Use of Intra-Operative Fascial Traction in Robotic eTEP approach for complex ventral hernias: Technique and outcomes

Abstract

Abstract Background: Tension-reduced midline closure remains a key challenge during minimally invasive repair of large and complex ventral and incisional hernias. Commonly employed adjuncts such as botulinum toxin A (BTA), progressive pneumoperitoneum (PPP) and component separation(CS) increase treatment complexity and may add morbidity. Intra-operative fascial traction (IFT) has been described in open surgery to facilitate fascial medialisation, but data related to minimally invasive and robotic approaches supplementing IFT is scarce. Methods: A retrospective analysis was conducted on six patients who underwent robotic-assisted enhanced-view totally extraperitoneal (eTEP) ventral hernia repair with adjunctive IFT between June 2024 and March 2025. Comprehensive preoperative workup included clinical evaluation and computed tomography (CT) imaging. Fascial defect width was meticulously measured intraoperatively before and after traction. For patients with transverse defects exceeding 15 cm, preoperative BTA injections were administered. Results: The mean pre-traction defect width was 15.8 ± 5.4 cm, which reduced to 8.9 ± 3.2 cm following traction, achieving a mean medialisation of 6.9 ± 1.8 cm. Tension-reduced midline closure was achieved in all patients without the need for CS or conversion to open surgery. Postoperative recovery was uneventful, with low pain scores, early ambulation, no surgical site complications, and no 30-day readmissions. Conclusion: IFT is a feasible and effective adjunct in robotic eTEP repair of large ventral hernias. When combined with robotic precision, it facilitates closure without undue fascial tension while preserving abdominal wall integrity and avoiding CS. Larger studies are warranted to validate these findings.