Comprehensive Approach to the Milos Procedure for Hernia Repair
The Milos (Mini or Less Open Sublay) procedure is a minimally invasive technique for ventral hernia repair that combines the advantages of open sublay and laparoscopic IPOM repair, providing excellent outcomes with lower complication rates compared to traditional approaches. 1
Overview of the Milos Technique
The Milos concept represents an evolution in hernia repair that addresses limitations of both traditional open and laparoscopic approaches:
- Basic Concept: Uses mini or less incision hybrid with endoscopic techniques to accomplish minimally invasive sublay repair 1
- Key Advantage: Allows mesh placement in the retromuscular (sublay) position without opening the abdominal cavity or requiring large skin incisions 2
- Variations:
- MILOS: Original technique with open approach
- EMILOS: Endoscopic variation of the same concept
- E/MILOP: Preperitoneal variation of the technique 3
Surgical Technique
Approach and Incision
- Make a small incision (average 5.2 cm) directly over the hernia defect 2
- Carefully enter the hernia sac and develop the preperitoneal or retromuscular space trans-hernially 3
Dissection and Mesh Placement
- Create a retromuscular plane either via open technique (MILOS) or endoscopically (EMILOS) 2
- Place a synthetic mesh in the retromuscular/preperitoneal space
- Ensure adequate mesh-to-defect ratio (reported average of 12.9) 3
- Close the defect with sutures
Technical Considerations
- For larger defects (>3 cm), mesh reinforcement is strongly recommended 4
- Non-absorbable sutures should be used for primary repair 5
- Mesh can be placed without fixation in many cases 2
- For complex cases with larger defects, a larger mesh (e.g., 20 × 30 cm) may be used 2
Indications and Patient Selection
The Milos procedure is particularly well-suited for:
- Primary umbilical hernias 6
- Epigastric hernias 6
- Incisional ventral hernias 3
- Midline hernias with coexisting rectus diastasis 2
Outcomes and Advantages
Clinical Outcomes
- Recurrence Rate: Very low (0-0.5% at 1-year follow-up) 6
- Infection Rate: Minimal (0-0.2%) 6
- Chronic Pain: Low rates (1.5-4.2% depending on hernia type) 6
- Hospital Stay: Short (average 1.9-3.2 days) 3, 2
Advantages Over Traditional Approaches
- Less operative trauma compared to open repair 1
- Avoids mesh-related complications associated with intraperitoneal placement 1
- Reduces risk of bowel injury compared to laparoscopic IPOM 1
- Lower postoperative pain compared to traditional techniques 1
- High economic efficiency 1
Postoperative Care
- Day surgery is recommended for most uncomplicated hernia repairs 4
- Patients should resume normal activities as soon as comfortable 4
- Pain management should follow a multimodal approach:
- NSAIDs and acetaminophen as first-line agents
- Opioids reserved for severe, uncontrolled pain
- Gabapentin or pregabalin for neuropathic pain components 4
Potential Complications and Management
- Surgical Site Occurrences: Reported in approximately 30% of cases but rarely require intervention 3
- Paralytic Ileus: May occur in a small percentage of patients 7
- Surgical Site Infection: Rare but may require appropriate antibiotic management 6
Evolution and Related Techniques
The Milos concept has inspired several related techniques:
- e-TEP (extended Totally Extra Peritoneal) approach
- TES (Transabdominal Endoscopic Sublay)
- SCOLA (Subcutaneous Onlay Laparoscopic Approach)
These techniques share the core principle of minimally invasive access with retromuscular or preperitoneal mesh placement 7.
The Milos procedure represents an important advancement in hernia repair techniques, offering surgeons a reliable, reproducible, and standardizable approach with excellent outcomes and patient satisfaction.