Robotic-assisted pulley technique for the ventral hernia

When approaching complex abdominal wall hernias at either index operation or a subsequent reoperation for recurrent incarcerated abdominal wall hernias, a majority of surgeons consider mesh placement a key step in the prevention of a future recurrence. While the laparoscopic and open approaches show no significant difference in hernia recurrence, the laparoscopic approach to complex abdominal wall hernias does reduce surgical-site infection, postoperative ileus, improves short-term quality-of-life scores, and reduces hospital length of stay (Davies et al. in Am Surg 78(8):888-892, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3500604/ , 2012, McGreevy et al. in Surg Endosc 17(11):1778-1780, https://www.ncbi.nlm.nih.gov/pubmed/12958679 , 2003, Bittner et al. in Surg Endosc 33:3069-3139, https://doi.org/10.1007/s00464-019-06907-7 , 2019). In this paper, we describe a robotic approach with a pulley technique to the fixation of polypropylene mesh in complex abdominal wall reconstruction. Our primary aim is to offer a new perspective to the re-creation of challenging abdominal walls and to encourage other surgeons to gain proficiency in the robotic approach. Additionally, the material cost to the technique is lower than that of self-expanding or deployable mesh reinforcements used in other laparoscopic approaches. Over time, as an institution breaks even on the cost of a robot with their return on investment, this technique offers potential cost-saving.