The challenge the team set out to solve is one of the most stubborn in abdominal wall surgery. When a ventral or incisional hernia grows large, particularly in patients with loss of domain, in which a substantial volume of intestine has chronically herniated into the hernia sac and the abdominal cavity has permanently shrunk to accommodate it, simply sewing the fascial edges together generates excessive tension. That tension drives recurrence, wound breakdown, pain, and postoperative complications. Surgeons have traditionally reached for adjuncts such as progressive preoperative pneumoperitoneum, in which air is gradually insufflated into the abdomen over weeks to stretch the cavity, botulinum toxin A injections that paralyse the lateral abdominal wall muscles for months and allow passive lengthening, or component separation, in which the layers of the abdominal wall are surgically divided so the muscles can slide toward the midline.

Each of those strategies carries a price. Pneumoperitoneum demands extended preoperative preparation. Component separation increases surgical complexity and is associated with seroma formation, denervation of the abdominal wall, functional impairment, mesh infection, and long-term hernia recurrence. Botulinum toxin requires a four-week wait and adds cost. Intraoperative fascial traction offers a different philosophy: rather than cutting or chemically relaxing anything, it mechanically elongates the myofascial structures with a controlled, symmetrical stretching force, exploiting the viscoelastic properties of living tissue to lengthen the lateral muscle complex and medialise the rectus muscles while preserving the structural integrity of the abdominal wall.

Until now, that philosophy had been demonstrated almost exclusively in open surgery, where devices can be clamped directly onto the fascia. Only a single case report, by Bloemendaal and colleagues in 2022, had described fascial traction inside a robotic repair, and that was in a transabdominal retromuscular approach using an intra-abdominal technique. The Delhi team, led by Vivek Bindal, Dhananjay Pandey, Deepak Kumar, Shahiq Ahmed, and Aakash Patel at Max Super Specialty Hospital, applied traction within the extraperitoneal eTEP space, a technically distinct plane that never enters the abdominal cavity, using a different port strategy and suture methodology. It is, by their account, the first reported use of fascial traction in a robotic eTEP approach.

The technical execution is intricate. All six operations were performed on the Da Vinci Xi robotic system between June 2024 and March 2025, using the Fasciotens Hernia System to generate the traction. Patients were positioned supine with the left arm tucked to optimise exposure, and the operating table was adjusted so the robotic arms could reach without colliding with the traction frame. Access to the retromuscular space came through a left upper abdominal incision just medial to the linea semilunaris, entered with a 5-millimetre optical trocar at an insufflation pressure of 14 millimetres of mercury. Two additional 8-millimetre robotic trocars were placed under direct vision, and the robot was docked on the patient’s right side.

From there the surgeons performed a Rives-Stoppa style repair, expanding the retrorectus space bilaterally, crossing over into the opposite side in the upper abdomen, and dividing the posterior rectus sheath in the midline down to the arcuate line, where the sheath becomes continuous with the fascia transversalis and opens into the spaces of Retzius and Bogros. The hernia sac was meticulously reduced and extensive adhesiolysis freed the fascial edges, with care taken to preserve the neurovascular bundles that run through the abdominal wall. Then came the traction step itself. The anterior rectus sheath defect was measured cranio-caudally and divided into six equal segments. A Vicryl No. 1 suture was introduced through the robotic port, grasped by the robotic needle holder, and passed through the edge of the anterior rectus sheath in a 2-centimetre U-shaped loop at the first segment, leaving a 1-centimetre margin from the edge. Both ends of the loop were brought out transabdominally through a spinal needle suture passer, and the process was repeated across all six segments and then mirrored on the contralateral side.

The suture retention frame of the Fasciotens device was positioned above the abdomen and aligned with the fascial edges, and calibrated vertical traction of 14 to 18 kilograms was applied gradually over 30 minutes while anaesthesia maintained complete muscular relaxation, allowing progressive viscoelastic elongation of the musculofascial components. Crucially, the entire procedure was carried out without undocking the robot, a logistical feat given the proximity of the robotic patient cart to the operating table. In one patient the team initially applied traction to the posterior rectus sheath, which obliterated the extraperitoneal working space and compromised vision; they inserted an additional 5-millimetre port in the right upper abdomen, removed the traction sutures under vision, and reapplied them to the anterior rectus sheath instead. Following sufficient medialisation, the peritoneum-posterior rectus sheath complex was approximated with running barbed delayed absorbable sutures, a macroporous polypropylene mesh was placed in the sublay plane with adequate overlap, and the anterior sheath edges were closed with non-absorbable barbed sutures. Intra-abdominal pressure was indirectly assessed through airway pressure monitoring rather than pneumoperitoneum, confirming the closure was tension-free.

Five of the six patients, all with transverse defects exceeding 15 centimetres, received preoperative botulinum toxin A injections four weeks before surgery to further optimise fascial compliance by paralysing the lateral abdominal wall musculature. The cohort had a mean age of 54.2 years, a mean body mass index of 28.5, and was dominated by incisional hernias, with five of six patients having developed the hernia after previous surgery and two presenting with recurrence. Mean operating time was 165 minutes. Pain scores, measured on a 0-to-10 numeric scale, averaged 5.6 at six hours, 3.8 at 24 hours, and 2.2 by postoperative day 3. Every patient ambulated within 24 hours, first bowel movement came at a mean of 1.5 days, and the average hospital stay was 2.5 days. Five of six patients returned to professional work by postoperative day 21, routine daily activities resumed at a mean of seven days, and there were no surgical site complications, no conversions to open surgery, no re-intubations, and no 30-day readmissions.

The authors argue that combining robotic precision with fascial traction yields benefits beyond either modality alone. The robotic platform provides magnified three-dimensional visualisation, tremor-free articulation, and superior ergonomics for dissecting in the avascular retromuscular and preperitoneal planes, while intracorporeal suturing of the posterior sheath is significantly easier and more precise with robotic instruments. Traction complements this by allowing real-time adjustments during medialisation and closure, and by obviating component separation entirely, preserving the native integrity of the lateral abdominal wall and avoiding its associated morbidity. The team’s own earlier comparative work at the same high-volume centre found that robotic eTEP repairs outperformed laparoscopic repairs in operating time, postoperative pain, and wellbeing scores, with a lower need for component separation in larger defects.

The evidence base remains narrow. Six patients, a retrospective design, a single experienced surgeon, and no long-term recurrence data mean these findings are preliminary, and the authors themselves call for larger-scale studies to validate the approach. Questions also persist about the differential effects of fascial traction on the anterior and posterior fascial layers, which the team says is essential knowledge for refining the technique. Still, for a condition that affects millions of people worldwide and recurs frustratingly often after conventional repair, the demonstration that a hernia defect averaging nearly 16 centimetres can be closed through keyhole incisions, with a robot doing the sewing and a traction frame doing the stretching, marks a genuinely novel waypoint in the evolution of complex abdominal wall reconstruction.

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

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

Article References: Bindal, V., Pandey, D., Kumar, D., Ahmed, S., & Patel, A. (2026). Use of intraperitoneal fascial traction in robotic eTEP approach for complex ventral hernias: technique and outcomes. Journal of Abdominal Wall Surgery, 5, Article 16438. https://doi.org/10.3389/jaws.2026.16438

Image Credits: AI Generated

DOI: 10.3389/jaws.2026.16438

Keywords: intraperitoneal, fascial, traction, robotic, eTEP, approach, complex, ventral, hernias, technique, outcomes, scientific research

The scale of the underlying problem is considerable. Incisional hernias, which occur when tissue pushes through a healed surgical scar, affect an estimated 10 to 50 percent of patients after open abdominal surgery. Even after repair, recurrence rates between 8.7 and 32 percent have been reported. Simple suture repair of the fascia, the tough connective tissue layer that holds the abdominal contents in place, carries recurrence rates as high as 60 percent according to long-term randomized trial data. Adding mesh to reinforce the repair reduces that figure to around 24 percent, which is why mesh has become a standard part of modern hernia surgery. But mesh introduces its own dilemma when the surgical field is contaminated.

Synthetic prosthetic mesh, typically made of permanent polymer materials, performs well in clean surgical environments and reduces recurrence effectively. In contaminated fields, however, it carries serious long-term risks: mesh infection, wound dehiscence, and the formation of enterocutaneous fistulas, in which bowel abnormally connects to the skin. Biologic mesh, made from processed collagen scaffolds of human or animal origin, was developed partly to address this. Because the material is decellularized collagen rather than plastic, it is far more resistant to infection and can become integrated into the patient’s own tissue through revascularization and cellular ingrowth. The trade-off is cost: biologic mesh can cost up to 200 times more than a synthetic equivalent, a disparity that has fueled an ongoing debate about whether the clinical benefits justify the expense.

The case report centers on a 73-year-old woman who arrived with nausea, vomiting, and abdominal pain. Her history was complicated: hypertension, high cholesterol, a heart attack two decades earlier treated with stenting, coronary bypass surgery, and a hysterectomy thirty years before that had been complicated by infection and a temporary colostomy. On examination, she had a large, non-reducible hernia in her left lower abdomen with what surgeons call loss of domain, meaning so much bowel had migrated into the hernia sac that returning it to the abdominal cavity would be difficult. Her laboratory values told a worrying story: an elevated white blood cell count of 15.5 thousand per microliter, impaired kidney function, and a prealbumin level of 10 milligrams per deciliter indicating significant malnutrition. A CT scan revealed a 7.8-centimeter abdominal wall defect packed with loops of small and large bowel.

What the surgical team found in the operating room was worse than the imaging suggested. After beginning the procedure robotically and encountering dense adhesions, they converted to an open laparotomy. The hernia contained the entire cecum and roughly 140 centimeters of small intestine. Buried within the defect was old permanent mesh from a repair the patient did not know she had received, and stuck to that mesh was a chronic fistulous tract surrounded by infectious material. The team resected the diseased segment of bowel, created a side-to-side anastomosis to restore continuity, removed necrotic hernia sac and ulcerated skin, and irrigated the field copiously. With a 15-centimeter fascial defect remaining and the patient becoming hemodynamically unstable on vasopressor medications, definitive reconstruction was judged too risky. Instead, they placed an AbThera negative pressure dressing, a temporary wound vacuum system, and transferred her to the surgical intensive care unit, intubated and sedated.

Two days later, with her white blood cell count improving and her ventilator requirements minimal, the team returned to the operating room for the second stage. This is the technical heart of the report. Because the bowel could not be reduced through the fascial defect, the surgeons performed a left-sided anterior component separation, a technique first described by Ramirez and colleagues in 1990. The procedure involves releasing the external oblique muscle from the internal oblique along the lateral abdominal wall, which allows the rectus abdominis muscles to slide medially and gain several centimeters of closure. In this patient, releasing the external oblique yielded roughly 8 centimeters of immediate fascial mobilization. Even so, the fascial edges could not be brought together without tension, so the team bridged the gap with a 20 by 25 centimeter piece of XenMatrix, a porcine-derived, non-crosslinked collagen mesh, sutured in an underlay position beneath the fascia using running absorbable sutures, with the skin loosely approximated over a wound vacuum.

The choice of underlay placement and non-crosslinked material reflects deliberate biomechanical reasoning. Underlay mesh, positioned beneath the abdominal wall, distributes forces across a larger area than mesh placed on top of the fascia, and published series report recurrence rates of 7 to 30 percent with this configuration. The Rives-Stoppa retrorectus technique, in which mesh is sandwiched between well-vascularized tissue planes, may be more durable but is often technically impossible in patients with multiple prior surgeries because those planes have been obliterated by scar tissue. The absence of cross-linking in XenMatrix allows tissue integration within about two weeks and, critically, permits safe direct contact with bowel. In this case, the mesh lay directly on the intestine with no fistulization at twelve-month follow-up, a feared complication that did not materialize.

The recovery was not smooth, and the report is candid about that. The patient required wound vacuum changes three times weekly for a month, an operative debridement of necrotic skin edges three weeks after the index operation, temporary dialysis through a permacath, intravenous antibiotics, and total parenteral nutrition to optimize healing. Her kidney function eventually normalized, the dialysis catheter was removed, and she tolerated a low-fiber diet without nutritional supplementation before discharge to a skilled nursing facility. At outpatient follow-up, her wound shrank progressively with granulation tissue filling in under a portable wound vacuum, and she has had no readmissions for postoperative infection. She remains ambulatory and satisfied with her quality of life.

The authors situate their result within a genuinely contested literature. A randomized trial by Rosen and colleagues found a 20.5 percent recurrence rate with biologic mesh versus 5.6 percent with synthetic mesh at two years in contaminated single-stage repairs, alongside the stark cost differential, leading some surgeons to argue synthetic mesh remains preferable. Carbonell and colleagues, by contrast, found nearly identical mesh-removal rates for infection, around 4 to 5 percent, between the two materials. Studies of bridging repairs consistently show higher recurrence than repairs achieving fascial closure, because biologic mesh stretches under prolonged tension due to its inherent elasticity. Here, even after component separation, a 3 to 4 centimeter midline gap remained, so the surgeons recreated a pseudo-midline by suturing the anterior sheath to the mesh with at least 5 centimeters of overlap, a recognized salvage maneuver. Multistaged approaches, such as removing infected mesh, treating with antibiotics, and repairing later, have produced recurrence rates around 19 percent at 32 months.

The report’s honest limitations are as instructive as its success. Twelve months is a short follow-up interval; most hernia recurrences appear within two to four years, so the absence of recurrence so far is encouraging but not definitive. The authors themselves note that in hindsight, definitive closure might have been delayed further to allow a longer antibiotic course in the contaminated field. They conclude that non-crosslinked porcine biologic mesh combined with anterior component separation is a safe and reasonable option for high-risk patients with contaminated wounds, particularly those too unstable for a single-stage repair, and they call for prospective randomized trials with larger samples and longer follow-up to settle the questions of mesh type, placement, and cost-effectiveness. For now, the case adds a practical, well-documented template: achieve source control first, let the infection clear, then rebuild with a technique that respects both the biology of healing and the mechanics of the abdominal wall.

Subject of Research: Dual-stage abdominal wall reconstruction for contaminated incisional hernia using component separation and biologic mesh

Article Title: Dual-stage abdominal wall reconstruction using component separation and bridging underlay biologic mesh in a contaminated incisional hernia: a case report and literature overview

Article References: Bland, S., & Wood, B. (2025). Dual-stage abdominal wall reconstruction using component separation and bridging underlay biologic mesh in a contaminated incisional hernia: a case report and literature overview. BMC Plastic and Reconstructive Surgery, 1(1), Article 4. https://doi.org/10.1186/s44452-025-00003-7

Image Credits: AI Generated

DOI: 10.1186/s44452-025-00003-7

Keywords: incisional hernia, abdominal wall reconstruction, component separation technique, biologic mesh, XenMatrix, contaminated surgical field, enterocutaneous fistula, underlay mesh placement, negative pressure wound therapy, hernia recurrence, case report, general surgery