Totally endoscopic sublay (TES) repair for midline ventral hernia: surgical technique and preliminary results

Mini-invasive surgery for diastasis recti: an overview on different approaches

Diastasis recti abdominis (DRA) is an acquired condition defined by a widening of the linea alba exceeding 2 cm and the subsequent separation between the two medial margins of the rectus muscles, accompanied by a laxity of the ventral abdominal muscles, and often by ventral midline hernias. It is a quite common problem in women after pregnancy. In addition to the aesthetic implications resulting from the swelling of the anterior abdominal wall in the case of increased pressure within the abdominal cavity, DRA leads to several physical functional disorders, including muscle weakness, prolapses of the pelvic organs, urinary and fecal incontinence, low back and pelvic pain and sexual dysfunction. The management of diastasis recti can be conservative, with physiotherapy and specific physical exercises, but, especially in case of concomitant hernia, surgery can be considered as the first choice of treatment in order to restore the midline and repair the hernia. Through recent years, a large amount of mini-invasive surgical techniques has been proposed, approaching the abdominal differently, and to date there is still lack of evidence on the optimal choice for surgeons and patients. So, the present review aims to give the reader an overview on the different techniques proposed, focusing on the three main categories of approaches (pre-aponeurotic, retro-muscular and pre-peritoneal), their specific features and results, with a view on the newly proposed robotic approaches that can theoretically reproduce each single technique.

Comparative analysis of efficacy and quality of life between totally extraperitoneal sublay and intraperitoneal onlay mesh repair for ventral hernia

Ventral hernias pose a prevalent challenge in abdominal wall surgery, with ongoing advancements in repair techniques designed to enhance patient outcomes. This study evaluates the efficacy, safety, and socio-economic impact of Totally Extraperitoneal Sublay Repair (TES) versus Laparoscopic Intraperitoneal Onlay Mesh Repair (IPOM) for small to medium-sized ventral hernias, with a particular focus on postoperative quality of life and patient satisfaction. A retrospective cohort study was conducted, encompassing 125 patients who underwent ventral hernia repair between May 2018 and November 2023. The cohort included 55 patients treated with TES and 70 with Laparoscopic IPOM. Baseline characteristics, including age, gender, BMI, operative time, postoperative pain, hospitalization costs, and patient satisfaction score, were compared. Postoperative quality of life was evaluated through outpatient visits or telephone follow-ups. The propensity score matching (PSM) technique was applied in a 1:1 ratio to balance the significant differences in general characteristics between the two groups. Out of 125 patients, 70 cases were successfully matched using the PSM method, resulting in 35 cases in each group. The baseline characteristics of patients in groups were well-matched (P > 0.05). The TES group exhibited a significantly longer operative duration (P < 0.001); however, this group also experienced markedly reduced postoperative pain, decreased hospitalization costs, and diminished postoperative drainage (all P < 0.001). The length of hospital stay and the incidence of long-term complications were similar between the two groups. Follow-up evaluations at 3 and 6 months showed a significantly improved quality of life and higher patient satisfaction in the TES group. Both TES and IPOM demonstrate comparable safety and efficacy in the repair of ventral hernias. Although TES is associated with a longer operative duration, it provides significant advantages in postoperative quality of life, patient satisfaction, and cost-effectiveness, thereby supporting its broader clinical adoption.

Laparoendoscopic extraperitoneal surgical techniques for ventral hernias and diastasis recti repair: a systematic review

PURPOSE

this systematic review aims to classify and summarize the characteristics and outcomes of the different laparoendoscopic extraperitoneal approaches for the repair of ventral hernias and diastasis recti described in the last 10 years.

METHODS

a literature search was performed by two reviewers in December 2023 including articles from January 2013, 01 to December 2023, 15. The techniques were selected according to the surgical access site (anterior or posterior to the rectus sheath), the access type (laparoendoscopic, single incision laparoscopic, mini or less open), the main space used to repair the defect (subcutaneous or retromuscular) and the mesh place (onlay, sublay-retromuscular or sublay-preperitoneal) and classified as anterior or posterior approaches.

RESULTS

the literature search retrieved 1755 results and 27 articles were included in the study. The studies included 1874 patients, the mean age ranged from 37.8 to 60.2 years. The access site was anterior in 16 cases and posterior in 11 cases. The mesh was positioned onlay in 13 cases and sublay in 13 cases, with only one study using no mesh. Complications were: seroma, ranging from 0.8 to 81%, followed by skin complications (leak, ischemia, necrosis) from 0.8 to 6.4%, surgical site infections and bleeding. Recurrences ranged from 0% to 12,5%, with a mean follow-up from 1 to 24 months.

CONCLUSION

this systematic review confirms the presence of several new minimally invasive extraperitoneal techniques for the repair of abdominal wall defects, with different advantages and disadvantages. Further studies, with more extensive follow-up data and wider patient groups, are necessary to define specific indications for each technique.

Laparoscopic modified e-tep repair of concomitant inguinal and ventral hernias

BACKGROUND

Laparoscopic hernia repair in recent times has gained the most acceptance among both the surgical community and the patient groups, as it has proven benefits of lesser postoperative hospital stay and less pain scores. The incidence of both inguinal and ventral hernias has increased significantly in the present days. Various methods have been postulated by different surgical groups for repairing the same but no there is no standard consensus on managing concomitant inguinal and ventral hernias. The conventional e-TEP requires an extensive dissection with increased operative time. We present our experience in managing cases with both inguinal and primary M2/M3 and W1 ventral hernias with or without divarication of recti using a modified up to down approach for inguinal hernia followed by down to up approach for the ventral hernia, from a tertiary care center in South India.

MATERIALS AND METHODS

We managed 16 cases with simultaneous incidence of inguinal and primary M2/M3 and W1 ventral hernias with or without divarication of recti between January 2022 and November 2023. Institute ethical committee clearance and informed consent was obtained from all the 16 patients. They were all subjected to an extra peritoneal repair of both the hernias. All the demographic data, intraoperative data, postoperative complications and follow up were digitally stored. All patients were followed up for six months after surgery.

RESULTS

Out of 16 patients, 15 were males and 1 was female. The mean age was 48 years and the mean BMI of all the patients was 29.2 kg/m2. The postoperative recovery was smooth in all patients and being discharged within 24 h after surgery. The pain scores of all patients were significantly lower than patients who underwent intraperitoneal repair.

CONCLUSION

e-TEP hernia repair is gaining popularity and has amused the hernia surgical community. Our method of e-TEP RS repair in cases with concomitant inguinal and primary M2/M3 W1 ventral hernias with or without divarication helps in addressing both the hernias in the extra-peritoneal space. Our technique reduces the area of dissection needed for mesh placement and preserves the integrity of abdominal musculature in the upper abdomen when compared with the conventional technique. It further allows extension of the e-TEP inguinal space into the Rectro rectus space without much alteration in the port arrangement allowing simultaneous repair of groin and umbilical hernias. Good knowledge of anatomy and laparoscopic skills are pertinent for safe and effective hernia repair by this technique.

Management of diastasis recti during ventral hernia repair: an analysis of the abdominal core health quality collaborative

PURPOSE

Advancements of minimally invasive techniques leveraged routine repair of concomitant diastasis recti (DR), as those approaches facilitate fascial plication and wide mesh overlap while obviating skin incision and/or undermining. Nevertheless, evidence on the value of such intervention is lacking. We aimed to investigate the management and outcomes of concomitant DR during ventral hernia repair (VHR + DR) from surgeons participating in the Abdominal Core Health Quality Collaborative (ACHQC).

METHODS

Patients who have undergone VHR + DR with a minimum 30-day follow-up complete were identified. Outcomes of interest included operative details, surgical site occurrences (SSO), medical complications, and readmissions.

RESULTS

169 patients (51% female, median age 46, median body mass index 31 kg/m2) were identified. Most hernias were primary (64% umbilical, 28% epigastric). Median hernia width was 3 cm (IQR 2-4) and median diastasis width and length were 4 cm (IQR 3-6) and 15 cm (IQR 10-20), respectively. Most operations were robotic (79%), with a synthetic mesh (92%) placed as a sublay (72%; 59% retromuscular, 13% preperitoneal). DR was repaired with absorbable (92%) and running suture (93%). Considering our cohort's relatively small diastasis and hernia size, a high rate of transversus abdominis release was noted (14.7%). 76% were discharged the same day and the 30-day readmission rate was 2% (2 ileus, 1 pneumonia). SSO rate was 4% (6 seromas, 1 skin necrosis) and only one patient required a procedural intervention.

CONCLUSIONS

ACHQC participating surgeons usually perform VHR + DR robotically with a retromuscular synthetic mesh and close the DR with running absorbable sutures. Short-term complications occurred in approximately 6% of patients and were mainly managed without interventions. Larger studies with longer-term follow-up are needed to determine the value of VHR + DR.

Potential applications of single-incision laparoscopic totally preperitoneal hernioplasty

BACKGROUND

The totally preperitoneal (TPP) approach is a new concept that was recently introduced. Although the TPP approach combined with single-incision laparoscopic hernia repair has its own advantages, there is little evidence reflecting the characteristics and feasibility of either approach.

AIM

To analyze the potential applications of single-incision laparoscopic TPP (SIL-TPP) inguinal hernia hernioplasty for the treatment of inguinal hernias.

METHODS

A total of 152 SIL-TPP surgeries were performed at the First Affiliated Hospital of Ningbo University from February 2019 to November 2022. A single-port, named Iconport, and standard laparoscopic instruments were used during the operation. Demographic data, intraoperative parameters and short-term postoperative outcomes were collected and retrospectively analyzed.

RESULTS

The demographic data of 152 patients underwent SIL-TPP were shown in Table 1. The average age was 49.5 years (range from 21 to 81 years). The average body mass index was 27.7 kg/m2 (range from 17.7 kg/m2 to 35.6 kg/m2). SIL-TPP were conducted successfully in 147 patients. Three patients were converted to the SIL-transabdominal preperitoneal laparoscopic herniorrhaphy at the initial stage of the study due to a lack of experience. In 2 patients with incisional hernias, an auxiliary operation hole was added during the SIL-TPP procedure, as required for surgery. The mean operative time was 64.5 minutes (range: 36.0-110.0 minutes) for unilateral direct and femoral hernias and 81.6 minutes for indirect hernias (range: 40.0-150.0 minutes). The mean postoperative hospital stay was 3.4 days.

CONCLUSION

SIL-TPP is feasible and has advantages for inguinal hernia repair. SIL-TPP has potential benefits for patients with various abdominal wall hernias. Consequently, doctors should be encouraged to actively apply the TPP approach combined with a single incision in their daily work.

Inside to outside puncture following endoscopic localization-A novel technique to insert ports and create retromuscular space in eTEP for ventral hernias

PURPOSE

Enhanced-view totally extraperitoneal plasty (eTEP) has been used worldwide to repair ventral hernias. This study aimed to describe a novel technique to insert ports and create retromuscular space in more detail.

METHODS

From 2020 to 2022, 23 consecutive ventral hernia repairs were performed using the eTEP technique. In all cases, inside-to-outside puncture following endoscopic localization was utilized to insert ports and create retromuscular space.

RESULTS

All cases were completed with the eTEP technique, and no cases with conversion to open repair or IPOM technique. There were no epigastric vessel injuries and posterior sheath tears due to puncture. In addition, no postoperative hematoma cases were reported.

CONCLUSION

Inside-to-outside puncture following endoscopic localization to insert ports and create retromuscular space is a safe, feasible, reproducible technique in eTEP for ventral hernia repair.

Totally endoscopic sublay/extraperitoneal (TES)-Sugarbaker repair for type IV parastomal hernia

TECCHNIQUE

The totally endoscopic sublay/extraperitoneal (TES) technique has become a substantial supplement for the treatment of ventral hernias. The fundamental principle of this technique is to break down the boundaries and connect the spaces, then create a sufficient sublay/extraperitoneal space for hernia repair and mesh placement. This video demonstrates the surgical details of the TES operation for an EHS type IV parastomal hernia. The main steps include retromuscular/extraperitoneal space dissection in the lower abdomen, circumferential incision of the hernia sac, stomal bowel mobilization and lateralization, closure of each hernia defect, and final mesh reinforcement.

RESULTS

The operative time was 240 min, and no blood loss occurred. No significant complications were noted during the perioperative period. Postoperative pain was mild, and the patient was discharged on postoperative day 5. During the half-year follow-up, no recurrence or chronic pain was detected.

CONCLUSIONS

The TES technique is feasible for carefully selected difficult parastomal hernias. To our knowledge, this is the first reported case of endoscopic retromuscular/extraperitoneal mesh repair of a challenging EHS type IV parastomal hernia.

Laparoscopic repair for interparietal hernia after enhanced-view totally extraperitoneal hernia repair: A case report

INTRODUCTION

The enhanced-view totally extraperitoneal (eTEP) technique, an endoscopically performed Rives-Stoppa method, has been used extensively for ventral hernia repairs. However, in this technique, the necessity of posterior rectus sheath re-approximation and mesh fixation remains unclear. There are a few reports of post-eTEP interparietal hernias (IHs) occurring because of dehiscence of the re-approximated posterior rectus sheath; however, IH secondary to mesh migration is rare. Herein, we report a rare case of IH due to mesh migration after eTEP repair for an incisional hernia.

PRESENTATION OF CASE

A 70-year-old man underwent eTEP repair for an incisional hernia using a self-gripping mesh without mesh fixation and posterior rectus sheath re-approximation one year previously, developed an IH. An elective laparoscopic surgery revealed an orifice to the retrorectus space as though the IH sac between the retrorectus muscle and the posterior layer including the bilateral posterior rectus sheaths, peritoneum, and mesh. We placed eight transmural sutures with 0 nylon thread and closed the orifice. The patient was then discharged on postoperative day two and was asymptomatic at 24 months without evidence of ventral hernia recurrence.

DISCUSSION

We consider that strenuous activity and deep bending may cause mesh migration or dislocation. If that occurs in the early post-eTEP period without posterior rectus sheaths closure, the vulnerable peritoneal area will be exposed, which consider to be an IH orifice.

CONCLUSIONS

Even after using the self-gripping mesh in eTEP repair, mesh fixation remains the best option to prevent postoperative complications, including IH.

A new approach to enter Retzius space in laparoscopic transabdominal preperitoneal bilateral inguinal hernia repair

BACKGROUND

To investigate the feasibility, safety and efficacy of the right-side approach to enter Retzius space in laparoscopic transabdominal preperitoneal bilateral inguinal hernia repair.

METHODS

Retrospective analysis was performed on 189 patients who were diagnosed with bilateral inguinal hernia preoperatively or intraoperatively and underwent selective TAPP in the General Surgery I Section of Shaanxi Provincial People's Hospital from January 2015 to September 2020. 94 cases were performed using the right-side approach (research group), and 95 cases with conventional approach (control group). Intraoperative and postoperative conditions of the two groups were observed and compared.

RESULTS

All operation were completed successfully. The operative time of research group was significantly shorter than that of control group (128.8 ± 35.4 vs 144.1 ± 40.9 min, P = 0.006). There were no significant differences in postoperative hospital stay, VAS score on first postoperative day, incidence of seroma and hematoma, urinary retention and other complications (P > 0.05). None of the patients occured hernia recurrence, mesh infection, intestinal obstruction and other complications.

CONCLUSIONS

The right-side approach to enter Retzius space is safe and feasible in TAPP surgery of bilateral inguinal hernia. Compared with the conventional approach, it can shorten the operative time and has certain advantages.

Stapled fascial suture: ex vivo modeling and clinical implications

BACKGROUND

Recently, in the field of abdominal wall repair surgery, some minimally invasive procedures introduced the use of staplers to provide a retromuscular prosthetic repair. However, to the knowledge of the authors, there are little data in the literature about the outcomes of stapled sutures adoption for midline reconstruction. This study aims to investigate the biomechanics of stapled sutures, simple (stapled), or oversewn (hybrid), in comparison with handsewn suture. From the results obtained, we tried to draw indications for their use in a clinical context.

METHODS

Human cadaver fascia lata specimens, sutured (handsewn, stapled, or hybrid) or not, underwent tensile tests. The data on strength (maximal stress), ultimate strain (deformability), Young's modulus (rigidity), and dissipated specific energy (ability to absorb mechanical energy up to the breaking point) were recorded for each type of specimens and analyzed.

RESULTS

Stapled and hybrid suture showed a significantly higher strength (handsewn 0.83 MPa, stapled 2.10 MPa, hybrid 2.68 MPa) and a trend toward a lower ultimate strain as compared to manual sutures (handsewn 344%, stapled 249%, hybrid 280%). Stapled and hybrid sutures had fourfold higher Young's modulus as compared to handsewn sutures (handsewn 1.779 MPa, stapled 7.374 MPa, hybrid 6.964 MPa). Handsewn and hybrid sutures showed significantly higher dissipated specific energy (handsewn 0.99 mJ-mm3, stapled 0.73 mJ-mm3, hybrid 1.35 mJ-mm3).

CONCLUSION

Stapled sutures can resist high loads, but are less deformable and rigid than handsewn suture. This suggests a safer employment in case of small defects or diastasis (< W1 in accord to EHS classification), where the presumed tissutal displacement is minimal. Oversewing a stapled suture improves its efficiency, becoming crucial in case of larger defects (> W1 in accord to EHS classification) where the expected tissutal displacement is maximal. Hybrid sutures seem to be a good compromise.

Robotic retromuscular abdominal wall repair using an inverted TEP (iTEP) approach: surgical technique and short-term outcomes

PURPOSE

Robotic retromuscular abdominal wall repair (RAWR) for ventral hernias can be performed transabdominal or extraperitoneal by using an enhanced view totally extraperitoneal repair (eTEP). For defects in the meso- or epigastric region, an inverted approach can be used, starting the development of the totally extraperitoneal plane in the suprapubic region and progressing in a caudal-to-cranial direction (inverted TEP, iTEP). The aim of the study is to present the surgical technique and to report the short-term outcomes.

METHODS

A retrospective analysis of a prospectively maintained database was performed, including patients who underwent a robotic RAWR using the iTEP approach between December 2019 and January 2022. The surgical technique was described, and patients' characteristics and intra- and postoperative parameters were studied and compared to the TARUP technique (robotic transabdominal retromuscular umbilical prosthetic hernia repair).

RESULTS

Thirty-four patients were treated with an iTEP approach, and 14 patients underwent a TARUP procedure. The median length of stay was 1 day (range 1-3), and there were no intraoperative complications in both groups. One patient (3%) required reoperation after an iTEP approach for a small bowel internal herniation due to a rupture of the posterior rectus sheath. There were no recurrences or mortality with a median follow-up of 15 months (range 3-29) in the iTEP group, compared to 35 months (range 29-37) in the TARUP group.

CONCLUSION

For defects in the upper abdominal region, a robotic RAWR with an iTEP approach appears to be safe and feasible. Long-term follow-up is needed to evaluate the late recurrence rate.

Comparative review of outcomes: single-incision laparoscopic total extra-peritoneal sub-lay (SIL-TES) mesh repair versus laparoscopic intraperitoneal onlay mesh (IPOM) repair for ventral hernia

To compare outcomes between single-incision laparoscopic totally extra-peritoneal sub-lay (SIL-TES) mesh repair and laparoscopic intraperitoneal onlay mesh (IPOM) repair of ventral hernia (VH). A retrospective selection of 104 patients who underwent VH repair (50 and 54 in the SIL-TES and IPOM groups, respectively) was made. Patient data were collected, and quality of life was evaluated using Carolinas Comfort Scale (CCS) 1 month and 3 months after surgery. There were no significant differences in sex, American Society of Anesthesiologists class, defect size, mesh area, estimated blood loss, and complication rate between the groups. Age was lower, body mass index was higher, prevalence of primary VH was significantly higher (p < 0.0001), and pain was less at 24 and 48 h post procedure (p < 0.0001) in the SIL-TES group. Drainage placement was more (p < 0.0001), operation time was shorter (p = 0.012), and hospitalization duration and total hospitalization cost were greater in the IPOM group than that in SIL-TES group (8.3 ± 0.3 vs 4.3 ± 0.4 days, p < 0.0001; $7126.9 ± 141.4 vs $2937.3 ± 58.3, p < 0.0001, respectively). Pain and movement limitation scores evaluated by CCS were significantly worse at 1 month (4.93 ± 0.28 vs 1.75 ± 0.28: p < 0.0001; 2.52 ± 0.24 vs 1.15 ± 0.18: p < 0.0001, respectively) and 3 months (4.32 ± 0.37 vs 0.9 ± 0.29: p < 0.0001; 2.06 ± 0.25 vs 0.69 ± 0.11: p < 0.0001, respectively) in IPOM group, compared with the according scores in SIL-TES group. There was no readmission within 30 days and no hernia recurrence at mean follow-up of 12 months. SIL-TES mesh repair is safe and effective and is superior to IPOM repair.

Totally endoscopic sublay/extraperitoneal Sugarbaker mesh repair for parastomal hernia

INTRODUCTION

Shared consensus is that a nonslit-mesh-based laparoscopic repair technique is the optimal treatment principle for parastomal hernia (PSH).

MATERIALS AND SURGICAL TECHNIQUE

An 81-year-old female parastomal hernia patient who had a previous history of laparoscopic abdominoperineal resection presented for surgical treatment. We performed a novel totally endoscopic sublay/extraperitoneal Sugarbaker mesh repair (TES-Sugarbaker) for this disease. The mesh was deployed in the sublay/extraperitoneal plane in a Sugarbaker configuration.

DISCUSSION

TES-Sugarbaker repair for parastomal hernia is technically feasible, it requires no anti-adhesive coated mesh and less traumatic fixation, then reduces the mesh-related complication and postoperative pain, making it more cost effective. The present described case represents an early attempt to perform endoscopic sublay/extraperitoneal mesh repair for PSH.

Mid-term results of VTEP (Ventral hernia repair by Totally ExtraPeritoneal approach)

BACKGROUND

Techniques of retromuscular repair of ventral hernias aim at avoiding complications linked to intraperitoneal patch. Aim of the study was to evaluate results of the VTEP technique.

METHODS

On 187 patients who underwent a VTEP, evaluation was carried out on 128 patients with a minimum follow-up of 1 year. The surgical technique consisted of creating connection between both retro-rectus spaces, by division of the medial edges of the posterior sheath and deploying the patch in the retromuscular patch without fixation. The posterior sheath was repaired in 16 cases. The patients were sent a questionnaire and invitation to have physical examination by the surgeon.

RESULTS

The mean hernia and patch size were 9 (1-50) and 225 (50-500) cm², respectively. The mean follow-up was 21.2 (12-35) months; 120 (93.7%) patients were evaluated, 21 by physical examination, 41 by questionnaire, 58 by telephone and 8 (6.3%) were lost to follow-up. Hundred (83%) patients felt no pain at rest, and 88 (73%) during effort. Among patients who felt some degree of pain, the mean VAS value was 2 (1-4) at rest and 2.6 (1-7) during effort. Two recurrences occurred, 3 patients were worried about a persisting diastasis bulging at the upper border of the patch and 8 patients in which the posterior sheath was not repaired complained they felt that their upper abdomen was somewhat distended or swollen.

CONCLUSION

The VTEP procedure provides a low level of chronic pain but can entail some drawbacks, such as the swollen abdomen, which can be attributed to the absence of repair of the posterior sheath. It may be that restoring or preserving structural integrity of the abdominal belt formed by the posterior sheath constitutes a key point in retromuscular techniques.

Modified Laparoscopic Sugarbaker Repair of Parastomal Hernia With a Totally Extraperitoneal Technique

Purpose: Many patients develop a parastomal hernia within the first 2 years of stoma formation, and even surgical repair is associated with high recurrence rates. An intraperitoneal approach is typically used for the laparoscopic repair of parastomal hernia; it is unknown whether a totally extraperitoneal technique (TEP) is feasible. Here we describe a laparoscopic TEP approach using a modified Sugarbaker method for the repair of parastomal hernia.

Methods: Seven patients underwent parastomal hernia repair. The retrograde puncture technique was used to create the extrapneumoperitoneum, and the peritoneum was separated with a laparoscopic TEP approach; the mesh was placed using a modified Sugarbaker technique.

Results: All patients had an oncologic etiology for stoma creation. The mean (±SD) size of the hernia defect was 3.1 ± 2.7 cm and the mesh size was 303.4 ± 96.8 cm². The mean operative time was 195.5 ± 20.7 min and average length of hospital stay after surgery was 4.8 ± 2.1 days. One patient had intraoperative subcutaneous emphysema. The average follow-up time was 8.5 ± 2.7 months; mild pain occurred in 2 patients, 3 experienced seroma formation (with no special treatment required), and 1 had early intestinal obstruction (which was treated with conservative care). There was no hernia recurrence, wound complications, or infections of the surgical site or mesh during follow-up.

Conclusion: A laparoscopic TEP technique is technically challenging but feasible. Modified laparoscopic Sugarbaker repair of a parastomal hernia with the TEP technique is safe and effective, although the recurrence rate and late complications require confirmation in more cases with long-term follow-up.

Closing the gap: evidence-based surgical treatment of rectus diastasis associated with abdominal wall hernias

PURPOSE

Rectus diastasis (RD) associated with abdominal hernias present a surgical challenge associated with a paucity in treatment guidelines. The objective of this systematic review is to review surgical techniques and assess complication and recurrence rates of RD in patients with concurrent abdominal hernias.

METHODS

PubMed and EMBASE databases were systematically searched, and data extraction was performed on articles which met the inclusion criteria. Pooled analyses of complication and recurrence rates were performed to compare open vs. minimally invasive surgery. Student t tests were performed to compare differences in continuous outcomes.

RESULTS

Twenty-eight studies were included in this review. RD can be surgically repaired by both open and laparoscopic approaches using both non-absorbable and absorbable sutures. The majority of the techniques reported included mesh insertion either above the aponeurosis, retromuscular, preperitoneal, or intraperitoneal. Open techniques, compared to laparoscopic approaches, were associated with a significantly higher rate of skin dehiscence (6.79% vs. 2.86%; p = 0.003) and hematoma formation (4.73% vs. 1.09%; p < 0.001) and a significantly lower rate of post-operative seroma formation (2.47% vs. 8.29%; p < 0.001). No significant difference in RD recurrence rates were observed between open and laparoscopic repair (0.22 vs. 0.63%, p = 0.17).

CONCLUSION

Both open and laparoscopic surgery are safe and effective methods that can be used to repair RD in patients with RD and concurrent abdominal hernias as evident by the low recurrence and complication rates and almost negligible major complications post repair.

Comparison of outcomes in rectus abdominis diastasis repair-which data do we need in a hernia registry?

INTRODUCTION

Rectus abdominis diastasis (RAD) ± concomitant hernia is a complex hernia entity of growing significance in everyday clinical practice. Due to a multitude of described surgical techniques, a so far missing universally accepted classification and hardly existing comparative studies, there are no clear recommendations in guidelines. Therefore, "RAD ± concomitant hernia" will be documented as a separate hernia entity in the Herniamed Registry in the future. For this purpose, an appropriate case report form will be developed on the basis of the existing literature.

METHODS

A systematic search of the available literature was performed in March 2021 using Medline, PubMed, Google Scholar, Scopus, Embase, Springer Link, and the Cochrane Library. 93 publications were identified as relevant for this topic.

RESULTS

In total 45 different surgical techniques for the repair of RAD ± concomitant hernia were identified in the surgical literature. RAD ± concomitant hernia is predominantly repaired by plastic but also by general surgeons. Classification of RAD ± concomitant hernia is based on a proposal of the German Hernia Society and the International Endohernia Society. Surgical techniques are summarized as groups subject to certain aspects: Techniques with abdominoplasty, open techniques, mini-less-open and endoscopic sublay techniques, mini-less-open and endoscopic subcutaneous/preaponeurotic techniques and laparoscopic techniques. Additional data impacting the outcome are also recorded as is the case for other hernia entities. Despite the complexity of this topic, documentation of RAD ± concomitant hernia has not proved to be any more cumbersome than for any of the other hernia entities when using this classification.

CONCLUSION

Using the case report form described here, the complex hernia entity RAD ± concomitant hernia can be recorded in a registry for proper analysis of comparative treatment options.

Subxiphoid top-down endoscopic totally preperitoneal approach (eTPA) for midline ventral hernia repair

PURPOSE

Midline abdominal wall hernia repair is among the most common surgical interventions performed worldwide. However, the optimal surgical technique remains controversial. To overcome the disadvantages of both open and transabdominal procedures, we developed a totally endoscopic preperitoneal approach (eTPA) with placement of a large mesh.

METHODS

From December 2019 to October 2020, 20 consecutive patients with small to medium-sized midline ventral hernias underwent repair using a completely preperitoneal subxiphoid top-down approach. The preperitoneal space was entered directly below the xiphoid, and careful endoscopic development of the plane between the peritoneum and posterior sheath of the rectus fascia was then performed behind the linea alba. The hernia sac and its contents were identified and reduced. The hernia defect was closed with sutures, and a mesh with an adequate high defect: mesh ratio was placed in the newly created preperitoneal space.

RESULTS

Twenty patients were enrolled in this study, including 14 with primary umbilical hernias, 4 with primary epigastric hernias, and 2 with recurrent umbilical hernias. 15 patients suffered from a mild concomitant diastasis recti. All operations were successfully completed without conversion to open repair. The mean operative time was 105.3 min (range, 60-220 min). Postoperative pain was mild, and the mean visual analog scale score for pain was 1.8 on the first postoperative day. The average postoperative hospital stay was 1.8 days (range, 1-4 days). One patient developed a minor postoperative seroma, but it had no adverse impact on the final outcome. No patients developed recurrence during the 3- to 10-month follow-up period.

CONCLUSIONS

The subxiphoid top-down totally endoscopic preperitoneal approach (eTPA) technique is feasible and effective. It may become a valuable alternative for the treatment of primary small- (defect size < 2 cm) and medium-sized (2-4 cm) midline ventral hernias, particularly in presence of a concomitant diastasis recti.

Stapled VTEP (sVTEP), diastasis and the "swollen abdomen"

BACKGROUND

In the VTEP series, some patients declared that their abdomen was "somewhat swollen", and the authors suggested that this might be related to disruption of the posterior sheath due to the crossing. Following this observation, we decided to evaluate the systematic repair of the posterior sheath.

METHODS

In 50 consecutive patients operated for ventral hernias, the VTEP procedure was modified, using the linear stapler to perform simultaneous division and closure of the posterior sheath. Perioperative data and short-term results were prospectively assessed.

RESULTS

Six (12%) complications occurred: one hematoma, one sudden death at home five days after surgery in a man with history of cardiac disease, and 4 cases of dehiscence of the staple line, which were successively reoperated by suture of the gap and posterior sheath release incision (PSR). With a mean follow-up of 7.5 months (4-12) there were no recurrences and 2 cases of "swollen abdomen", in patients who undergone PSR. The "swollen abdomen" did not occur when the posterior sheath was repaired without PSR. Preoperative diastasis bulging present in 11 cases, was totally or partially corrected in 8 and 1 cases, respectively, and unchanged in 2 cases.

CONCLUSION

The sVTEP procedure, can contribute to prevent the swollen abdomen and to diastasis correction. The PSR can prevent staple line disruption or permit tension-free repair of the dehiscence, but then, the newly created lateral gaps can finally entail the same drawback. Search for the best solution to treat the gap in the posterior sheath requires further studies.

Strategies for Mesh Fixation in Abdominal Wall Reconstruction: Concepts and Techniques

SUMMARY

Ventral hernias have numerous causes, ranging from sequelae of surgical procedures to congenital deformities. Patients suffering from these hernias experience a reduced quality of life through pain, associated complications, and physical disfigurement. Therefore, it is important to provide these patients with a steadfast repair that restores functionality and native anatomy. To do this, techniques and materials for abdominal wall reconstruction have advanced throughout the decades, leading to durable surgical repairs. At the cornerstone of this lies the use of mesh. When providing abdominal wall reconstruction, a surgeon must make many decisions with regard to mesh use. Along with the type of mesh and plane of placement of mesh, a surgeon must decide on the method of mesh fixation. Fixation of mesh provides an equal distribution of tension and a more robust tissue-mesh interface, which promotes integration. There exist numerous modalities for mesh fixation, each with its own benefits and drawbacks. This Special Topic article aims to compare and contrast methods of mesh fixation in terms of strength of fixation, clinical outcomes, and cost-effectiveness. Methods included in this review are suture, tack, fibrin glue, mesh strip, and self-adhering modes of fixation.

Comorbid rectus abdominis diastasis is a risk factor for recurrence of umbilical hernia in Japanese patients

INTRODUCTION

Rectus abdominis diastasis (RAD) is characterized by thinning and widening of the linea alba and laxity of the ventral abdominal muscle. RAD, when coexistent with umbilical hernia, is considered a risk factor for hernia recurrence. We investigated the impact of comorbid RAD in patients with umbilical hernia who had undergone hernia repair.

METHODS

We enrolled 30 patients who had undergone umbilical hernia repair using either a laparoscopic or anterior approach between April 2006 and May 2018. We diagnosed RAD according to preoperative CT. The outcomes of patients with umbilical hernia, the RAD group, and the non-RAD group were compared, especially in terms of recurrence.

RESULTS

Twenty-five patients (83%) presented with RAD, including three patients (12%) with postoperative recurrence who were allocated to the RAD group. The median BMI in the RAD group was 27.2 kg/m² . In the RAD group, a prosthesis mesh was used in 12 patients (48%), and nonabsorbable suture material was used in four patients (16%). There was no statistically significant difference between the two groups in terms of age, hernial orifice diameter, surgical technique, or operative time.

CONCLUSION

The rate of comorbid umbilical hernia in Japanese patients with RAD was high, as was the recurrence rate of umbilical hernia. We strongly recommend preoperative detection of RAD. We also recommend mesh-based repair of the midline and nonabsorbable suture material to decrease the recurrence rate, irrespective of hernia size.

Total endoscopic sublay mesh repair for umbilical hernias

Umbilical hernias constitute some of the most common surgical diseases addressed by surgeons. Endoscopic techniques have become standard of care together with the conventional open techniques for the treatment of umbilical hernias. Several different approaches were described to achieve laparoscopic sublay repair.We prospectively collected and reviewed the medical records of 10 patients with umbilical hernias underwent total endoscopic sublay repair (TES) at our institution from November 2017 to November 2019. All operations were performed by a same surgical team. The demographics, intraoperative details, and postoperative complications were evaluated.All TES procedures were successfully performed without conversion to an open operation. No intraoperative morbidity was encountered. The average operative time was 109.5 minutes (range, 80-140 minutes). All the patients resumed an oral diet within 6 hours after the intervention. The mean time to ambulation was 7.5 hours (range, 4-14 hours), and mean postoperative hospital stay was 2.2 day (range, 1-4 days). One patient developed postoperative seroma. No wound complications, chronic pain, or recurrence were registered during the follow-up.Initial experiences with this technique show that the TES is a safe, and effective procedure for the treatment of umbilical hernias.

Endoscopic Totally Extraperitoneal Repair of Parastomal Hernia: A Case Report

A parastomal hernia is a type of incisional hernia that occurs in abdominal integuments in the proximity of a stoma. It is a frequent late complication following colostomy. Surgical repair is currently the only treatment option for parastomal hernia. Here we present the case of a 74-year-old patient with parastomal hernia and a history of open surgery treated with a totally extraperitoneal (TEP) endoscopic approach. There was no recurrence of the hernia at the 3-month follow-up. We discuss the feasibility and possible operative approaches for endoscopic repair of parastomal hernia with the TEP technique.

[Abdominal wall hernias part 2 : Operative treatment techniques]

In accordance with the guidelines suture procedures, a preperitoneal mesh technique, the laparoscopic intraperitoneal onlay mesh (IPOM) or the new minimally invasive techniques, i.e. the endoscopic mini/less open sublay (E/MILOS) technique, enhanced-view totally extraperitoneal (eTEP) repair and totally endoscopic sublay (TES) repair should be used for primary abdominal wall hernias (umbilical hernia, epigastric hernia) depending on the defect size and patient characteristics (obesity, rectus abdominis muscle diastasis). For incisional hernias the sublay operation and laparoscopic IPOM continue to be the techniques most commonly used, whereby laparoscopic IPOM is being increasingly replaced by the open sublay operation and the new techniques (E/MILOS, eTEP and TES). For defects greater than 10 cm posterior component separation with transversus abdominis muscle release is becoming increasingly more established. There are also abdominal wall hernias (recurrences, lateral and combined lateral and medial defects) necessitating an open IPOM or an onlay technique.

[Ventral hernias part 1 : Operative treatment techniques]

Primary (umbilical, epigastric hernias) and secondary (incisional hernias) ventral hernias are among the most common surgical indications in general and visceral surgery. The defect width and defect localization have a considerable impact on treatment decision-making and outcomes. Therefore, preoperative computed tomography (CT) examination is increasingly recommended particularly for larger incisional hernias. Despite the good results reported in meta-analyses and registry analyses, in recent years there has been a marked trend away from the intraperitoneal onlay mesh (IPOM) technique as severe complications have repeatedly been reported. To continue to benefit from the advantages conferred by a minimally invasive access route with fewer wound complications, a myriad of new techniques with small incisions or endoscopic access have been developed. These involve mesh placement in the sublay/retromuscular/preperitoneal position. This provides a relatively differentiated tailored approach.

Totally endoscopic sublay (TES) repair for lateral abdominal wall hernias: technique and first results

BACKGROUND

The optimal surgical treatment for lateral hernias of the abdominal wall remains unclear. The presented prospective study assesses for the first time in detail the clinical value of a totally endoscopic sublay (TES) technique for the repair of these hernias.

METHODS

Twenty-four consecutive patients with a lateral abdominal wall hernia underwent TES repair. This technique is naturally combined with a transversus abdominis release maneuver to create a sufficient retromuscular/preperitoneal space that can accommodate, if necessary, a giant prosthetic mesh.

RESULTS

The operations were successful in all but one patient who required open conversion because of dense intestinal adhesion. The mean defect width was 6.7 ± 3.9 cm. The mean defect area was 78.0 ± 102.4 cm² (range 4-500 cm²). The mean mesh size used was 330.2 ± 165.4 cm² (range 108-900 cm²). The mean operative time was 170.2 ± 73.8 min (range, 60-360 min). The mean visual analog scale score for pain at rest on the first day was 2.5 (range 1-4). The average postoperative stay was 3.4 days (range 2-7 days). No serious complications (Dindo-Clavien Grade 2-4) were seen within a mean follow-up period of 13.3 months.

CONCLUSIONS

A totally endoscopic technique (TES) for the treatment of lateral hernias is described. The technique revealed to be reliable, safe and cost-effective. The first results are promising, but larger studies with longer follow-up periods are recommended to determine the real clinical value.

A Comprehensive, Evidence-Based Literature Review of the Surgical Treatment of Rectus Diastasis

BACKGROUND

Rectus diastasis is a common condition that can result in a protruding abdomen, causing cosmetic and functional disability. Although it is usually repaired during abdominoplasty or herniorrhaphy, there is a lack of consensus with regard to the repair indications and optimal surgical techniques. The goal of this study is to provide an updated review of the surgical techniques used for rectus diastasis repair and their comparative efficacy.

METHODS

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the PubMed, Embase, and Cochrane databases were searched for articles that discussed the surgical management of rectus diastasis and reported on either outcomes, complications, or recurrence rates. Data detailing surgical techniques were extracted, and pooled analyses of complication and recurrence rates were performed, controlling for surgical approach, common variations in technique, and an associated herniorrhaphy.

RESULTS

Thirty-seven studies describing 45 techniques were included. An open rectus diastasis repair was performed in 24 of the studies. After controlling for an associated herniorrhaphy, there was no statistically significant difference in surgical complication and recurrence rates between open and laparoscopic approaches (p = 0.165 and p = 0.133, respectively). Although a double-layer suture closure was associated with a significantly lower rate of complications (p = 0.002), no significant difference was found for suture type absorbability.

CONCLUSIONS

Surgical repair of rectus diastasis is safe and effective through both open and laparoscopic approaches. Although suture type absorbability does not affect complication or recurrence rates, a double-layer suture closure can decrease surgical complications. The pooled analysis of complication and recurrence rates can help improve informed consent and patient education.

Learning Curve of Robotic Rives-Stoppa Ventral Hernia Repair: A Cumulative Sum Analysis

Background: Robotic Rives-Stoppa ventral hernia repair (rRS-VHR) is a minimally invasive technique that incorporates extraperitoneal mesh placement, using either transabdominal or totally extraperitoneal access. An understanding of its learning curve and technical challenges may guide and encourage its adoption. We aim at evaluating the rRS-VHR learning curve based on operative times while accounting for adverse outcomes. Materials and Methods: We conducted a retrospective analysis of patients undergoing rRS repair for centrally located ventral and incisional hernias. A single surgeon operative time-based cumulative sum (CUSUM) analysis learning curve was created, and a composite outcome was used for risk-adjusted CUSUM (RA-CUSUM). Results: Eighty-one patients undergoing rRS-VHR were included. A learning curve was created by using skin-to-skin times. Accordingly, patients were grouped into three phases. The mean skin-to-skin time was 72.2 minutes, and there was a significant decrease in skin-to-skin times throughout the learning curve (Phase-I: 86.4 minutes versus Phase-III: 63.8 minutes; P = .001), with a gradual decrease after 29 cases. Eleven patients experienced adverse composite outcomes, which were used to create a RA-CUSUM graph. Results showed the highest adverse outcome rates in Phase-II, with a gradual decrease in risk-adjusted operative times after 51 cases. Conclusions: Consistently decreasing operative times and adverse outcome rates in rRS-VHR was observed after the completion of 29 and 51 cases, respectively. Future studies that provide group learning curves for this procedure can deliver more generalizable results in terms of its performance rates.

Endoscopic preaponeurotic access for complex ventral hernia repair with sublay mesh and bilateral anterior component separation: A case report

Introduction

Minimally invasive techniques are now routine in complex abdominal wall defects repair. Although laparoscopy allows to reduce post-operative pain, promoting a more rapid recovery and shortening hospital stay, it is associated with risk of bowel injury and adhesions development, when intraperitoneal mesh is placed. We report the case of a patient affected by large recurrent incisional hernia, treated with a new hybrid endoscopic approach.

Presentation of case

Patient treated with the novel approach is a 53-year-old male, BMI 27, smoker, with epigastric recurrence of incisional hernia and prosthetic fistula. An endoscopic preaponeurotic subcutaneous access was used. Repair with sublay mesh, bilateral anterior component separation and muscular reinsertions was conducted. Three months after surgery, no signs of recurrence were observed and complete functional recovery had been achieved.

Discussion

The new technique adopted benefits from all the advantages of minimally invasive surgery, allowing to avoid risks associated with laparoscopic access. Bilateral anterior component separation with muscular reinsertions is the key for tension-free suture.

Conclusion

To our knowledge, this is the first time that a complex recurrent incisional hernia is repaired with the hybrid technique aforementioned. The approach used is certainly technically challenging, thus requiring a team skilled in the use of laparoscopy. Good outcomes reported are a further demonstration that minimally invasive surgery can be a valid alternative to traditional open techniques for large abdominal wall defects repair.

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Minimally invasive surgical techniques are commonly used in complex ventral hernia repair.

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Laparoscopy is effective but it is associated with the risk of bowel injury and adhesions development.

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Component separation allows tension-free suture in presence of large hernia defects.

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A hybrid approach with endoscopic preaponeurotic access can be used to treat complex cases.

[Minimally invasive correction of anatomical features of anterior abdominal wall and ventral hernias]

Conventional «open» procedures for ventral hernias and diastasis recti are widely known, used everywhere and have a great number of author's improvements related to surgeon's experience, availability of modern information, equipment and materials. K. LeBlanc and W. Booth (1993) reported IPOM-method with non-adhesive coating that is considered a milestone in surgery of anterior abdominal wall and ventral hernia. This technique has gained recognition among surgeons around the world due to its technical simplicity, minimal invasiveness and high reproducibility. However, certain disadvantages of this technique have been shown over the past time that justified advisability of searching for another methods of anterior abdominal wall reinforcement. Thus, E-Milos, LIRA, TESAR, eTEP, REPA, TARM, TARUP techniques are currently available. This review is devoted to technical features of these techniques, their potential advantages and disadvantages.

A preliminary multicenter evaluation of endoscopic sublay repair for ventral hernia from China

Background

For ventral hernia, endoscopic sublay repair (ESR) may overcome the disadvantages of open sublay and laparoscopic intraperitoneal onlay mesh repair. This retrospective study presents the preliminary multicenter results of ESR from China. The feasibility, safety, and effectiveness of ESR were evaluated; its surgical points and indications were summarized.

Methods

The study reviewed 156 ventral hernia patients planned to perform with ESR in ten hospitals between March 2016 and July 2019. Patient demographics, hernia characteristics, operative variables, and surgical results were recorded and analyzed.

Results

ESR was performed successfully in 153 patients, 135 with totally extraperitoneal sublay (TES) and 18 with transabdominal sublay (TAS). In 19 patients, TES was performed with the total visceral sac separation (TVS) technique, in which the space separation is carried out along the peritoneum, avoiding damage to the aponeurotic structure. Endoscopic transversus abdominis release (eTAR) was required in 17.0% of patients, and only 18.3% of patients required permanent mesh fixation. The median operative time was 135 min. Most patients had mild pain and resume eating soon after operation. No severe intraoperative complications occurred. Bleeding in the extraperitoneal space occurred in two patients and was stopped by nonsurgical treatment. Seroma and chronic pain were observed in 5.23 and 3.07% of patients. One recurrence occurred after TAS repair for an umbilical hernia.

Conclusion

ESR is feasible, safe, and effective for treating ventral hernias when surgeons get the relevant surgical skills, such as the technique of “partition breaking,” TVS, and eTAR. Small-to-medium ventral hernias are the major indications.

New techniques in ventral hernia surgery - an evolution of minimally-invasivehernia repairs

Incisional ventral hernia occurs after almost every fourth laparotomy. Still, both simple suturing of the hernia defect and open mesh repair, lead to a high incidence of infections and recurrences. In recent years, we have observed a further evolution of operational techniques used in order to reduce the number of complications. The search for effective repair methods is currently going in two directions: on the one hand, techniques to reduce tissue tension in the suture line are being developed and disseminated (including modifications to the so-called Ramirez technique); on the other hand, minimally invasive techniques are introduced that allow placement of large synthetic meshes without the need for extensive tissue dissection using open repair. In the first group of presented techniques, emphasis is put on basics and access in the following repair method: original Ramirez technique, modified Ramirez technique, anterior component separation with periumbilical perforator-sparing, endoscopic anterior component separation and transversus abdominis release. In the second part of the manuscript, attention is drawn to the following hernia repair techniques: eTEP, reversed TEP, MILOS/eMILOS, stapler repair, TAPP, TARUP, TESLA, SCOLA, REPA, LIRA, IPOM, IPOM-plus. When choosing the optimal technique for a given patient, the surgeon should first of all be guided by technical feasibility, availability of materials, their own experience, as well as the characteristics of the patient and overall burdens. Nevertheless, surgeons undertaking reconstruction of the abdominal wall in the case of hernias should know different surgical accesses and individual spaces of the abdominal integument, in which a synthetic material may be placed. However, it should be emphasized that poor ergonomics of novel techniques, complex anatomy and complicated dissection of space, as well as the need for laparoscopic suturing in a difficult arrangement of tissue layers and in a narrow space, without a full triangulation of instruments, make these operations a challenge even for a surgeon experienced in minimally invasive surgeries.

Extended View: Totally Extra Peritoneal (e-TEP) Approach for Ventral and Incisional Hernia-Early results from a single center

BACKGROUND

Laparoscopy for ventral hernia repair is now an established technique with its proven benefits of less pain, early recovery, low-recurrence rate as compared to open repair. Several techniques have been described such as IPOM, MILOS, TES, EMILOS, SCOLA, e-TEP. e-TEP was originally conceptualized as an alternative approach to inguinal hernia in difficult cases (obese, previous scars) and for training surgery residents. Application of this approach for ventral hernia repair has recently been reported by few surgeons. We present our experience of e-TEP approach for ventral hernia from a tertiary care center in South India over one year duration.

MATERIALS AND METHODS

Electronically maintained data of patients who underwent e-TEP for ventral hernia during a period of November 2017 to November 2018 was reviewed retrospectively. Their demographic data, intraoperative details, postoperative complications and follow up data for a period of 6 months was noted.

RESULTS

171 patients underwent e-TEP approach ventral hernia repair. Mean age was 49.34 ± 10.75 years with hypertension being most common comorbidity. Mean BMI was 29.2 ± 4.1 kg/m². Mean defect area was 51.35 ± 45.09 cm² and mean mesh size used was 397.56 ± 208.83 cm². Fifty patients required TAR. Mean duration of surgery was 176.75 ± 62.42 min and blood loss was 78.7 ± 24.4 ml. Mean length of stay was 2.18 ± 1.27 days. Seven cases had paralytic ileus, 5 cases had surgical site infection, and 3 cases had recurrence at 6 months follow up.

CONCLUSION

e-TEP is a minimally invasive approach which is safe, feasible and also avoids placement of mesh in peritoneal cavity. Since it is a relatively new approach it requires further studies for standardization of techniques, criteria for patient selection and to study long-term outcomes.

Endoscopic totally extraperitoneal approach (TEA) technique for primary ventral hernia repair

Background

Up to now the totally extraperitoneal (TEP) technique is limited to the treatment of inguinal hernias. Applying this anatomical repair concept to the treatment of other abdominal wall hernias, we developed an endoscopic totally extraperitoneal approach (TEA) to treat primary midline ventral hernias, including umbilical and epigastric hernias, in which for mesh placement, an anatomical space is developed between the peritoneum and the posterior rectus sheath in the ventral part of the abdominal wall (preperitoneal space).

Methods

Between September 2017 and December 2019 according to the selection criterions, 28 consecutive primary midline ventral hernias were repaired using TEA. After extensive endoscopic development of the midline extraperitoneal plane, which was started in the suprasymphysic area, and reduction of the hernia sac, the hernia defect was closed and a large mesh was placed in the preperitoneal position to enforce the anterior abdominal wall.

Results

All operations were successfully performed without conversion to open surgery. The mean operation time was 103.3 min (range 85–145 min). Patient-reported postoperative pain was qualitatively mild with a mean pain visual analogue scale score of 1.9 on postoperative day 1. The average hospital stay was 1.9 days (range 1–3 days). Three patients developed minor complications and were treated with no long-term adverse effects. Readmissions within 30 days or hernia recurrences were not observed with a mean follow-up period of 18 months (range 10–27 months).

Conclusion

In selected cases, TEA is a safe and feasible minimally invasive alternative in treating primary ventral hernias. This technique preserves the anatomical and physiological structure of the abdominal wall and may significantly reduce trauma and postoperative complications. Additionally, anti-adhesion-coated meshes and fixation tackers are not required, thus being cost-effective. Further studies are necessary to proof the true clinical efficacy in comparison to well-known alternative techniques.

Ventral hernia repair by totally extraperitoneal approach (VTEP): technique description and feasibility study

BACKGROUND

The repair of ventral hernias by intra-peritoneal patch (IPOM) involves a risk of pain due to stapling as well as intestinal adhesions. Extraperitoneal placement of the patch without fixation can prevent these drawbacks. Techniques of endoscopic preperitoneal repair were previously described by others. The aim of this article is to describe our technique and to evaluate the feasibility and short-term results.

METHODS

The totally endoscopic technique consists of dividing the median aponeurotic structures, while preserving the proper linea alba, to create a unique retro-muscular space, in which the patch is deployed without any fixation. Hundred twelve consecutive patients were operated on for ventral hernias (82 umbilical, 20 epigastric, 10 combined). Perioperative data including duration of operation, technical problems, conversions and complications, as well as postoperative pain, time to resume daily activities and time off work were prospectively assessed.

RESULTS

98 (87.5%) patients were operated in ambulatory surgery, and 14 (12.5%) in overnight stay. The mean sizes of the hernia and the patch were 9 (1-50) cm² and 225 (50-500) cm², respectively. The mean operation duration was 75 (30-270) min. The peritoneum was opened in 43 (38.4%) cases and closed by suture in 41 instances. There were 5 (4.5%) conversions to IPOM and 4 (3.6%) complications (1 seroma, 1 urine retention, 1 transitory ileus, and 1 intestinal obstruction) which were reoperated. The mean VAS value of postoperative pain was 2.45 (0-8), pain was scored 0 by 17 (15%) patients. The mean times to resume daily activity and work were 4 (1-15) days and 11.5 (1-30) days, respectively.

CONCLUSION

Our results suggest that VTEP is safely feasible by surgeons skilled in laparoscopy, and might contribute to minimize pain, though this must be established by comparative studies.

Precostal top-down extended totally extraperitoneal ventral hernia plasty (eTEP): simplification of a complex technical approach

PURPOSE

Retromuscular mesh augmentation is generally considered to be the ideal technique for repairing ventral hernias and can be performed laparoscopically by 'enhanced view totally extraperitoneal plasty' (eTEP)-a technically complex procedure that requires a high level of surgical expertise. We aimed to develop a simplified technical modification.

METHODS

Thirty-one patients with ventral hernias were operated with a modified precostal, top-down eTEP approach, and prospectively recorded in our hernia registry. We describe this novel standardized precostal access and the bilateral development of both retromuscular compartments with a cylindrical dilating balloon port. Demographic-, hernia-specific-, and perioperative data were analyzed retrospectively.

RESULTS

Twenty-two primary and 9 incisional hernias with an average defect size of 34.5 cm² were repaired. An average implant of 420 cm² always completely covered diastasis recti and/or scars from previous midline laparotomies. Average procedure time was 128 min. One conversion was required due to peritoneal injury. Postoperatively there was one local infection and one patient suffered an interparietal herniation. There were no recurrences during the average 8-month follow-up period.

CONCLUSION

With technical modification of precostal access and pneumatic balloon dilation of both retro-rectus compartments, the complex procedure can be simplified through time saving and straightforward unidirectional 'top-down' dissection. The better overview facilitates the crossover for connecting both retro-rectus spaces. In addition, the cranial access allows the anterior- and posterior layers to be closed up to the xiphoid.

Lateral approach totally extraperitoneal (TEP) robotic retromuscular ventral hernia repair

BACKGROUND

The enhanced (or extended) view total extraperitoneal (TEP) access that was initially described for laparoscopic inguinal hernia repair has been applied to first laparoscopic and now robotic retromuscular ventral hernia repair (RRVHR). However, a 'dynamic' port setup that is based on the area of interest is preferred by most surgeons. In this study, we present our center's early operative outcomes after utilizing a lateral approach TEP-access RRVHR with and without transversus abdominis release (TAR).

METHOD

An evaluation of a prospectively maintained database of hernia patients was conducted identifying patients who underwent a lateral approach TEP-access RRVHR between February 2013 and April 2019. The lateral approach TEP-access RRVHR was described. Patient demographics, intraoperative and postoperative variables were reviewed. Preoperative and postoperative results were presented according to recommended classification systems by European Hernia Society.

RESULTS

Fifty-two patients who underwent a lateral approach TEP-access RRVHR were included in this study. A lateral dock setup was utilized for all patient who had a midline defect, as well as a lateral defect. The mean console time was 121.6 min., skin-to-skin time was 138.5 min. There was no intraoperative complication or conversion. The mean hospital length of stay was 0.71 day. During the mean 6.5 months follow-up period, no hernia recurrence arose.

CONCLUSION

The lateral approach TEP-access RRVHR with and without TAR is a reproducible technique. Feasibility of this approach needs to be demonstrated by other surgeons familiar with retromuscular hernia repair in addition to long-term follow up.

[New laparoendoscopic and minimally invasive extraperitoneal mesh augmentation techniques for ventral hernia repair]

In recent years techniques for ventral hernia repair have undergone a dynamic evolution with the development of minimally invasive and laparoendoscopic techniques. Despite the multitude of methods, five main criteria for setting the target have emerged: 1) functional and morphological reconstruction of the abdominal wall, 2) extraperitoneal mesh augmentation, 3) abandonment of penetrating fixation elements, 4) minimal surgical access trauma of the abdominal wall and 5) minimized intraperitoneal dissection that jeopardizes adherent intestinal structures. The mesh position varies between preperitoneal retromuscular and supraneurotic or preaponeurotic on the anterior rectus sheath. The different approaches can be carried out transhernially or distant from the abdominal wall defect. The latter can be realized by laparoscopic transperitoneal, endoscopic subcutaneous and endoscopic retromuscular/preperitoneal approaches. Some techniques can be extended to anterior or posterior component separation to reduce tension and to enlarge the space for mesh placement. Robot-assisted surgery opens up new perspectives in laparoendoscopic abdominal wall surgery due to additional instrumental degrees of movement. This enables the possibility of preperitoneal ventral hernia operations also behind and lateral to the posterior rectus muscle compartments as was only previously known below the arcuate line from inguinal hernia surgery.

Totally Endoscopic Sublay Anterior Repair for Ventral and Incisional Hernias

BACKGROUND

Endoscopic technique is a valid and safe approach for the treatment of abdominal wall defects. To combine the advantages of complete endoscopic extraperitoneal surgery with those of sublay mesh repair we propose Totally Endoscopic Sublay Anterior Repair (TESAR) a safe and feasible approach for the treatment of ventral and incisional midline hernias.

METHODS

From May to November 2018, 12 patients were referred to our unit for clinical and radiological diagnosis of midline ventral or incisional hernia and selected for TESAR. Exclusion criteria were: complicated ventral or incisional hernia (i.e., incarcerated hernia), maximum defect width >7 cm, and contraindications to general anesthesia.

RESULTS

All procedures were completed with endoscopic approach, with no conversion to laparoscopy or open surgery. No intraoperative complications were registered. Total mean operative time was 148 ± 18.5 minutes. No postoperative major complications were registered. Only one subcutaneous seroma was registered (8.3%) and treated conservatively. The mean postoperative stay was 2.6 ± 0.6 days.

CONCLUSIONS

TESAR is a safe and feasible technique for the extraperitoneal sublay repair of ventral hernias with a totally endoscopic approach. It provides accurate hernia repair with good outcomes in terms of resolution of symptoms and postoperative complications.

Classification of Rectus Diastasis-A Proposal by the German Hernia Society (DHG) and the International Endohernia Society (IEHS)

Introduction: Recently, the promising results of new procedures for the treatment of rectus diastasis with concomitant hernias using extraperitoneal mesh placement and anatomical restoration of the linea alba were published. To date, there is no recognized classification of rectus diastasis (RD) with concomitant hernias. This is urgently needed for comparative assessment of new surgical techniques. A working group of the German Hernia Society (DHG) and the International Endohernia Society (IEHS) set itself the task of devising such a classification.

Materials and Methods: A systematic search of the available literature was performed up to October 2018 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library. A meeting of the working group was held in May 2018 in Hamburg. For the present analysis 30 publications were identified as relevant.

Results: In addition to the usual patient- and technique-related influencing factors on the outcome of hernia surgery, a typical means of rectus diastasis classification and diagnosis should be devised. Here the length of the rectus diastasis should be classified in terms of the respective subxiphoidal, epigastric, umbilical, infraumbilical, and suprapubic sectors affected as well as by the width in centimeters, whereby W1 < 3 cm, W2 = 3− ≤ 5 cm, and W3 > 5 cm. Furthermore, gender, the concomitant hernias, previous abdominal surgery, number of pregnancies and multiple births, spontaneous birth or caesarian section, skin condition, diagnostic procedures and preoperative pain rate and localization of pain should be recorded.

Conclusion: Such a unique classification is needed for assessment of the treatment results in patients with RD.