What is the recommended approach for robotic-assisted laparoscopic repair of incisional hernia with Intraperitoneal Onlay Mesh (IPOM)?

Robotic-Assisted Laparoscopic Repair of Incisional Hernia with IPOM

Robotic-assisted laparoscopic IPOM repair is a safe and effective approach for incisional hernia repair, offering shorter hospital stays and reduced wound complications compared to traditional laparoscopic IPOM, though it requires longer operative times and should be reserved for clinically stable patients with experienced surgical teams. 1, 2

Technical Approach and Patient Selection

The robotic IPOM technique involves intraperitoneal mesh placement with the robotic platform providing enhanced visualization and dexterity for mesh positioning and fixation. 1 The procedure should only be considered in:

• Clinically stable patients without signs of bowel strangulation or need for bowel resection 2
• Centers with experienced surgical and nursing teams trained in robotic surgery 2
• Clean surgical fields (CDC wound class I) where synthetic mesh is appropriate 2

Comparative Outcomes: Robotic vs Standard Laparoscopic IPOM

The most recent high-quality comparative data from the Americas Hernia Society Quality Collaborative demonstrates clear advantages for robotic IPOM:

• Significantly shorter hospital length of stay (0 vs 1 day median) 1
• Lower surgical site occurrence rates (5% vs 14%) 1
• Similar rates of complications requiring procedural intervention (0% vs 1%) 1
• Longer operative times (47% vs 31% exceeding 2 hours) 1

Mesh Selection and Fixation

Synthetic mesh is the standard for clean surgical fields, with various options including PVDF (DynaMesh-IPOM) and ePTFE (Gore DUALMESH Plus) showing comparable safety and recurrence rates around 6-7%. 3 Key technical considerations include:

• Ensure at least 5-cm mesh overlap beyond the defect edges 2
• Use transfascial sutures for defect closure to reduce seroma formation and recurrence 4
• For suprapubic hernias, consider mobilizing the urinary bladder to create proper mesh compartmentalization 4

Advantages Over Open IPOM

Both robotic and standard laparoscopic IPOM demonstrate superior outcomes compared to open IPOM:

• Reduced postoperative pain (significantly lower Visual Analog Scale scores) 5
• Shorter hospital stays (6 vs 8 days for standard laparoscopic vs open) 6
• Lower surgical site infection rates (1% vs 21%) 6
• Fewer overall complications (10% vs 23%) 6
• Comparable long-term recurrence rates (19-20% at 5.5 years) 6
• Faster return to routine activities 5

Critical Contraindications

Avoid minimally invasive approaches including robotic IPOM when:

• Bowel strangulation is suspected or confirmed 2
• Bowel resection is anticipated 2
• Patient is hemodynamically unstable 2
• Gross enteric spillage or peritonitis is present 2
• Patient cannot tolerate general anesthesia 7

In these scenarios, open preperitoneal approach is preferable 2, and for unstable patients with severe sepsis, open management with damage control surgery principles should be employed 2.

Common Pitfalls to Avoid

• Do not delay repair in incarcerated hernias, as this increases morbidity and mortality risk 8
• Ensure adequate mesh overlap (minimum 5 cm) to prevent recurrence 2
• Avoid mesh placement in contaminated fields (CDC class III-IV) where biological mesh or delayed repair is more appropriate 2
• Do not underestimate operative time requirements for robotic approach when scheduling cases 1
• Ensure proper patient selection—robotic approach is not appropriate for emergency complicated hernias in unstable patients 2

Expected Complications and Management

Minor complications occur in approximately 20% of cases and include:

• Seromas (most common) 3
• Prolonged ileus 3
• Hematoma formation 3

No significant difference in complication rates exists between different synthetic mesh types when proper technique is employed. 3