Complex abdominal wall reconstruction: pushing the boundaries of minimally invasive surgery

Robotic platforms have expanded the indications and techniques for abdominal wall reconstruction (AWR). This comprehensive narrative review examines current evidence on the evolution, technical variations, clinical outcomes, and cost implications of robotic AWR (rAWR), taking data from systematic reviews, meta-analyses, randomized clinical trials, and large registry studies. Robotic platforms provide enhanced dexterity and three-dimensional visualisation, facilitating complex repairs such as transversus abdominis release using extraperitoneal, transabdominal, and hybrid approaches. Published data suggest rAWR is associated with comparable or reduced rates of visceral injury and surgical site occurrence compared with open repair, but shorter hospital stay (median 1 day vs. 3-4 days for open), and lower readmission rates. There are similar long-term recurrence rates across open, laparoscopic, and robotic approaches, though the learning curve impacts early outcomes. There is conflicting evidence regarding early postoperative pain. Despite higher upfront expenditure, hybrid approaches appear most cost-effective due to reduced complications and length of stay. rAWR is safe and effective, offering advantages in visualisation, and recovery, with outcomes comparable to or better than open repair. Future priorities include standardised credentialing, rationalization of technique selection, and generating long-term data registries. Finally, rAWR should be delivered within multidisciplinary abdominal wall teams to optimise patient selection and outcomes.