Single centre experience of Robotic primary midline ventral hernias (PMVH) repairs using a novel modular robotic system and comparative study of the two techniques used [robotic Preperitoneal extended Total Extraperitoneal (rPeTEP) vs robotic Transabdominal Preperitoneal (rTAPP)]

The human abdominal wall is a complex structure of muscle and tissue that holds our internal organs in place. When a weakness develops in the midline of this wall, often due to age, weight, or previous surgery, the internal contents can push through, creating a bulge known as a primary midline ventral hernia. Repairing this defect requires more than just stitching the hole closed; surgeons must reinforce the area with a synthetic mesh to prevent it from happening again. The challenge lies in where to place that mesh. Placing it on top of the abdominal muscles can lead to more pain and infection, while placing it underneath the muscles but outside the abdominal cavity offers a stronger, more comfortable recovery. In recent years, surgeons have turned to robotic systems to perform these delicate repairs, using tiny instruments controlled by a surgeon at a console to navigate the tight spaces of the body with extreme precision.

Two specific robotic approaches have emerged for placing this mesh in the preperitoneal space, the area between the abdominal muscles and the lining of the abdomen. One method, known as the robotic transabdominal preperitoneal repair, involves entering the abdominal cavity first, lifting the lining like a curtain to create a pocket for the mesh, and then closing it back up. The other, a newer technique called the robotic preperitoneal extended totally extraperitoneal repair, avoids entering the abdominal cavity entirely. Instead, the surgeon creates a working space directly between the muscles and the lining from the bottom up. A team of surgeons at Apex Hospital in India recently set out to compare these two methods. They wanted to see which approach was faster, which caused less pain for the patient, and how long it took a surgeon to master each technique using a novel, modular robotic system.

The researchers reviewed the records of 133 patients who underwent hernia repair between July 2023 and May 2026. The group was split into two: 82 patients received the transabdominal approach, while 51 received the totally extraperitoneal method. The study revealed that the choice of technique often depended on the patient's specific anatomy. Patients in the totally extraperitoneal group were more likely to have a condition called divarication of the recti, where the two main abdominal muscles have separated, creating a wider gap that needed repair. These patients also tended to have a higher body mass index. Despite these differences in the patient groups, both surgical methods proved to be safe and effective. Every patient in the study was able to go home the day after surgery, and none experienced complications within the first month that would prevent a full recovery.

When looking at the immediate results, the totally extraperitoneal method showed a distinct advantage in patient comfort. On the first day after surgery, patients who underwent this procedure reported significantly lower pain scores than those who had the transabdominal repair. This difference was likely due to the fact that the totally extraperitoneal approach does not require inflating the abdominal cavity with gas, which can cause discomfort, and involves placing the surgical ports lower on the body. However, the transabdominal method offered a different kind of flexibility. It allowed surgeons to easily perform other necessary operations at the same time, such as removing a gallbladder or repairing an inguinal hernia, without needing to change the patient's position or add extra ports. In contrast, the totally extraperitoneal technique is more specialized; while it excelled at fixing the separation of the abdominal muscles, it was less suited for combining with other internal surgeries.

The study also examined how long it took the surgeon to become proficient with each technique. By analyzing the time taken for each operation in chronological order, the researchers found that the surgeon reached a steady level of speed and efficiency after performing 18 cases of the transabdominal repair. For the totally extraperitoneal method, it took 25 cases to reach that same level of mastery. This suggests that while the totally extraperitoneal technique is highly effective for specific complex hernias and causes less pain, it has a steeper learning curve and requires more practice to perform efficiently. The transabdominal approach, while slightly more painful in the immediate postoperative period, is easier to learn and more versatile for patients who need multiple procedures done at once.

Ultimately, the research confirms that both robotic techniques are viable options for repairing these hernias using the new modular robotic system. The decision on which method to use depends on the individual patient's needs. If a patient has a wide separation of the abdominal muscles and needs a repair that minimizes early pain, the totally extraperitoneal approach is the superior choice. If a patient requires additional abdominal surgery or is older with a history of previous operations, the transabdominal method offers a safer and more adaptable path. The study concludes that while both techniques work well, the totally extraperitoneal repair is a less painful operation that handles complex muscle separation better, whereas the transabdominal repair is easier to learn and better suited for combined procedures. Larger studies with longer follow-up periods are needed to confirm how these results hold up over many years, but for now, surgeons have two reliable tools to choose from.