as well. These include but are not limited to Ehlers-Danlos syndrome, prostate hypertrophy, prostatectomy, chronic obstructive pulmonary disease (COPD), chronic constipation, and pos­sibly peritoneal dialysis [4].

Increasingly in the USA, surgeons are educating patients about modiable risk factors that impact the success of hernia repair. Multiple risk strati­cation tools are available for use in educating patients about their individual risk, dening the impact of modiable risk factors, and helping select operative technique. Some of the com­monly used tools in the USA include the modi­ed ventral hernia working group grading system, American College of Surgeons Risk Calculator, Ventral Hernia Risk Index, and HERNIAscore [14–17].

centers in the USA now discuss (often require) medically supervised or surgical weight loss with appropriate patients, mandate smoking cessation, ensure glycemic control, supplement nutrition, and modify immunotherapy. Other modiable comorbidities that pose perioperative risk are car­diopulmonary and hematologic disease, speci­cally cardiopulmonary function and history of venous thromboembolism, coagulopathy, or bleeding diathesis. These evidence-based pre­habilitation strategies can be used in conjunction with a postoperative enhanced recovery pathway and other adjuncts to improve patient outcomes.

complications and hernia recurrence. This has led an increasing number of surgeons to learn and adopt open posterior component separation, spe­cically transversus abdominis release (TAR). When performed by experienced surgeons, open TAR yields lower wound morbidity compared with open anterior component separation, though the risk for wound-related events remains an issue [21]. Novitsky and colleagues [21] reported on 428 consecutive open TAR patients and found surgical site events in 18.7%, surgical site infec­tions in 9.1%, hernia recurrence in 3.7%, and mesh debridement in 0.7% at a mean follow-up of 31.5 months. Teaching institutions, surgical organizations, and industry partners throughout the USA offer training in open TAR at surgical meetings, workshops, and hands-on courses, speaking to the evidence-based popularity of the technique.

Given the proven benets of both a mini­mally invasive approach to hernia repair and TAR, some expert surgeons in the USA, includ­ing the author, are capitalizing on those benets by offering laparoscopic and/or robot-assisted TAR for VIH repair. A retrospective, multi-insti­tutional propensity-matched cohort study of patients from the Americas Hernia Society Quality Collaborative demonstrated the benets of robot-assisted retromuscular VIH repair regarding hospital length of stay, surgical site occurrence, surgical site infection, and surgical site infection requiring procedural intervention [22]. The study propensity matched 222 patients who underwent open retromuscular VIH repair to 111 patients who had robot-assisted retro­muscular VIH repair. A similar proportion of patients in each cohort underwent TAR (83% open vs. 85% robotic, P=0.7). Ultimately, the authors showed that patients who underwent a robot-assisted retromuscular VIH repair experi­enced a signicantly shorter hospital length of stay (1day) with no difference in 30-day surgi­cal site infection rates (4% vs. 2%, P=0.5). Out to 30 days postoperatively, few patients in the open and robot-assisted retromuscular VIH repair groups suffered surgical site occurrence requiring procedural intervention (5% vs. 4%, P=0.8) [22].

Various patient factors including comorbidi­ties, surgical history, and hernia type and location can impact the choice of mesh location. Potentially modiable risk factors such as body mass index [30], smoking status [11], wound class [31], and hernia-specic risk score [14–16] impact the choice of mesh location as well. Operative approach, based on patient acuity, sur­geon skill set and experience, and availability of equipment for minimally invasive procedures, may alter options for mesh location. A recent meta-analysis, which analyzed 21 published arti­cles (3 randomized controlled trials, 5 prospec­tive cohort studies, and 13 case series), found that the pooled hernia recurrence rates between 5 and 60months postoperatively varied by mesh loca­tion (16.5% onlay, 30.2% inlay, 7% sublay, and

14.7% underlay). Similarly, mesh location

tion in the form of national presentations and published reports demonstrating better surgeon ergonomics compared to traditional laparoscopy [37], greater ability to perform more complex cases [38], improved short-term outcomes and shorter convalescence compared to an open approach [22, 39], and increasing availability of the robotic surgical platform.