Endoscopic mini/less open sublay technique (EMILOS)-a new technique for ventral hernia repair

The MILOS concept (mini/less open sublay repair) was developed to realize the benefits of minimally invasive surgery and avoid the disadvantages of traditional open techniques in repair of primary and secondary abdominal wall hernias. Utilizing the MILOS concept, the mesh can be placed in the retromuscular position without opening of the abdominal cavity or without the necessity to perform a large skin incision. The dissection of the retromuscular plane may be done by an open technique (MILOS) or endoscopically (EMILOS). From June 2015 to July 2016, a total of 33 patients were operated using the MILOS concept, 8 patients underwent the original MILOS technique, and 25 patients had the EMILOS operation. The operative steps of this novel endoscopic variation, the EMILOS procedure (endoscopic mini/less open sublay), are described in detail. Operative indications were a midline umbilical, epigastric, or incisional hernia with a coexisting rectus diastasis. In all cases, a large mesh (20 x 30) was implanted in the retromuscular space without any fixation. The average skin incision was 5.2 cm; mean operative time was 157 min and 122 min in the last five cases. The average hospital stay was 3.2 days. The median pain score (VAS) under physical stress (e.g., climbing stairs) was 2.7. The EMILOS operation has the potential to become an important supplementary method in the spectrum of surgical techniques for repair of abdominal wall hernias. The technique is reliable, reproducible, and easy to standardize.