Use of intraperitoneal fascial traction in robotic eTEP approach for complex ventral hernias: technique and outcomes

Tension-reduced midline closure remains a key challenge in the minimally invasive repair of large and complex ventral and incisional hernias. Commonly employed adjuncts, such as botulinum toxin A (BTA), progressive pneumoperitoneum (PPP), and component separation (CS), increase treatment complexity and may be associated with additional morbidity. Intraoperative fascial traction (IFT) has been described in open surgery to facilitate fascial medialisation; however, data related to its application in minimally invasive and robotic approaches supplementing IFT are scarce.

A retrospective analysis was conducted of six patients who underwent robotic-assisted enhanced-view totally extraperitoneal (eTEP) ventral hernia repair with adjunctive IFT between June 2024 and March 2025. A comprehensive preoperative workup was performed, which included clinical evaluation and computed tomography (CT) imaging. The width of the fascial defect was meticulously measured intraoperatively before and after traction. For patients with transverse defects exceeding 15 cm, preoperative BTA injections were administered.

The mean pre-traction defect width was 15.8 ± 5.4 cm and reduced to 8.9 ± 3.2 cm following traction, achieving a mean medialisation of 6.9 ± 1.8 cm. Tension-reduced midline closure was achieved in all patients, without the need for CS or conversion to open surgery. Postoperative recovery was uneventful, with low pain scores, early ambulation, and no surgical site complications or 30-day readmissions.

IFT is a feasible and effective adjunct in robotic eTEP repair of large ventral hernias. When combined with robotic precision, it facilitates closure without undue fascial tension while preserving abdominal wall integrity and avoiding CS. Larger-scale studies are warranted to validate these findings.