Robotic Transversus Abdominis Release (TAR)

A 58-year-old patient underwent robotic bilateral transversus abdominis release (TAR) for repair of a recurrent incisional hernia following prior hernia repair complicated by mesh infection and subsequent explantation. This approach was selected based on the patient’s surgical history, the size of the hernia defect, and the extent of incarcerated small bowel. A double-docking technique was employed to facilitate bilateral TAR, and a large macroporous polypropylene mesh was placed. This case highlights the operative decision-making involved in complex hernia repair and demonstrates the technical considerations for performing a robotic bilateral TAR.

Recurrent hernia; ventral hernia; robotic transversus abdominis release; incisional hernia. 

Recurrent incisional hernias are a common complication following abdominal surgery, particularly in patients who have required prior mesh removal or experienced mesh failure. Most recurrent hernias are repaired with mesh to reduce the risk of further recurrence. Although mesh can be placed in various planes within the abdominal wall, careful consideration of mesh location is especially important in the setting of prior mesh placement. Advanced abdominal wall reconstruction techniques, including component separation, are increasingly utilized to decrease tension on fascial closure and optimize mesh overlap. In this case, a robotic bilateral transversus abdominis release (TAR) was performed to repair a recurrent incisional hernia in a patient with a history of intraperitoneal onlay mesh placement complicated by mesh infection and subsequent explantation.

The patient is a 58-year-old male with a body mass index (BMI) 35 kg/m², American Society of Anesthesiologists (ASA) physical status class II, and no history of anticoagulant use. His surgical history is notable for an umbilical hernia repair performed in 2021 using an intraperitoneal onlay mesh, from which he recovered without complication. In 2023, he developed acute appendicitis and underwent a laparoscopic appendectomy. During that operation, a trocar was placed through the previously implanted mesh, resulting in mesh disruption. Additionally, the intraperitoneal mesh was exposed throughout the procedure. Postoperatively, the patient developed a mesh infection and subsequently required open mesh explantation for definitive management. He has since developed a recurrent incisional hernia, which has progressively enlarged and become symptomatic, with pain as his primary complaint.

On exam, he had a tender non-reducible umbilical (M3 zone) incisional hernia. There were no overlying skin changes. 

CT scan of the abdomen demonstrated a 4-cm upper abdominal diastasis as well as an 8-cm hernia defect in the M3 zone. The rectus muscles themselves both measured approximately 8 cm in size. The hernia contained loops of non-obstructed small bowel with suggestions of adhesions to the sac. 

Figure 1. Axial view of a CT abdomen pelvis of this patient demonstrating a midline ventral hernia with an 8-cm fascial defect. There is evidence of small bowel within the hernia. The bilateral rectus can also be seen and also measure approximately 8 cm in size.

In adults, hernias typically follow one of two clinical courses: they may remain relatively stable in size or progressively enlarge over time. While some patients are minimally symptomatic, others may experience pain, functional limitations, or complications such as bowel obstruction. Hernias do not resolve spontaneously and require surgical intervention for definitive management. Surgical repair is generally recommended for symptomatic hernias, unless significant medical comorbidities render operative intervention prohibitively high risk.

The patient was symptomatic, with progressive hernia enlargement and associated pain that significantly impaired his quality of life; therefore, operative intervention was indicated. Several factors were considered in operative planning, including hernia size and location, as well as the patient’s surgical history, particularly prior hernia repair. Wound morbidity was a key consideration, and surgical approaches that minimize the risk of surgical site complications were prioritized, especially given the patient’s history of mesh infection.

When considered in isolation, the size and location of this hernia would be amenable to multiple surgical approaches, including minimally invasive intraperitoneal, preperitoneal, retromuscular, and onlay repairs. These approaches differ primarily in mesh position: intraperitoneal placement within the abdominal cavity; preperitoneal placement external to the peritoneal lining; retromuscular placement in the plane posterior to the muscles; and onlay placement superficial to the anterior fascia.

In this case, the patient’s history of prior intraperitoneal mesh infection and subsequent explantation, in conjunction with preoperative computed tomography findings, guided operative decision-making. Several concerns were identified with respect to performing either a total extraperitoneal repair or an open retrorectus approach. The patient demonstrated a borderline Carbonell ratio (retrorectus width approximately equal to defect width), with approximately 8 cm of bilateral retrorectus space in the setting of an 8-cm fascial defect. Additionally, a substantial volume of bowel was present within the hernia defect, raising concern for incarceration. Given the prior explantation of intraperitoneal onlay mesh, there was also concern for attenuation or absence of the peritoneum and/or posterior rectus sheath.

Taking these factors into account and following a detailed discussion with the patient regarding operative options and risks, the decision was made to proceed with a robotic bilateral TAR.

This case illustrates the application of robotic bilateral TAR for the management of a complex recurrent incisional hernia in the setting of prior intraperitoneal mesh placement, infection, and explantation. Operative access was safely achieved using an optical entry technique in the right upper quadrant, an approach commonly recommended in patients with prior abdominal surgery to minimize the risk of visceral injury during peritoneal entry. Three robotic ports were placed on the right side, allowing for controlled adhesiolysis and exposure of the hernia defect.

As anticipated based on preoperative imaging, incarcerated omentum and small bowel were encountered within the hernia sac. Careful and meticulous adhesiolysis was performed to fully reduce the hernia contents prior to reconstruction. Complete reduction of incarcerated viscera is essential to restore normal anatomy and prevent postoperative complications, including bowel obstruction or ischemia.¹ The robotic platform facilitates precise dissection in this setting, offering enhanced visualization and instrument articulation, which may reduce the risk of enterotomy during complex hernia repair compared with traditional open approaches.

A staged, double-docking approach was utilized to complete a bilateral TAR. While a single-dock robotic TAR has been described and may be feasible in selected patients with smaller defects or unilateral pathology, a double-docking technique was favored in this case to optimize ergonomics, visualization, and instrument reach during bilateral myofascial release. This approach is particularly advantageous when extensive adhesiolysis and symmetric bilateral release are required, as was the case here.

Alternative technical modifications, such as the Madrid modification of TAR, may be considered in patients with favorable anatomy, particularly when preservation of the posterior rectus sheath continuity is possible throughout the length of the dissection. In this patient, however, preoperative imaging and intraoperative findings raised concern for attenuation and potential discontinuity of the posterior elements following prior intraperitoneal mesh infection and explantation, making a more traditional TAR approach preferable to ensure recreation of a durable retromuscular plane.

TAR provides substantial medial advancement of the abdominal wall musculature while preserving the neurovascular bundles, thereby enabling tension-free midline closure even in large or recurrent defects. In patients with prior intraperitoneal mesh explantation, TAR additionally offers the advantage of recreating a well-vascularized retromuscular space for mesh placement, which has been associated with lower infection and recurrence rates compared with intraperitoneal mesh positioning.²

Following completion of the bilateral TAR, the posterior layer was re-approximated to re-establish a durable barrier between the mesh and intra-abdominal contents. While portions of the peritoneum were recruitable and incorporated into the closure, areas of attenuated or deficient posterior rectus sheath were encountered, likely related to the prior intraperitoneal mesh infection and explantation. In such settings, closure often necessitates a composite repair incorporating both posterior sheath and peritoneum.

Although the optimal management of posterior layer defects—whether through complete posterior sheath reconstruction versus peritoneal bridging—remains an area of ongoing investigation, restoration of a continuous posterior layer is generally favored to reduce the risk of mesh-related visceral complications. Available data suggest comparable outcomes between these strategies when tension-free closure is achieved, though long-term comparative studies remain limited.

Given that recruitable peritoneum was present once the hernia contents were reduced, an alternative strategy could have included transitioning to a total extraperitoneal approach with an extended totally extraperitoneal (ETEP) TAR. While ETEP TAR offers the advantage of maintaining peritoneal integrity and avoiding intraperitoneal access, this approach can be technically challenging in patients with extensive prior intra-abdominal surgery, dense adhesions, or concern for posterior layer attenuation. In this case, the need for extensive adhesiolysis and the uncertain integrity of the posterior elements favored continuation of the transabdominal robotic TAR rather than conversion to an ETEP approach.

Anterior fascial closure was completed with concomitant plication of the hernia sac to reduce dead space. Hernia sac plication has been described as a useful adjunct to decrease postoperative seroma formation, particularly in large defects where residual space may persist despite midline closure.

A large 30×30-cm macroporous polypropylene mesh was selected and tailored to fit the retromuscular pocket, ensuring wide overlap beyond the defect margins. Placement of large-format mesh with adequate overlap remains a fundamental principle of durable hernia repair and is consistently associated with reduced recurrence rates.¹ Retromuscular mesh positioning, as achieved with TAR, provides robust tissue incorporation and favorable biomechanical support while minimizing wound morbidity compared with onlay or intraperitoneal techniques.²

Drain placement within the retromuscular or pretransversalis space following TAR remains variable among surgeons. In this case, the decision regarding drainage was individualized based on the extent of dissection, dead space management through sac plication, and meticulous hemostasis. While some authors advocate routine drainage to reduce seroma formation, others report acceptable outcomes with selective or no drain use, highlighting the need for patient-specific decision-making.

Preoperative chemical component separation with botulinum toxin A was considered but ultimately not utilized. Although botulinum toxin A can facilitate medialization of the abdominal wall in patients with large defects or significant loss of domain, this patient demonstrated a borderline Carbonell ratio (retrorectus width approximately equal to defect width) without evidence of true loss of domain, making adequate closure achievable with surgical myofascial release alone.

Finally, bilateral transversus abdominis plane (TAP) blocks were performed intraoperatively to optimize postoperative pain control. Multimodal analgesia strategies, including TAP blocks, are increasingly incorporated into enhanced recovery pathways for abdominal wall reconstruction and have been shown to reduce opioid consumption and improve postoperative recovery.

In summary, this case demonstrates that robotic bilateral TAR is a safe and effective option for complex recurrent incisional hernias in patients with a history of intraperitoneal mesh infection and explantation. Thoughtful consideration of alternative techniques, adjuncts, and posterior layer reconstruction strategies is essential in tailoring repair to individual patient anatomy and surgical history. The robotic platform enhances the surgeon’s ability to perform these technically demanding steps while potentially reducing morbidity, supporting its expanding role in advanced abdominal wall reconstruction.

Nothing to disclose.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.