In recent years, there has been a notable surge in interest in robotic surgery, driven by its potential to provide enhanced dexterity, precision, three-dimensional optics, and improved surgeon ergonomics. This research endeavors to assess whether these anticipated advantages result in measurable changes in both clinical and economic outcomes in ventral hernia repair. The focal points of evaluation include hospital length of stay and the recurrence of hernias, serving as primary indicators to gauge the impact of robotic surgery on patient outcomes and the overall economic land­scape [20, 21].

The management of hernia in individuals with obesity necessitates a multidis­ciplinary strategy. Obese patients experience notably higher perioperative compli­cations and recurrence rates. For those at a low risk of hernia complications, undergoing a bariatric procedure prior to hernia repair might be considered. The outcomes of laparoscopic hernia repair in overweight patients have been enhanced through the adoption of robotic techniques, resulting in a high success rate in clos­ing gaps and implanting mesh extraperitoneally [30]. The investigation into peri­operative outcomes in patients undergoing RVHR has previously overlooked retrospectively a comparison between those with a BMI above 35kg/m2 and those below this threshold by our group. Despite this gap, our ndings suggest that individuals with a BMI of 35kg/m2 or higher experience similar advantages from RVHR as their counterparts with a lower BMI [31]. Surprisingly, our study did not uncover any discernible differences between these two groups regarding postop­erative morbidity and serious surgical events. This unexpected result challenges our initial hypothesis, indicating that BMI≥35kg/m2 does not exert a signicant inuence on the short-term postoperative outcomes of RVHR. Moreover, the absence of notable perioperative morbidity, the avoidance of conversions to con­ventional surgeries, and the lack of perioperative mortality collectively under­score the safety and efcacy of RVHR in patients classied as class II and class III obese. These outcomes provide compelling support for the utilization of RVHR as a viable surgical option in this demographic. Our previous research marks a signicant milestone as the pioneering exploration of RVHR in individuals clas­sied as morbidly obese. Our ndings provide robust evidence supporting the safety and feasibility of implementing RVHR in this challenging patient demo­graphic. Notably, we identied several key factors—such as elevated BMI, the extent of adhesiolysis, prolonged off-console time during surgery, and the place­ment of intraperitoneal mesh—that correlated with heightened complication rates, particularly concerning early postoperative pain and discomfort [32]. Moving forward, it is imperative that further prospective studies are undertaken to delve deeper into the nuanced role of robotic surgery in the management of hernias in morbidly obese patients. These forthcoming investigations will play a pivotal role in not only rening surgical techniques but also in optimizing patient outcomes within this specic subset of the population. Further development of interdisci­plinary protocols is required to facilitate a personalized approach. Subsequent research endeavors will continue to rene the advantages of robotic surgery and offer guidance for optimal customization.

The rectus to defect ratio (RDR) was developed to aid in preoperative surgical decision-making, serving as a valuable tool for predicting fascial closure during open incisional hernia repair with bilateral rectus myofascial release and placement of retromuscular mesh. This metric offers an objective measure that can be easily replicated using basic CT imaging. However, concerns arise regarding the applica­bility of RDR in robotic repairs, given the requirement for pneumo-insufation dur­ing the procedure, which may affect its predictability as initially described for open repairs. The ndings of this study afrm that RDR remains valid for robotic repair, albeit with a notable shift toward higher ratios. Specically, an RDR exceeding 2.5 indicates a 94.2% likelihood of achieving fascial closure in robotic enhanced view total extraperitoneal (eTEP) repairs utilizing bilateral rectus myofascial release alone [34]. This underscores the utility of RDR as a simple, cost-effective, readily available, and reproducible method for anticipating the necessity of lateral myofas­cial release to achieve fascial closure following retromuscular dissection, applicable to both open and robotic approaches. The incorporation of RDR into surgical plan­ning not only facilitates patient informed consent but also informs clinicians about the potential requirement for referral for specialized complex abdominal wall reconstruction procedures.

In certain clinical contexts involving loss of domain due to muscle retraction and large defects exceeding 20cm in width, the strategic application of botulinum toxin A (Botox®) has demonstrated efcacy in optimizing preoperative planning. Botox is utilized to induce temporary paralysis, resulting in elongation of the lateral abdominal wall muscles by an average of 4cm. The procedure involves administer­ing 200–300units of Botox, appropriately diluted in 30ml of saline, via six targeted injections meticulously delivered into both the external and internal oblique mus­cles, guided by ultrasound visualization. Patients typically undergo follow-up within 4weeks, including a repeat CT scan to assess hernia volume before denitive robotic hernia repair as a predictor of complications. However, relying solely on absolute measurements may lead to unreliable outcomes due to variations in total abdominal volume among patients. To establish a more standardized measure across individuals, expressing hernia volume as a ratio or percentage of the total volume may be necessary. Additionally, dening intra-abdominal volume could vary depending on whether retroperitoneal organs are included or excluded from mea­surement [35].

Regarding for the indications and contraindications for robotic TAR are not clearly determined in the literature as of now. Patients with an elevated risk of wound com­plications, such as those with diabetes, chronic obstructive pulmonary disease, or obesity, are likely to derive benets from this minimally invasive approach. Individuals exhibiting poor skin condition, including extensive scars from prior wound issues or skin grafts, are not suitable candidates for robotic TAR.Caution is warranted when approaching hernias exceeding 20cm, as closing such substantial defects can be challenging even in open approach. The decision on whether to pro­ceed with robotic approach in these cases relies on the surgeon’s judgment, experi­ence, and the patient’s abdominal wall compliance upon physical examination. Successful application of the robotic approach has been demonstrated for the clo­sure of defects measuring 20cm and beyond. On the other hand, patients with her­nias, less than 10cm, typically do not necessitate extensive myofascial release for defect reapproximation. Defects of this size are commonly repaired using variations of robotic ventral hernia repair, either through preperitoneal mesh placement or a single-dock approach that avoids TAR [6, 36].