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Mini- or Less-open Sublay Operation (MILOS)

A New Minimally Invasive Technique for the Extraperitoneal Mesh Repair of Incisional Hernias

Reinpold, Wolfgang MD*; Schröder, Michael MD*; Berger, Cigdem MD*; Nehls, Jennifer DVM*; Schröder, Alexander MD; Hukauf, Martin MSc(Statistics); Köckerling, Ferdinand MD, PhD§; Bittner, Reinhard MD, PhD

doi: 10.1097/SLA.0000000000002661

Objective: Improvement of ventral hernia repair.

Background: Despite the use of mesh and other recent improvements, the currently popular techniques of ventral hernia repair have specific disadvantages and risks.

Methods: We developed the endoscopically assisted mini- or less-open sublay (MILOS) concept. The operation is performed transhernially via a small incision with light-holding laparoscopic instruments either under direct, or endoscopic visualization. An endoscopic light tube was developed to facilitate this approach (EndotorchTM Wolf Company). Each MILOS operation can be converted to standard total extraperitoneal gas endoscopy once an extraperitoneal space of at least 8 cm has been created. All MILOS operations were prospectively documented in the German Hernia registry with 1 year questionnaire follow-up. Propensity score matching of incisional hernia operations comparing the results of the MILOS operation with the laparoscopic intraperitoneal onlay mesh operation (IPOM) and open sublay repair from other German Hernia registry institutions was performed.

Results: Six hundred fifteen MILOS incisional hernia operations were included. Compared with laparoscopic IPOM incisional hernia operation, the MILOS repair is associated with significantly a fewer postoperative surgical complications (P < 0.001) general complications (P < 0.004), recurrences (P < 0.001), and less chronic pain (P < 0.001). Matched pair analysis with open sublay repair revealed significantly a fewer postoperative complications (P < 0.001), reoperations (P < 0.001), infections (P = 0.007), general complications (P < 0.001), recurrences (P = 0.017), and less chronic pain (P < 0.001).

Conclusions: The MILOS technique allows minimally invasive transhernial repair of incisional hernias using large retromuscular/preperitoneal meshes with low morbidity. The technique combines the advantages of open sublay and the laparoscopic IPOM repair. Identifier NCT03133000

*Gross-Sand Hospital Hamburg, Academic Teaching Hospital of Hamburg University Hospital, Hamburg, Germany

Department of Surgery, Creighton University Hospital, Omaha, NE

StatConsult GmbH, Institute for Statistics, Magdeburg, Germany

§Department of Surgery, Vivantes Hospital Berlin Spandau, Berlin, Germany

Hernienzentrum Rottenburg am Neckar, Winghofer Medicum Plus GmbH, Rottenburg, Germany.

Reprints: Wolfgang Reinpold, MD, Gross-Sand Hospital Hamburg, Academic Teaching Hospital of Hamburg University Hospital, Gross-Sand 3, D-21107 Hamburg, Germany. E-mail:

Disclosure: The authors declare no conflicts of interest.

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