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

Retrograde puncture for trocar placement for the establishment of the preperitoneal space in laparoscopic totally extraperitoneal repair for groin hernias: 10 years of experience

OBJECTIVES

The aim of this study was to investigate the feasibility and safety of retrograde puncture for trocar placement for the establishment of the preperitoneal space in laparoscopic total extraperitoneal repair (TEP) for groin hernias.

METHODS

A retrospective analysis of the clinical data of 1388 patients who underwent TEP surgery for a groin hernia at the General Hospital of Northern Theater Command of the Chinese People's Liberation Army (hereinafter referred to as the General Hospital of Northern Theater Command) from August 2013 to August 2023 was conducted. The feasibility and safety of retrograde puncture for trocar placement for the establishment of the preperitoneal space were examined.

RESULTS

All 1388 operations were successful, with no conversion to open surgery. The mean time for unilateral placement of the Trocars was 6.36 ± 2.32 min. The mean time for unilateral hernia surgery was 42.73 ± 10.33 min, and the mean time for bilateral hernia surgery was 73.11 ± 20.31 min. Peritoneal injuries were observed in 8 patients (0.58%), but there were no abdominal organ injuries. Two patients (0.14%) had inferior epigastric vascular injuries, and 16 patients (1.15%) experienced muscle hemorrhage during retrograde puncture. Twenty-five patients (1.80%) had postoperative local hematomas of the abdominal wall, and 37 patients (2.67%) had subcutaneous emphysema. Sixty-four patients (4.61%) experienced seroma retention, and 13 patients (0.94%) experienced urinary retention. The postoperative follow-up period ranged from 3 to 124 months, with a median follow-up time of 66 months. None of the patients experienced recurrence, persistent pain, localized foreign body sensation, mesh infection, or incision infection.

CONCLUSIONS

The retrograde puncture method for placing trocars to establish the preperitoneal space in laparoscopic TEP surgery for groin hernias is feasible and safe.

A retrospective cohort study of laparoscopic enhanced view totally extra-peritoneal Rives-Stoppa (eTEP-RS) repair of incisional ventral hernias in patients with morbid obesity

BACKGROUND

Incisional hernia (IH) repair in morbidly obese (MO) patients poses significant challenges due to higher risks of complications and recurrence. Traditional open repairs are linked to increased morbidity, driving interest in minimally invasive techniques. The enhanced view totally extra-peritoneal Rives-Stoppa (eTEP-RS) technique shows promise as a laparoscopic method for IH repair, but data on its efficacy and safety in MO patients are limited. This study aims to evaluate the efficacy, safety, and feasibility of the eTEP-RS approach specifically for IH repair in this high-risk population.

METHODS

Analysis of a retrospective cohort of consecutive patients undergoing laparoscopic eTEP-RS for IH repair between 2017 and 2022 which included 135 patients, categorized into two groups based on body mass index (BMI): the MO group (BMI > 35 kg/m2) and the control group (BMI ≤ 35 kg/m2). We compared demographics, comorbidities, hernia characteristics, intra-operative data, post-operative outcomes, and hernia recurrence rates.

RESULTS

Patients in the MO group had significantly more type 2 diabetes mellitus (n = 18, 51% vs n = 25, 25%; p = 0.004), hypertension (n = 35, 73% vs n = 75, 53%; p = 0.017), dyslipidemia (n = 29, 60% vs n = 58, 41%; p = 0.021), ASA score 3 (n = 18, 52% vs n = 23, 23%; p = 0.004), a history of previous umbilical hernia repair (n = 13, 27% vs n = 13, 9.2%; p = 0.002), and bariatric surgery (n = 10, 29% vs n = 13, 13%; p = 0.035). There were no differences in intra-operative characteristics, operative times, or intra-operative complications between groups. During a median follow-up period of 1 year (IQR 40-680 days), there were no differences in hernia recurrence (n = 2, 5.7% vs n = 9, 9%; p = 0.07), time to recurrence, or chronic analgesia usage between groups.

CONCLUSION

The laparoscopic eTEP-RS approach was safe and effective for IH repair in patients with MO, demonstrating comparable post-operative outcomes and recurrence rates to those with a lower BMI in a selected cohort of patients.

A comparative study between ETEP vs. IPOM repair for ventral hernia

BACKGROUND

Enhanced View Totally Extraperitoneal (eTEP) and Intraperitoneal Onlay Mesh (IPOM) are two widely performed laparoscopic approaches for ventral hernia repair. This randomized prospective study aimed to compare these two techniques in terms of various clinical outcomes.

MATERIALS AND METHODS

A total of 60 patients presenting with ventral hernias at our hospital between June 2022 and December 2023 were included in the study. All patients were fit for general anesthesia and were randomized into two groups, with 30 patients undergoing eTEP and 30 patients undergoing IPOM.

RESULTS

There were no significant differences in baseline characteristics such as age, sex, or comorbidities between the two groups. The operative time for eTEP was significantly longer, with a mean duration of 211 min compared to 177.5 min for IPOM (p < 0.001). Postoperative pain and analgesic requirements were significantly lower in the eTEP group. Two patients in the eTEP group required conversion to IPOM. No intraoperative complications occurred in either group. Two patients developed seromas on the seventh postoperative day, both of which were managed conservatively. The mean hospital stay was shorter for eTEP (3.43 days) compared to IPOM (6.16 days, p < 0.001). Patients undergoing eTEP had an earlier return to work and reported better abdominal wall quality of life. No recurrences were observed in either group during the six-month follow-up period.

CONCLUSION

eTEP repair for ventral hernias offers several advantages over the commonly performed IPOM technique, including reduced postoperative pain, shorter hospital stay, and faster recovery. However, the choice of procedure should be guided by the surgeon's expertise and confidence in performing either technique.

Single incision laparoscopic totally preperitoneal hernioplasty (SIL-TPP) for bilateral inguinal hernia repair: initial experience

OBJECTIVE

The aim of this study was to introduce and assess the safety and feasibility of single incision laparoscopic totally preperitoneal hernioplasty (SIL-TPP) for bilateral inguinal hernia repair.

METHOD

Forty-two SIL-TPP procedures for bilateral inguinal hernia repair were conducted from June 2018 to July 2022 at the First Affiliated Hospital of Ningbo University using standard laparoscopic instruments and a single-port device. Clinical data such as demographic intraoperative parameters and short-term postoperative outcomes were collected and analysed.

RESULTS

SIL-TPP was successful in 42 bilateral inguinal hernia patients, and no conversion occurred. Of these 42 patients, 38 were males and 4 were females. The average age was 57.4 ± 17 years. The participants' mean BMI was 22.67 ± 2.19 kg/m2 (range from 18.65 to 28.71 kg/m2). There were 4 types of bilateral hernias. The percentage of patients who underwent surgery before the SIL-TPP procedure in the same region was 21.43% (9/42). The mean operative time was 114 ± 34.24 min (range, 70-215 min). A total of 11 intraoperative complications occurred in 42 bilateral inguinal hernia patients, including unintentional peritoneum tears and hernia sac tears. No major complications occurred in the study. The postoperative complication rate was 2.38% (1/42). One patient experienced intestinal obstruction after the operation that resolved spontaneously without treatment. The surgical time in the SIL-TPP group decreased gradually as the number of operations increased. Moreover, the operation time trend decreased linearly (P < 0.0001, R²=0.42).

CONCLUSION

SIL-TPP is a safe and feasible procedure for treating bilateral inguinal hernias. The SIL-TPP procedure requires distinct skills and has specific advantages in treating bilateral hernias. Large-scale randomized controlled studies comparing SIL-TPP with conventional single-port and three-port laparoscopic TEP for bilateral inguinal hernia are needed to confirm these results.

Robot-Assisted Extraperitoneal Ventral Hernia Repair-Experience From the First 160 Consecutive Operations With Lateral eTEP and eTAR Techniques

Introduction

There is a growing consensus on the benefits of retro-muscular (RM) mesh positioning, highlighted by its recommendation in the latest edition of EHS guidelines. The eTEP method has facilitated minimally invasive hernia repairs with retro-muscular mesh placement. With the increasing availability of robotic systems, there has been a corresponding increase in robotic adaptations of minimally invasive techniques involving retro-muscular mesh placement.

Materials and Methods

All patients who underwent robotic ventral hernia repair using the lateral extraperitoneal eTEP technique at Kempten Hospital between September 2019 and December 2023 were includes in the study. Preoperative characteristics, perioperative parameters, postoperative parameters, and hernia-specific parameters, were retrospectively analyzed using the hospital information system.

Results

160 patients were operated using a lateral approach eTEP technique during the observation period, 111 (69.38%) for incisional hernia repair and 49 (30.63%) for primary hernia repair. 43 cases required TAR (30 unilateral TAR and 13 bilateral TAR). 139 patients had a medial (86.98%), seven patients (4.14%) a lateral and 14 patients (8.88%) a combined hernia defect. The median operative time was 143 min (range: 53 min-495 min). The median length of hospital stay was 3 days (range: 2-16). There was one intraoperative complication. The postoperative complication rate was 6.25% (10 patients), with 1.72% (2 patients) requiring reoperation. Sonographic follow-up examinations revealed seromas in 5 patients, with 4 located in the retromuscular mesh space and 1 in the former hernia sac. None of these seromas required surgical intervention.

Conclusion

The "lateral approach" of robotic eTEP provides a safe surgical method for treating ventral hernias using minimally invasive techniques and mesh augmentation in the retro-muscular space. Further studies are necessary to compare extraperitoneal with transperitoneal methods.

"Fully endoscopic preperitoneal ascending suprapubic approach for minimally invasive repair of anterior and lateral abdominal wall hernias"

PURPOSE

The aim of this work is to describe the rational, feasibility and clinical and Quality-of-life improvement results of a fully endoscopic preperitoneal repair for midline and lateral abdominal wall hernias, starting from the space of Retzius in a "bottom-to-up" approach.

METHODS

An observational prospective data-collected and quality of life study is performed in selected patients with less than 10 cm. in diameter midline and lateral abdominal wall hernias. A suprapubic upward e-TEP technique from a previously dissected Retzius space, is performed in all cases. The surgical goal is to perform a total free-tension abdominal wall reconstruction followed by a prosthetic hernioplasty. Clinical Data is classified in preoperative, intraoperative, and postoperative variables, including a quality-of-life clinical evaluation based on an improvement of HerQLes score.

RESULTS

A total of 30 patients underwent this approach from September 2017 to October 2022 in a single-surgeon practice. A total restoration of the previous abdominal wall anatomy and a prosthetic repair were achieved in all cases. The mean operative time was 142.53 min, with a significant shorter time in lateral hernias approach. Minor complications (Clavien-Dindo I) were collected in 10% of the patients. Major complications (Clavien-Dindo IIIb) occurred in 6.66% of the patients. The mean pain at discharge was 1.83 VAS, with a significant lower pain in M-eTEP approach for lateral hernias. The mean hospital stay was 42.4 h. No seroma, hematoma, chronic pain, or recurrence was observed in the mean follow-up (20.33 months). A clinical and quality of life improvement was found in 92.9% of the patients, measured by a minimal clinical important difference (MCID) between preoperative and postoperative HerQLes score.

CONCLUSION

Despite being a technically demanding approach, the results obtained by this approach are compatible in safety and feasibility with other minimally invasive preperitoneal hernia repair techniques, in addition to obtaining a significant improvement in the quality of life of patients.

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.

Ventral ETEP Versus REPA, Comparison of Two Novel Minimally Invasive Techniques for Midline Defects

Introduction: This report aimed to compare ventral extended vision extraperitoneal (ETEP) and preaponeurotic repair (REPA) techniques in terms of surgical procedure, outcomes, and patient evolution. Methods: This was a retrospective study performed at a tertiary care academic center between 2017 and 2022. All consecutive patients operated on for midline hernias and rectus diastasis using REPA and ETEP were included. Follow-up visits were at 15 days, 30 days, and 6 months postoperative. Age, sex, BMI, American Surgical Anesthesiologic Classification (ASA), surgical time, need for conversion to open surgery, time of stay, seroma, hematoma, surgical site infection (SSI), recurrence, and re-interventions were assessed. Results: For the present study, 148 patients were included. From them, 62 patients received the REPA procedure and 86 were operated on using the ETEP technique. REPA average time was 105 minutes (interquartile range [IR] 80-130), and ETEP average time was 120 minutes (RIC 95-285) (p = 0.03). Ambulatory procedures were 32.3% (n = 20) REPA and 20.9% (n = 18) ETEP (p = 0.23). In REPA, the mean time for drain extraction was 11.92 days and 8 days in ETEP (p < 0.001). Seroma incidence was identified in 40.3% (n = 25) of the REPA cases and 5.8% (n = 5) of the ETEP procedures (p = 0.001). In a multivariate analysis for seroma incidence REPA technique was associated with a significant risk of its incidence [odds ratio (OR) 16, 67 95% confidence interval ((CI95) 4.67-59.52), p < 0.001]. Conclusion: REPA and ETEP are safe and reproducible. Both approaches reported short hospitalization times and almost no major complications. We found a longer surgical time in ETEP and a higher incidence of seroma in REPA.

Implementation of the Versius Surgical System in Complex Abdominal Wall Repair: First Reported Case of an Robotic ETEP/TAR Procedure

BACKGROUND

Robotic ventral hernia repair has been increasing globally, with comparable outcomes to laparoscopic repair and lower rates of conversion to open surgery. Robotic surgery is increasing in popularity, and there is a number of new robotic systems entering the marketing. We report the first case of a Roboic eTEP using the Versius robotic system in a patient with an incisional hernia.

METHODS

Surgery was performed using the Versius system from CMR surgical which consists of bedside units for each instrument and a console. The patient presented with an incisional hernia measuring 9.5×5 cm in the left flank.

RESULTS

The patient was discharged on postoperative day (POD) 2 with a drain. There was no need for opioids. The drain was removed at POD 7. The patient presented at POD 10 with erythema and cellulitis in the area that previously had tape on it, and it was resolved with a short course of oral antibiotics.

CONCLUSION

The eTEP technique for hernia surgery was safe and feasible using the Versius robotic system. Implementation is possible in experienced hands with minimal changes to the surgical techniques.

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.

Switching from robotic-assisted extended transabdominal preperitoneal (eTAPP) to totally extraperitoneal (eTEP) hernia repair for umbilical and epigastric hernias

Our study aimed to assess the safety and effectiveness of the robotic-assisted extended totally extraperitoneal (eTEP) repair compared to transabdominal preperitoneal (eTAPP) repair with a suprapubic trocar insertion to treat umbilical and epigastric hernias. On a prospectively maintained database, we identified patients who underwent either eTEP or eTAPP for treating umbilical and epigastric hernias. During the study period, 53 patients were included, 32 in the eTEP group and 21 in the eTAPP group. The mean age was 59.0 ± 13.9 years, 45 patients (84.9%) were male, and the mean BMI was 28.0 ± 5.9 kg/m2. Most hernias were umbilical (81.1%) and primary (83.0%). The operative time for eTEP was slightly shorter than for eTAPP (106 ± 43 min vs. 126 ± 74 min, p = 0.232). Postoperatively, only one case of bleeding and one seroma were recorded. No complication occurred during a mean follow-up of 11.3 ± 6.4 months in the eTEP group and 20.5 ± 9.7 months in the eTAPP group. In conclusion, our study showed that the eTEP with suprapubic approach was safe and feasible in the treatment of epigastric and umbilical hernias. According to our experience, shorter operative time, integrity of the posterior layers and increased overlap size are the main surgical reasons of switching from eTAPP to eTEP.

Quality of life, post-operative complications, and hernia recurrence following enhanced-view Totally Extra-Peritoneal (eTEP) Rives-Stoppa for incisional and primary ventral hernia repair

The purpose of this study was to evaluate the quality of life (QoL), early post-operative complications, and hernia recurrence rate following laparoscopic enhanced-view Totally Extra-Peritoneal (eTEP) Rives-Stoppa (RS) for incisional and primary ventral hernia repair. Retrospective review of a prospectively maintained database of all patients undergoing eTEP-RS between 2017 and 2020. Data retrieved included demographics, and clinical and operative variables. QoL was assessed using the EuraHS-QoL scale prior to- and following eTEP-RS. During the study period, 61 patients met the inclusion criteria. Age and BMI were 62 (60.4 ± 13.8) years and 29.7 (30.4 ± 6) kg/m2, respectively. Incisional hernia was the most common pathology (n = 40, 65%) followed by primary ventral hernia (n = 21, 35%), with 24 patients (39%) having a previous hernia repair. Diastasis-recti repair was undertaken in 34 patients (55%), a concomitant inguinal hernia was repaired in 6 patients (10%), and 13 patients (21%) underwent transversus abdominis release (TAR). Median follow-up time was 13 months and 15 patients (25%) had at least 2 years of follow-up. Hernia recurrence was found in 4 patients (6.5%). Pre-operative and post-operative EuraHS-QOL questionnaire scores were available for 46 patients (75%) and showed significant improvement in pain (7 vs. 0.5, p < 0.0001; 5 vs. 0.5, p < 0.0001; 5 vs. 1.5; p < 0.006), restrictions (median of 5 vs. 0.5, p < 0.0001; 5 vs. 0, p < 0.0001; median of 5 vs. 1, p < 0.0001, of 6.5 vs. 1.5, p < 0.0001), and cosmetic appearance (8 vs. 4, p < 0.0001). Abdominal wall repair using the eTEP-RS approach significantly improves subjective QoL variables with an acceptable post-operative complications and hernia recurrence rates in a short-term follow-up.

Efficacy of extended view totally extra peritoneal approach versus laparoscopic intraperitoneal on lay mesh plus for abdominal wall hernias: a single center preliminary retrospective study

BACKGROUND

Laparoscopic minimally invasive surgery has become the primary treatment for ventral hernias. The laparoscopic intraperitoneal on lay mesh (IPOM) plus approach for abdominal wall hernias is the most used procedure, while extended view totally extraperitoneal (e‑TEP) repair is a newer option. This study aimed to compare the effectiveness and complications of the 2 procedures for abdominal wall hernias repair.

METHODS

This was a retrospective and comparative single-center study done at The Second Clinical Medical College, Jinan University Hospital (Shenzhen People's Hospital), Shenzhen, China. The study included patients with a 2 to 6 cm abdominal wall defect who underwent hernia repair from January 2022 to December 2022. Patients' baseline characteristics, hernia features, operative time, blood loss, postoperative pain level, and total hospitalization expenses were extracted from the medical records and compared between patients who underwent the IPOM plus and e-TEP repair.

RESULTS

A total of 53 patients were included: 22 in the e-TEP group and 31 in IPOM plus group. Patient demographic characteristics were similar between the 2 groups. The operation time of the e-TEP groups was significantly longer than the IPOM plus (98.5 ± 10.7 min vs. 65.9 ± 7.3 min, P < 0.01). Postoperative pain levels (VAS; visual analog scale) (4.2 ± 0.9 vs. 6.7 ± 0.9, P < 0.01), analgesic requirements (Tramadol) (25.0 ± 37.0 mg vs. 72.6 ± 40.5 mg, P < 0.01), length of hospital stay (1.2 ± 0.5days vs. 2.2 ± 0.6days, P < 0.01), and total hospitalization expenses (19695.9 ± 1221.7CNY vs. 35286.2 ± 1196.6CNY, P < 0.01) were significantly lower in the e-TEP group. The mean intraoperative blood loss was similar between the 2 groups. No postoperative complications were observed in either group.

CONCLUSION

The e-TEP approach for abdominal wall hernias appears to be better than IPOM plus with respect to postoperative pain levels(VAS: 4.2 ± 0.9 vs. 6.7 ± 0.9, P < 0.01), analgesic requirements(25.0 ± 37.0 mg vs. 72.6 ± 40.5 mg, P < 0.01), length of hospital stay(1.2 ± 0.5days vs. 2.2 ± 0.6days, P < 0.01), and hospitalization costs (19695.9 ± 1221.7CNY vs. 35286.2 ± 1196.6CNY, P < 0.01).

An Observational Comparative Study of the Impact of Accidental Pneumoperitoneum in Understanding the Learning Curve for Totally Extraperitoneal and Extended Totally Extraperitoneal Inguinal Hernia Repair

BACKGROUND

Abdominal wall hernia repair is among the fundamental procedures in general surgical practice. Subsequent to the advent of minimally invasive repair, there have been efforts to find the most reliable technique, with easily reproducible results that can be practiced by surgeons worldwide. From an analytical point of view, this study aimed to highlight the advantages and disadvantages of two techniques.

MATERIALS AND METHODS

A total of 60 participants were divided into two groups of 30 patients: the totally extraperitoneal (TEP) and the extended TEP (eTEP) hernia repair groups. Covariates and outcomes were analyzed using the chi-square and Mann-Whitney U tests. The study was carried out at a tertiary postgraduate teaching hospital in the western zone of Maharashtra, Pune, India, by a single surgeon. The operative procedures were as per standard surgical practice for both groups. The study was conducted to understand types of difficulties observed in the early implantation stages and the learning curve of these procedures.

RESULTS

Ten percent of the procedures in the TEP group and 6.7% of procedures in the eTEP group required Veress needle use to manage accidental pneumoperitoneum (P=0.64). The mean operative time in the eTEP group was significantly shorter than that of the TEP group (P=0.031).

CONCLUSION

Compared with the TEP approach, eTEP repair is associated with shorter operative times, owing to a shorter learning curve, a wider-angle view, a wider range of motion for instrument manipulation, and an ergonomically superior operative experience.

Comparison of outcomes of the extended-view totally extraperitoneal rives-stoppa (eTEP-RS) and the intraperitoneal onlay mesh with defect closure (IPOM-plus) for W1-W2 midline incisional hernia repair-a single-center experience

BACKGROUND

The eTEP technique is a new approach that has recently gained popularity in abdominal wall hernia surgery. This study aimed to compare the outcomes of the eTEP-RS and IPOM-plus procedures in W1 and W2 midline incisional abdominal wall hernia (IAWH) repairs performed by the same surgeon.

METHODS

Prospectively collected data of laparoscopic abdominal wall repairs performed on 61 patients with eTEP between November 2018 and April 2022 and on 67 patients with IPOM-plus between January 2016 and April 2022 were retrospectively analyzed. A total of 74 out of 128 patients, 30 in the eTEP-RS group and 44 in the IPOM-plus group, who underwent W1-W2 midline incisional hernia repair were included in the study. The mean follow-up was 24 months in the eTEP-RS group and 45 months in the IPOM-plus group.

RESULTS

There was no statistically significant difference between the groups regarding age, sex, BMI, ASA score, or active smoking. No difference was seen between the two groups in terms of the mean defect area (MDA, 28.17 cm² vs. 27.41 cm², p = 0.84), but the mean mesh area (MMA) and mesh/defect (M/D) ratio were higher in the eTEP-RS group (404.11 cm² vs. 267.85 cm², p < 0.001 and 20.96 vs. 12.36, p = 0.004). In the eTEP-RS group, the hospital length of stay (LOS) (1.48 days vs. 2.58 days, p < 0.001) and pain on the first and 10th postoperative days were significantly lower (p < 0.001), while the operative time was significantly longer (204.07 min vs. 88.33 min, p < 0.001). There was no significant difference in terms of intraoperative complications (p = 0.56), seroma formation (p = 0.83), or recurrence (p = 0.83).

CONCLUSION

The eTEP-RS technique has advantages over the IPOM-plus approach, such as a shorter LOS and less early postoperative pain with W1-W2 midline IAWH repair. However, the eTEP technique has a longer operative time.

Learning Curve of Robotic Enhanced-View Extraperitoneal Approach for Ventral Hernia Repairs

Introduction: The enhanced-view extraperitoneal (eTEP) technique was first described for minimally invasive inguinal hernia repairs and later for laparoscopic ventral hernia repair. The objective of this study was to report our early experience and learning curve (LC) with the robotic-assisted eTEP (R-eTEP) approach. Materials and Methods: We performed a retrospective analysis of patients undergoing R-eTEP repair for ventral hernias from December 2018 to September 2021. A single surgeon operative time (OT)-based LC was evaluated. Results: A total of 81 patients underwent an R-eTEP from December 2018 to September 2021. Sixty-five patients were ultimately included in our analysis. Fifty-seven patients underwent eTEP-Rives-Stoppa (RS) and 8 patients underwent eTEP-transversus abdominis release (TAR). The median age in the whole cohort was 57 years (interquartile range [IQR] 51.5-64.5 years) with no difference between the groups. The median body mass index (BMI) was 31 kg/m² (IQR 27-34.7 kg/m²) in the eTEP-RS group and 29.7 kg/m² (IQR 28.5-31 kg/m²) in the eTEP-TAR group. There were 36 incisional hernias (63%) in the eTEP-RS group and 8 (100%) in the eTEP-TAR group. There were 14 recurrent hernias (25%) in the eTEP-RS group and 2 (25%) in the eTEP-TAR group. The LC was evaluated only in the eTEP-RS cases. We divided the cohort into 3 chronological groups (G1, G2, and G3), including 19 cases each. The median OT in each group was 177 (IQR 147-200), 153 (IQR 127-187), and 125 minutes (IQR 106-152 minutes), respectively. There was no difference in the median OT between G1 and G2 (P = .390). G3 had a shorter median OT than G2 (P = .02) and G1 (P = .001). There was no difference between these groups in median age, BMI, defect area, defect width, and mesh area. Conclusions: The R-eTEP approach has been shown to be safe and feasible for ventral and incisional hernia repairs. A statistically significant decrease in OT was observed after 38 cases.

Pitfalls and complications of enhanced-view totally extraperitoneal approach to abdominal wall reconstruction

BACKGROUND

The enhanced-view totally extraperitoneal access technique (eTEP) to minimally invasive retromuscular abdominal wall reconstruction is a relatively novel technique that has continued to gain popularity. There is a paucity of information regarding the prevention and management of eTEP complications. We reviewed the literature to evaluate the complications reported with eTEP ventral hernia repair and discuss the main complications associated with this technique.

METHODS

A literature search via PubMed was performed focusing on eTEP ventral hernia repair. Based on the available literature and own practice experience, the authors discuss key strategies for preventing and managing complications associated with the eTEP approach.

RESULTS

One hundred fifty studies were identified. Forty-seven studies were fully reviewed and twenty-four were included in this review. The technical details of the technique were described as performed by the authors. Postoperative complications were classified into different categories and discussed separately.

CONCLUSION

As the eTEP approach continues to gain popularity, it is essential to consider its unique complications. A focus on prevention with anatomical bearings and sound surgical technique is paramount.

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.

Short-term outcomes of minimally invasive retromuscular ventral hernia repair using an enhanced view totally extraperitoneal (eTEP) approach: systematic review and meta-analysis

Background

The enhanced view totally extraperitoneal (eTEP) approach is becoming increasingly more widely accepted as a promising technique in the treatment of ventral hernia. However, evidence is still lacking regarding the perioperative, postoperative and long-term outcomes of this technique. The aim of this meta-analysis is to summarize the current available evidence regarding the perioperative and short-term outcomes of ventral hernia repair using eTEP.

Study design

A systematic search was performed of PubMed, EMBASE, Cochrane Library and Web of Science electronic databases to identify studies on the laparoscopic or robotic-enhanced view totally extraperitoneal (eTEP) approach for the treatment of ventral hernia. A pooled meta-analysis was performed. The primary end point was focused on short-term outcomes regarding perioperative characteristics and postoperative parameters.

Results

A total of 13 studies were identified involving 918 patients. Minimally invasive eTEP resulted in a rate of surgical site infection of 0% [95% CI 0.0–1.0%], a rate of seroma of 5% [95% CI 2.0–8.0%] and a rate of major complications (Clavien–Dindo III–IV) of 1% [95% CI 0.0–3.0%]. The rate of intraoperative complications was 2% [95% CI 0.0–4.0%] with a conversion rate of 1.0% [95% CI 0.0–3.0%]. Mean hospital length of stay was 1.77 days [95% CI 1.21–2.24]. After a median follow-up of 6.6 months (1–24), the rate of recurrence was 1% [95% CI 0.0–1.0%].

Conclusion

Minimally invasive eTEP is a safe and effective approach for ventral hernia repair, with low reported intraoperative complications and good outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10029-021-02557-8.

A Detailed History of Retromuscular Repairs for Ventral Hernias: A Story of Surgical Innovation

BACKGROUND

We performed a historical review of events concerning retromuscular hernia repairs over the last two centuries. This may shed light on surgical innovators and their novel techniques that have evolved into current practices.

METHODS

Literature reviews of notable surgeons in the subspecialty were reviewed. Historical context was obtained by personal communication with contemporary surgeons who witnessed changes in established techniques firsthand.

RESULTS

Even though retromuscular repairs are the central theme of this exercise, it is important to note several adjacent events which steered surgical progress. The status of hernia surgery today is the result of the work of several pioneers separated by time and distance.

CONCLUSIONS

It may be important to understand the circumstances that have propelled past surgical breakthroughs to stimulate future progress.

Extended totally extraperitoneal Rives-Stoppa (eTEP-RS) technique for ventral hernia: initial experience of The Wall Hernia Group and a surgical technique update

The enhanced-view extended totally extraperitoneal (eTEP) approach for ventral hernia repair is a novel surgical technique. We present the results from the initial experience with eTEP repair Rives-Stoppa (eTEP-RS) at two Italian centers, and we provide an update on this approach. Between December 2018 and July 2020, 19 patients suffering from ventral hernia were treated with the eTEP-RS. Patients' characteristics, operative details, and complications were analyzed. The median follow-up time was 16 (range 6-24) months. Thirteen (68.4%) patients with ventral incisional hernias and 6 (31.6%) with primary ventral hernia underwent an eTEP-RS procedure. The average defect area was 21 cm² and the prosthesis's average size was 380 cm². We registered complications in two cases (10.5%); 1 patient had an asymptomatic seroma (Clavien-Dindo grade 1), and another had intestinal obstruction on the 10th postoperative day (Clavien-Dindo grade 3B). The mean hospital stay was 3.9 (range: 2-6) days. There was no hernia recurrence. The eTEP-RS is a feasible and safe approach in ventral hernia repair with minimally invasive surgery. Further studies are needed to define patients' selection and to know long-term outcomes.

e-TEP repair for midline primary and incisional hernia: technical considerations and initial experience

INTRODUCTION

The Enhanced-View Totally Extra Peritoneal Rives-Stoppa (e-TEP-RS) Technique for the repair of large, complex, ventral abdominal hernias has gained popularity especially in overcoming the disadvantages with Intra Peritoneal Onlay Mesh (IPOM) repairs and to enable siting of a large prosthetic mesh in an anatomical plane distinct from the abdominal cavity and its contents. Evolving variations of the original technique have allowed the definitive repair of such defects in a reproducible manner. We present our initial experience of this approach and detailed steps of our native technical modifications in overcoming the challenges in performing this complex and potentially challenging procedure.

MATERIALS AND METHODS

This is a retrospective review of the clinical data of midline, large, complex, ventral abdominal hernia patients who underwent e-TEP-RS with and without Transversus Abdominis Release (TAR). Patients, with or without Diastasis of Rectus Abdominis Muscle (DRAM) were included. Key outcomes measured were post-operative pain, operative morbidity, readmission, Quality of Life (QoL), hernia recurrence.

RESULTS

A total of 58 midline, ventral abdominal hernia patients who underwent e-TEP-RS with and without Transversus Abdominis Release (TAR), between March 2018 and December 2019 were studied. Mean defect area was 41.0 ± 28 cm² and the mean mesh surface area was 473.5 ± 165 cm². e-TEP-RS was done in 35 cases, e-TEP RS TAR in 15 cases and e-TEP-RS with e-TEP inguinal in 08 cases. There was no intraoperative morbidity. Mean duration of surgery was 156.2 ± 40 min and mean blood loss was 40.5 ± 26 cc. The CCS QoL scores improved from 34.6 (± 2) pre-operatively to 27.2 (± 4) at the end of 6 months. One patient had a supra-umbilical recurrence following bilateral TAR over the superior edge of the mesh. Follow-up ranged from 6 to 22 months, with a mean of 14 months. Major complications (n = 12; 20.7%) were seroma formation and prolonged ileus.

CONCLUSION

The e-TEP-RS technique for large, complex, midline, ventral abdominal hernias can be used with excellent results and acceptable morbidity. This technique is technically challenging and should be mastered in relatively smaller ventral hernias to achieve good results before attempting it in larger, complex ones.

Enhanced-view totally extraperitoneal (eTEP) approach for the treatment of abdominal wall hernias: mid-term results

INTRODUCTION

Multiple minimally invasive techniques have been described for ventral hernia repair. The recently described enhanced view totally extraperitoneal (eTEP) ventral hernia repair seems an appealing option since it allows to address midline and lateral hernias, placing the mesh in the retromuscular position without the use of traumatic fixation.

AIM

To report on the mid-term result of a series of patients with ventral hernias repaired by the eTEP approach.

METHODS

A retrospective analysis of our case series between June 2017 and December 2019. Demographic and clinical data were gathered. Hernia characteristics, surgical details, hernia recurrences, and complications are reported.

RESULTS

66 patients were included in the study. Median follow-up was 22 months (interquartile range 12-26). 60% of patients were male. Mean age, BMI, % of Type-2 diabetes and % of smoking were 59 ± 12 years, 30 kg/m², 24% and 23%, respectively. Mean hernia defect size was 5.5 ± 2.9 cm. Forty-three eTEP Rives-stoppa and 23 eTEP-Transversus abdominis release (14 unilateral, 9 bilateral) were performed. 22 inguinal hernias and 15 lateral defects were simultaneously repaired. We report 1 recurrence (1.5%) and 10 surgical site occurrences (15%; 6 seromas, 2 hematomas and 2 surgical site infections). Four patients required reinterventions (6%).

CONCLUSION

eTEP is a promising approach to treat midline hernias and allows the simultaneous treatment of lateral and inguinal defects, keeping the mesh in the retromuscular position. However, comparative studies must be performed to know its real benefit in laparoscopic ventral hernia repair.

A comparative prospective study of short-term outcomes of extended view totally extraperitoneal (e-TEP) repair versus laparoscopic intraperitoneal on lay mesh (IPOM) plus repair for ventral hernia

BACKGROUND

Currently, minimally invasive approach is preferred for the treatment of ventral hernias. After the introduction of extended view totally extraperitoneal (e-TEP) technique, there has been a constant debate over the choice of better approach. In this study, we compare the short-term outcomes of e-TEP and laparoscopic IPOM Plus repair for ventral hernias.

METHODS

This is a comparative, prospective single-center study done at GEM Hospital and research center Coimbatore, India from July 2018 to July 2019. All patients who underwent elective ventral hernia surgery with defect size of 2 to 6 cm were included. Patient demographics, hernia characteristics, operative and perioperative findings, and postoperative complications were systematically recorded and analyzed.

RESULTS

We evaluated 92 cases (n = 92), 46 in each group. Mean age, sex, BMI, location of hernia, primary and incisional hernia, and comorbidity were comparable in both the groups. Mean defect size for IPOM Plus and e-TEP was 4 cm and 3.89 cm, respectively. Operative time was significantly higher for e-TEP, while postoperative pain (VAS), analgesic requirement, and postoperative hospital stay were significantly less as compared to IPOM Plus. However, 2 cases (4.35%) of e-TEP had recurrence but none in IPOM Plus group.

CONCLUSION

e-TEP is an evolving procedure and comparable to IPOM Plus in terms of postoperative pain, analgesic requirement, cost of mesh, and length of hospital stay. More randomized controlled and multicentric studies are required with longer follow-up to validate our findings.