since its introduction in 1993 by leblanc , the laparoscopic approach to ventral hernia repair has enabled patients to return to normal activity earlier and has reduced the need for postoperative pain medications . traditionally , intraperitoneal mesh placement has been used for its ease , but the approach has associated risks .
, there have been reports of mesh erosion to the bowel , as well as mesh - related infection .
an alternative is to dissect and establish the preperitoneal space in which to place mesh and avoid exposure to intra - abdominal structures .
this method is customary in an open technique ; however , modern robotic platforms , which use 3-d cameras and wristed movement , have the potential to facilitate the creation of this space intraperitoneally in a minimally invasive manner .
we conducted a retrospective study , reviewing outcomes in 3 patients who underwent robot - assisted tapp ventral hernia repair in the spring of 2015 . demographic information and size of the hernia defect
an initial 12-mm port was placed in the left upper quadrant with an optical trocar .
subsequently , 2 lateral 8-mm ports were placed , 1 in the left lower quadrant and the other on the left side between the lower and upper trocars .
the edge of the hernia sac was used as the starting point for peritoneal dissection .
the right peritoneal flap was carefully created laterally 8 cm from the hernia sac . upon completion of the flap ,
three 8-mm ports were situated on the right side , mirroring the placement of the ports on the left .
after the peritoneal flaps were created , any preperitoneal fat found within the defect was reduced , and the defect was primarily closed with locking sutures .
once the redundant edges of the hernia sac were primarily closed , the mesh was placed in the abdomen and secured to the abdominal wall with absorbable tacks . after the mesh was secured in the preperitoneal space ( figure 1 ) , the peritoneal flap was closed with running locking sutures , fully covering the mesh ( figure 2 ) .
this method ensured that the mesh would be completely covered with the native peritoneum , creating a physiologic barrier ( figure 3 ) .
the mean age was 49 years , mean bmi was 32.67 kg / m , the mean operative time was 163.7 minutes , and the mean defect size of the hernia was 1219.00 mm ( table 1 ) .
no intraoperative complications were encountered in any of the cases . there were no intraoperative events and no conversions to open repair .
all 3 patients were discharged home within the 24-hour postoperative period , and postoperative pain was adequately treated with oral analgesics .
no postoperative complications were encountered during the 30 days after the procedures , including seroma , hematoma , or deep or superficial surgical wound infection . during a maximum of 3 months
although there have been many studies examining the utility of ventral hernia repair with preperitoneal mesh placement via the open approach , there are few studies in which a minimally invasive procedure was used . in 1997 , sarli et al compared laparoscopic tapp hernia repair to the intraperitoneal onlay mesh ( ipom ) approach , showing that the tapp approach had significantly fewer instances of recurrence , with similar rates of complications when compared to the ipom technique . in 2011 , prasad et al compared the tapp and ipom laparoscopic techniques and found that although the tapp method had a longer mean operative time , it reduced the risk of complications related to the intraperitoneal placement of mesh .
the authors concluded that the tapp approach should be the first choice for ventral hernia repair .
more cases and a longer follow - up are needed , to determine whether robot - assisted tapp ventral hernia repair reduces the risk of seroma and mesh - related infection .
we used primary closure of the hernia defect , because the obliteration of dead space theoretically results in less likelihood of seroma formation .
furthermore , closure of the midline enables adequate overlap of the mesh ( 56 cm ) within the limited confines of the preperitoneal space .
however , we acknowledge that in defects larger than 3 to 5 cm , primary closure may not be feasible . a larger mesh would be necessary , which would translate into a more extensive peritoneal flap dissection and may be technically challenging
. furthermore , the remaining sac may serve as a source of seroma formation , all of which may necessitate a different approach to the repair of ventral hernia defect .
the modern robotic surgery system allows increased mobility within the working space via wristed movement , affording better ergonomics for the surgeon , and visualization is improved by its 3-d camera system .
all these features facilitate the fine dissection of the preperitoneal space and repair of the peritoneum . despite these many benefits ,
the use of robot - assisted tapp ventral hernia repair has not yet been investigated .
we acknowledge that our technique , which involves docking on both sides , results in higher operative costs , and we are currently looking into ways to create the peritoneal flaps with a single dock .
we present our early experiences with this technique and believe that these cases demonstrate its feasibility and safety . limitations of this study include a small sample size and short follow - up period .
we noted that descriptions of the robot - assisted technique are lacking ; therefore , we wanted to present our early experiences and evaluate the feasibility of the robotic approach .
these early results are encouraging , and a prospective trial comparing outcomes between robot - assisted tapp , laparoscopic tapp , and the ipom techniques , with long - term follow - up , are warranted .
robot - assisted tapp ventral hernia repair is a feasible and safe therapeutic option when performed by an experienced surgeon .
the improved dexterity and visualization afforded by the robotic platform simplify a challenging procedure and provide a viable alternative to the more invasive open technique .
robot - assisted tapp ventral hernia repair is a feasible and safe therapeutic option when performed by an experienced surgeon .
the improved dexterity and visualization afforded by the robotic platform simplify a challenging procedure and provide a viable alternative to the more invasive open technique .
 background and objectives : we believe that complications due to the mesh used in ventral hernia repairs can be reduced by using the natural barrier afforded by the peritoneum . this can be challenging to do laparoscopically , however we felt that the robot - assisted laparoscopic approach reduces the difficulty in placing the mesh in the preperitoneal space , and we want to share our early experiences with this approach . 
 we describe the surgical technique used in robot - assisted laparoscopic transabdominal preperitoneal ( tapp ) ventral hernia repair with mesh . 
 in addition , we evaluate its feasibility and present preliminary perioperative results.methods:we performed robot - assisted laparoscopic tapp ventral hernia repairs in 3 patients in the spring of 2015 . demographic information and defect size 
 were measured . 
 conversion from a laparoscopic to an open procedure was the primary outcome variable.results:there were 3 cases of robot - assisted tapp ventral hernia repair with mesh . 
 the mean age of the patients was 49 years , the mean body mass index was 32.6 kg / m2 , and the mean operative time was 163.7 minutes . 
 the mean defect size was 1219.0 mm2 . 
 there were no conversions to open during this early learning phase . 
 all patients were discharged home within the 24-hour postoperative period . 
 no complications were noted during a mean follow - up of 3 months.conclusions:we present our early experience with robot - assisted tapp ventral hernia repair . 
 we note that because of improved ergonomics and wristed instrumentation , the robotic platform enabled creation of peritoneal flaps and complete coverage of mesh with peritoneum after primary closure of the defect . 
 the robotic approach is feasible and may provide a better environment for mesh integration and protection . 
 further investigations with long - term follow - up are needed to verify that this technique is effective in reducing mesh - related intra - abdominal complications . 
INTRODUCTION
MATERIALS AND METHODS
Surgical Technique
RESULTS
DISCUSSION
CONCLUSIONS