Robotic mini- or less open sublay for anterior abdominal wall hernia repair using the da Vinci single port robotic platform (SP MILOS): a preclinical feasibility study

Endoscopic Mini or Less Open Sublay (eMILOS) is a transhernial endoscopically assisted approach for anterior abdominal wall hernia repair that has demonstrated excellent long-term outcomes. Performed through a small skin incision directly over the hernia, the eMILOS technique minimizes additional access trauma, but remains technically demanding with conventional instruments. This study investigates the preclinical feasibility of adapting the da Vinci SP system to perform the transhernial SP MILOS technique. This preclinical study evaluated the technical feasibility of performing daVinci SP MILOS hernia repair using human cadavers. The da Vinci SP robotic platform and its standard instruments were employed. Procedural steps, technical considerations, limitations, and potential advantages were systematically documented. The procedure was completed through a 1.8-cm skin incision. Correct placement of the Access Port (AP) and defining the custom remote center (CRC) at the posterior fascial edge was essential for optimal trocar orientation and to limit collisions with the incision. The AP can be positioned below the skin or below the fascia depending on work flow and surgeon preference. The retrorectus space was developed robotically from xiphoid to pubis, with full 360° transhernial exposure. Transversus abdominis release and lateral dissection into the preperitoneal and pretransversalis planes were successfully achieved. In this preclinical cadaveric study, the SP MILOS technique provided 360° transhernial access to the retrorectus space without platform repositioning. Our initial experience supports its feasibility as a new single-port robotic option for ventral hernia repair, eliminating access trauma to the abdominal wall through a single, minimal skin incision.