Minimally invasive surgery (MIS) has revolutionised the management of complex hernias, offering reduced morbidity, faster recovery, and superior cosmetic outcomes compared to open approaches [1]. Despite these advantages, achieving tension-free fascial closure in ventral hernias remains a significant challenge, particularly in cases involving large defects or loss of domain (LOD), where conventional closure techniques often lead to excessive tension, increased recurrence rates, and postoperative complications [2].

Several preoperative and intraoperative strategies have been developed to address these challenges. Techniques such as Progressive Preoperative Pneumoperitoneum (PPP), Botulinum toxin A (BTA) injections, and Component separation (CS) procedures have been widely adopted to facilitate fascial approximation [3]. However, these methods are associated with limitations, including the need for extended preoperative preparation, increased surgical complexity, and a higher risk of complications such as seroma formation, mesh infection, and abdominal wall dysfunction [4].

IFT has emerged as an innovative technique that allows for the controlled elongation of the myofascial structures, enabling primary closure without excessive tension [5]. This approach uses mechanical traction devices to gradually medialise the rectus complex, increase intra-abdominal volume, and facilitate a reduced-tension repair by lengthening the lateral muscle complex [6]. Unlike CS techniques, IFT preserves the structural integrity of the abdominal wall, in view of reducing the risk of denervation, functional impairment, and long-term hernia recurrence [5].

IFT has primarily been used in the open repair of large ventral hernias. The use of IFT in MIS (Robotic/Laparoscopic) can be very useful, but it is technically demanding. To date, only one case report has been published describing the use of IFT in Robotic Surgery. Bloemendaal et al. described the application of IFT in a robotic transabdominal retromuscular repair (r-TARUP) using an intra-abdominal approach. In contrast, our manuscript demonstrates the application of IFT in a robotic eTEP retrorectus approach with a distinct technical methodology and port strategy [7]. We report the first use of IFT in a robotic eTEP approach.

This article explores the application of IFT in MIS, detailing its surgical technique, clinical outcomes, and potential to redefine the paradigm of complex hernia repair.

A retrospective data collection was conducted at Max Super Speciality Hospital, Vaishali, between June 2024 and June 2025, enrolling six patients who had undergone surgical intervention for complex hernia repair. The preoperative assessment included taking a comprehensive medical history, performing a physical examination and carrying out standard laboratory investigations. A CT scan of the abdomen and pelvis was performed to aid in preoperative planning. Baseline variables including age, gender, body mass index (BMI), comorbidities, and other relevant hernia-related information were also collected. The Da Vinci Xi Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) was utilised for robotic-assisted surgery. All surgeries were conducted by a single experienced surgeon.

All patients underwent an eTEP repair with IFT. In 5 out of 6 cases where the transverse defect exceeded 15 cm, preoperative administration of BTA was implemented to facilitate myofascial elongation. The size of the intraoperative defect was measured using an infant feeding tube before and after the application of fascial traction in order to evaluate its effectiveness in defect closure.

A total of 6 patients underwent IFT with Robotic Surgery. Five of these patients received preoperative BTA injections with an interval period of 4 weeks between the injections and the hernia repair. All patients received preoperative antibiotics and urinary catheterisation.

Six patients underwent robotic-assisted eTEP hernia repair facilitated by IFT using the Fasciotens® Hernia System. The mean age of the cohort was 54.2 ± 9.1 years, with a male-to-female ratio of 2:1. The average BMI was 28.5 ± 3.8 kg/m². The majority of patients (83.3%) had incisional hernias, and two patients (33.3%) presented with recurrent hernias. Table 1 summarizes the Demographic characteristics.

In our prospective case series involving six patients who received robotic-assisted eTEP hernia repair with the adjunct use of Intra-abdominal Fascial Traction (IFT), the perioperative and early postoperative outcomes were highly favourable. All surgeries were completed without conversion to an open technique or the need for re-intubation, underscoring the safety of the procedure and the effectiveness of the anaesthetic management during surgery.

The mean width of the pre-traction fascial defect was 15.8 ± 5.4 cm, which was successfully reduced to 8.9 ± 3.2 cm after fascial traction, achieving an average fascial medialisation of 6.9 ± 1.8 cm. This enabled tension-free midline closure without any signs of elevated intra-abdominal pressure. Table 2 summarizes the Perioperative Parameters of the patients.

Pain levels progressively declined in the immediate postoperative period, with a mean NRS score of 5.6 ± 0.5 at 6 h, improving to 3.8 ± 0.7 at 24 h, and 2.2 ± 0.6 by postoperative day 3, highlighting the efficacy of minimally invasive access and enhanced recovery protocols.

All patients ambulated within 24 h, with a mean time to first bowel movement of 1.5 ± 0.5 SD days. The average hospital stay was 2.5 ± 0.5 SD days, and no patients required readmission within the 30-day follow-up period. A standardised postoperative analgesia protocol was followed for all patients, consisting of intravenous paracetamol as routine baseline analgesia, with additional tramadol or diclofenac administered on an as-needed basis depending on postoperative pain assessment and patient requirements.

Return to routine daily activities occurred at a mean duration of 7.0 ± 1.3 days, and five out of six patients (83.33%) resumed professional duties by postoperative day 21. No postoperative complications were recorded.

In the context of large and complex incisional hernias, the concept of LOD is of paramount importance in preoperative assessment and surgical planning. LOD describes a condition in which a substantial volume of abdominal viscera has chronically herniated and become trapped in the hernia sac, resulting in a disproportionately reduced intra-abdominal cavity capacity [9].

In this clinical setting, IFT has emerged as a transformative adjunct in the surgical management of large ventral and incisional hernias, particularly those complicated by LOD. IFT is a technique designed to gradually elongate the abdominal wall by applying a controlled, symmetrical stretching force across the fascial edges, thereby facilitating their medialisation and subsequent tension-reduced closure. This controlled fascial traction induces progressive viscoelastic elongation and medialisation of the abdominal wall musculofascial components, thereby increasing abdominal wall compliance and facilitating tension-reduced midline closure in large ventral hernias [6].

Clinical evidence supports the efficacy of IFT in improving outcomes in abdominal wall reconstruction. In a prospective study by Pous-Serrano et al., IFT—when combined with preoperative progressive pneumoperitoneum and botulinum toxin A—enabled effective closure in patients with significant LOD without the need for CST, with a low rate of major complications [10]. Similarly, Moreno-Egea and Carrillo-Alcaraz reported that the use of fascial traction techniques significantly improved fascial approximation, minimised the need for extensive dissection, avoided the requirement of posterior component separation/transversus abdominis release, and reduced postoperative complications such as seromas and wound infections, thereby accelerating patient recovery [11].

Robotic-assisted surgery offers significant benefits in the management of complex and large ventral hernias. The robotic platform facilitates superior ergonomics, magnified 3D visualisation, and tremor-free articulation, all of which significantly enhance the surgeon’s ability to dissect in avascular planes such as the retromuscular or pre-peritoneal planes [12]. Moreover, intracorporeal suturing—an essential step in reconstructing the posterior sheath or performing transversus abdominis release (TAR)—is significantly easier and more precise with robotic instruments [13].

Our findings align with the retrospective outcomes reported in our earlier work, in which we compared laparoscopic and robotic-assisted eTEP repairs in a high-volume Indian centre. This study demonstrated that the robotic group had significantly better outcomes across multiple parameters, including reduced operating time, lower postoperative pain scores at 24 h and 14 days, and improved wellbeing scores. Importantly, a lower need for CS was also observed in larger defects managed robotically, further supporting the role of robotic surgery in achieving functional closure without increased morbidity [14].

Combining robotic surgery with IFT provides exponential benefits: the precise tension control of IFT is complemented by the visual and technical advantages of robotics, allowing for real-time adjustments during medialisation and closure. The minimally invasive nature of robotic access also reduces overall tissue trauma, shortens recovery time, and minimises the need for component separation techniques [15].

The technical intricacies of implementing IFT within a robotic setup involve the intracorporeal placement of traction suture mechanisms along the linea alba or fascial edges, followed by their gradual tightening under direct visual control. While spatial limitations around the operating table—primarily due to the proximity of the robotic patient cart—pose a logistical challenge, we successfully executed IFT without undocking the robot.

To further optimise fascial compliance, the preoperative administration of BTA has been shown to paralyse the lateral abdominal wall musculature, leading to passive lengthening and decreased tension on the midline closure [16]. This technique, when combined with IFT, provides a biomechanically favourable environment for durable fascial closure.

A notable advantage of IFT is that it can obviate the need for component separation techniques (CST), which are traditionally used to approximate the rectus muscles, but which are associated with significant morbidity, including seroma formation, nerve injury, and wound complications [5]. By preserving the native integrity of the lateral abdominal wall, IFT offers a less invasive alternative that aligns with the principles of functional restoration and reduced surgical trauma.

By achieving primary midline closure through tension-reducing modalities such as IFT and BTA, the need for CST can be avoided, thereby improving both short- and long-term patient outcomes [17]. These results collectively underscore the procedural safety, enhanced recovery, and functional restoration achieved by using robotic-assisted repair in conjunction with the Fasciotens® Hernia System.

The integration of IFT into minimally invasive and robotic-assisted hernia repair appears to be technically feasible and may serve as a useful adjunct for facilitating tension-reduced fascial closure in complex ventral hernias. Understanding the differential effects of fascial traction on anterior and posterior layers is essential for refining surgical techniques. Continued research and clinical experience will shape optimal management strategies for these challenging hernia cases.