of the visceral sac [13]. Over the decades, this approach has allowed for multiple iterative changes that have led to the modern day hernia practice [14]. Traditional open ventral hernia repair with myofascial advancement techniques have been associated with good outcomes in select populations. However, these techniques carried high rates of wound complications and perioperative morbidity. As such, surgeons explored minimally invasive techniques such as IPOM, with a goal of minimizing wound complications [7]. IPOM, though effective in the short term, had many weaknesses as defect closure was often not achieved. Further, the ability for surgeons to use IPOM to address hernias in atypical locations was poor, as circumferential penetrating fixation was required for success [9]. As a function of robotic technology, and expansion of our working understanding of the abdominal wall, newer techniques/approaches such as IPOM+, LIRA, rTAPP, and eTEP have since been introduced which allow for ventral hernia repair that results in more durable outcomes than IPOM [7, 10]. Our proposed procedure takes elements of these operations, specifically LIRA and rTAPP, to allow for surgeons to address moderate defects with an extraperitoneal mesh.

TAPP ventral hernia repair is now a common procedure among surgeons. For smaller defects, it serves a valuable role, allowing for defect closure, extraperitoneal mesh, and minimizes the need for penetrating fixation of mesh [9]. However, for larger defects, the TAPP approach can be associated with excessive tension during defect closure. For many surgeons, rather than attempting a preperitoneal repair for moderate defects, a retromuscular repair is conducted, which results in medialization of the rectus abdominis and anterior fascia through a variety of maneuvers [15]. The process of myofascial advancement in these techniques has been attributed to many factors, including incision of the posterior rectus sheath, dissection of the retrorectus space, incision of the posterior lamella of the internal abdominal oblique aponeurosis, and for advanced procedures, transection of the transversus abdominis muscle and subsequent dissection in the pretransversalis space [16, 17]. Unfortunately, complications related to retromuscular repair are significant and can burn many bridges to future repair [18]. Our described technique predominantly performs a dissection the preperitoneal plane and has a limited retromuscular component. By performing rectus aponeuroplasty, we are able to off-load tension, allowing for closure of larger defects.

Extended preperitoneal dissections have been described for many decades, but have been considered to be challenging and difficult to reproduce [19]. Outcomes at high volume centers have demonstrated iterative improvement in this technique. As general surgeons have become more comfortable with retromuscular dissection, this complex technique now appears to be more attainable. We find that TAPPRA is a reproducible option for hernia repair that does not obviate any other options for reconstruction. The operation may proceed with unilateral docking or a double docking technique. The double docking strategy is typically reserved for wider defects that will require broad mesh coverage. Rather than a traditional TAR procedure, this extended preperitoneal dissection allows for extension of the dissection beyond the semilunar line without disrupting the muscular and aponeurotic elements of the abdominal wall. Similar strategies have been implemented by the Madrid group, but often require a retrorectus dissection which may result in increased potential for neurovascular trauma to the abdominal wall [20].

This study has several notable limitations. First, it is a retrospective review of select cases performed at a high-volume hernia center. The surgeon included in this study has completed a formal fellowship in abdominal wall reconstruction and has overcome their initial learning curve in robotic ventral hernia repair. Second, this study exclusively evaluates feasibility of performing these repairs with limited information on long-term outcomes. Though those findings will be paramount, this technique is a derivative of commonly performed operations that are well described in the hernia literature and have demonstrated acceptable long-term results. We have been encouraged by the low rate of short-term complications and look forward to long-term follow up with these patients. Third, the operations are performed using robotic surgical platform. Though these techniques can be performed with traditional laparoscopic instruments, robotic assisted surgery facilitates management of complex peritoneal flaps and may make broad adoption challenging. More robust evaluation of this technique is necessary. We are currently collaborating with other hernia centers to evaluate the utility of this technique and compare it to other MIS techniques for ventral hernia repair.

In summary, we report our first experience of performing robotic TAPPRA technique for the management of moderate sized ventral hernias. This technique appears to be associated with a low complication profile and can be applied to many patients. Future studies evaluating the optimal patient selection strategy and long-term outcomes will be important in determining if this technique can be more broadly applied.