Anatomical Considerations and Tips for Laparoscopic and Robotic-Assisted Enhanced-View Totally Extraperitoneal Rives-Stoppa Repair for Midline Hernia

Comparison of Laparoscopic eTEP-RS/TAR and IPOM Techniques for Ventral Hernia Repair

Background

The laparoscopic intraperitoneal onlay mesh (IPOM) technique has been widely used for ventral hernia repair; however, concerns regarding mesh-related complications have led to the development of alternative approaches. The enhanced-view totally extraperitoneal (eTEP) technique has emerged as a promising alternative, offering improved anatomical restoration and reduced postoperative morbidity. This study compares the clinical outcomes of eTEP and IPOM for ventral hernia repair.

Methods

A retrospective cohort study was conducted at a tertiary referral centre in Thailand. Patients who underwent laparoscopic ventral hernia repair using either eTEP or IPOM between January 2016 and December 2021 were included. Demographic data, hernia characteristics, perioperative variables, and postoperative outcomes were analysed. Statistical comparisons were performed using parametric and non-parametric tests, with a significance threshold of p < 0.05.

Results

A total of 70 patients were included, with 32 undergoing eTEP and 38 undergoing IPOM. Both groups were comparable in baseline characteristics, with most cases classified as incisional hernias. The mean operative time was significantly longer in the eTEP group (360 vs. 240 min, p < 0.001). Subgroup analysis showed significantly lower postoperative pain scores at 12 and 24 h in the eTEP-RS and eTEP-TAR groups compared to the IPOM group (p < 0.001). The mean VAS scores at 12 h were 4 (eTEP-RS), 3 (eTEP-TAR), and 7.5 (IPOM), while at 24 h, they decreased to 2 (eTEP-RS), 2 (eTEP-TAR), and 4 (IPOM). Complication rates were comparable between groups; however, minor bowel injury was reported in some IPOM cases. The one-year recurrence rate was 3.1% for eTEP and 7.9% for IPOM (p = 0.620), increasing to 6.2% and 15.8% at 2 years, respectively (p = 0.275).

Conclusion

Laparoscopic eTEP is a safe and effective alternative to IPOM for medium to large ventral hernias, demonstrating lower postoperative pain and recurrence rates. However, its technical complexity and longer operative time highlight the importance of careful patient selection and surgical expertise. Further prospective studies with larger sample sizes are needed to validate these findings and optimise clinical outcomes.

The Enhanced-View Totally Extraperitoneal Repair for Ventral and Incisional Hernia: Midterm Results of an Evolving Technique

Introduction: In the field of abdominal wall hernias, several innovative procedures have been developed, including the extended/enhanced-view totally extraperitoneal (eTEP) hernia repair technique. Initially introduced for laparoscopic hernia repair by J. Daes, it was subsequently applied to ventral hernia repair (VHR) and incisional hernia repair (IVHR) by I. Belyansky et al. This article presents the midterm experience and outcomes of our center's experience with the endoscopic technique based on the principles of eTEP during IVHR and VHR. Method: A review was conducted of a prospectively collected database of abdominal wall hernia. Patients who underwent eTEP VHR or IVHR between October 2018 and February 2021 were identified. Results: A total of 51 patients underwent an eTEP-RS or eTEP-TAR procedure, with a 24-month follow-up period. Of the 51 patients included in the study, 43 underwent eTEP-RS treatment, while 8 required an additional transversus abdominis release (3 unilaterally). One patient developed a large hematoma necessitating reoperation and drainage via the eTEP approach. Seven patients developed seromas, which were treated conservatively, while 2 patients experienced surgical site infections, which were managed with a single-use negative pressure wound therapy system. Two patients exhibited recurrence at sites above the epigastric edge of the mesh. Conclusion: Moreover, the advancement of minimally invasive surgical techniques for abdominal wall reconstruction has rendered the eTEP approach a viable option for both primary and incisional VHR, with promising midterm outcomes.

Robotic trans-abdominal retromuscular hernia repair for medium-sized midline hernias: midterm outcomes and surgical site occurrence (SSO) analysis in 120 patients

Robotic surgery has become a popular method for treating ventral hernias due to its promising peri-operative outcomes. However, the long-term results of this approach are still unclear. In this study, 120 patients underwent robotic trans-abdominal retromuscular mesh placement (r-TARM) with a mean follow-up period of 18.1 months. This study aims to evaluate the feasibility of the robotic approach reporting peri-operative and midterm outcomes. Additionally, we examined possible risk factors that may contribute to the development of surgical site occurrences (SSOs). Between January 2021 and September 2023, 120 patients underwent r-TARM for midline hernias, including 39 primary, 71 incisional, and 10 recurrent cases. A retrospective analysis was performed. A logistic regression model was used to identify possible patient risk factors for SSO development. The average operative time was 153.5 ± 47.2 min, and there were no open or laparoscopic approach conversions. The mean length of hospital stay was 1.9 ± 0.9 days. We observed SSO in 16 patients (13.3%). One patient (0.8%) required angiographic embolization due to post-operative parietal bleeding. The mean follow-up time was 18.1 ± 7.8 months, and we observed hernia recurrence in only one (0.8%) patient. The logistic regression model did not identify any possible risk factors for SSO. r-TARM is a safe and effective method for treating ventral hernias not requiring posterior component separation. Our results indicate that patient and hernia characteristics were not predictive of SSO. Midterm outcomes are encouraging, though longer follow-up is needed.

Endoscopic enhanced-view totally extraperitoneal prosthetic (eTEP) versus open Rives-Stoppa repair as a treatment of midline abdominal wall hernias with rectus diastasis: comparison of postoperative pain and length of hospital stay in a single-centre surgical cohort

The Rives-Stoppa (RS) procedure is a gold standard treatment of midline abdominal wall hernias. Comparability of pain control and outcomes to the enhanced-view totally extraperitoneal prosthetic (eTEP) repair remain unclear. A single-centre retrospective surgical cohort was selected including 30 RS repairs (January 2019-November 2021) and 30 consecutive eTEP procedures (September 2021-August 2022) for midline abdominal wall hernia(s) with rectus abdominis diastasis. Postoperative pain and outcomes were compared up to 1 month. Presence and median duration of patient-controlled analgesia were, respectively, 90% and 3 nights with RS, versus 30% and 0 nights with eTEP. Median switch to only oral analgesics occurred at postoperative day (POD) 3 after RS and at POD 2 after eTEP. Postoperative analgesics and opioid prescription at discharge were comparable. Median length of hospital stay was six nights after RS versus 3 nights after eTEP. Median duration of surgery was 110.5 and 164.5 min for RS and eTEP, respectively. After RS, 30 patients had postoperative drain(s) compared to 3 patients after eTEP. Conversion was needed in 3 eTEP procedures. Postoperative complications were comparable. No early recurrences were observed. Minimal residual diastasis was seen at postoperative consultation in 11 patients after eTEP. Compared to RS, eTEP is a minimally invasive alternative treatment of midline abdominal wall hernias with rectus abdominis diastasis and is associated with a shorter length of hospital stay, less postoperative pain and a comparable risk of short-term complications. At 1 month after eTEP, minimal residual diastasis can be present. ClinicalTrials.gov: NCT05446675. Secondary identifying number: EC/EH/220608-SK. Date of Registration: June 24, 2022.

Robotic preperitoneal extended totally extraperitoneal (R-PeTEP) technique description for ventral hernia repair: preliminary results

PURPOSE

Transabdominal preperitoneal (TAPP) ventral hernia repair requires incising the peritoneum from within the abdominal cavity, developing a flap, and placing a reinforcing mesh after fascial closure from the preperitoneal space. We present a novel adaptation to this technique that allows placement of preperitoneal mesh without entering the abdominal cavity. The robotic totally extra- and preperitoneal (R-PeTEP) access for ventral hernia repair is best suited for small to moderate sized ventral hernias with concomitant diastasis recti.

METHODS

Our study is a retrospective review of all patients who underwent R-PeTEP from December 2022 to November 2023. A comprehensive description of the surgical technique is included. Patient demographics, hernia characteristics, as well as clinical outcomes are described.

RESULTS

A total of 25 patients underwent R-PeTEP for ventral hernia repair with diastasis recti plication. The median age was 55 years (IQR 43.5-63) and 92% (n = 23) were male. The median ASA score was 2 (IQR 1-2) and the median BMI was 30.4 (IQR 29.3-32.8) with 64% (n = 16) percent having a BMI ≥ 30. Median hernia width was 3 cm (IQR 3-4), with a median diastasis recti width of 4 cm (IQR 2.6-4) and length of 15 cm (IQR 11.8-16). The median operative time was 120 min (IQR 116-134). All repairs were reinforced with permanent mesh. Sixty-eight percent of the patients (n = 17) were discharged on the same day. With a median follow-up of 30 days (IQR 16-107), 8% (n = 2) seromas, 16% (n = 4) developed clinically insignificant hematomas, and one patient (4%) developed ileus that was managed conservatively.

CONCLUSION

This study establishes the feasibility and safety of R-PeTEP, which provides direct access to the preperitoneal space, avoiding disruption to the posterior rectus sheath, possibly reducing neurovascular bundle injuries, and omitting entry to the abdominal cavity. R-PeTEP facilitates wide flap creation for prosthetic overlap and allows for posterior plication of diastasis recti with little to no mesh fixation with overall excellent preliminary clinical outcomes.

Outcomes of Robotic Transabdominal Retromuscular Repair: 3-Year Follow-up

Background

Our study addresses the gap in ventral hernia repair literature, regarding the long-term effectiveness of robotic transabdominal retrorectus umbilical prosthetic repair (r-TARUP) for primary and incisional ventral hernias. This study aimed to report the 3-year recurrence rates and overall patient outcomes including quality of life.

Method

A retrospective review of prospective collected data analyzed 101 elective r-TARUP patients from August 2018 to January 2022. Data collected included demographics, hernia sizes, mesh types, postoperative outcomes and the European Hernia Society Quality of Life questionnaire (EuraHS-QoL) before and after surgery.

Results

The average age of the group of patients was 53, having a mean body mass index (BMI) of 32 kg/m, with 54% incisional and 46% primary hernias, with mean length and width of 4.4 cm and 6.1 cm, utilizing synthetic 58% and bioabsorbable 42% mesh types. The majority were classified as Centers of Disease Control and Prevention (CDC) class I wounds. Postoperative complications included seroma (2%), hematoma (3%), which required surgical intervention, with no significant correlation to mesh type. A strong positive correlation was found between Transversus Abdominis Release (TAR) and increased length of hospital stay (correlation coefficient: 0.731, p < 0.001). Preoperative quality of life assessments demonstrated statistically significant improvements when compared to postoperative assessments at 3 years, with a mean (±SD) of 61.61 ± 5.29 vs. 13.84 ± 2.6 (p < 0.001). Mean follow up of 34.4 months with no hernia recurrence at 1 year and 3 recurrence at the 2-3 years follow up (3.2%).

Conclusion

The r-TARUP technique has proven to be safe and effective for repairing primary and incisional ventral hernias, with a low recurrence rate during this follow up period with a noticeable improvement in quality of life (QoL).

eTEP Rives-Stoppa impact on abdominal contour: a retrospective observational and clinical quality improvement study using Ellipse 9 tool

BACKGROUND

The eTEP Rives-Stoppa (RS) procedure, increasingly used for ventral hernia repair, has raised concerns about postoperative upper abdominal bulging. This study aims to objectively evaluate changes in the abdominal contour after eTEP RS and explore potential causes using a novel analytical tool, the Ellipse 9.

METHODS

Thirty patients undergoing eTEP RS without posterior rectus sheath closure were assessed before and 3 months after surgery using CT scan images. Key measurements analyzed included the distance between linea semilunaris (X2), eccentricity over the Cord (c/a Cord), superior eccentricity (c/a Sup), Y2, and the superior perimeter of the abdomen. The Ellipse 9 tool, which provides graphical images and numerical representations, was utilized alongside patient-reported outcomes to assess perceived abdominal changes.

RESULTS

The study group exhibited a trend toward a flatter abdomen with reduced distance between linea semilunaris(X2). However, 17% of patients developed upper abdominal bulging (5). Significant differences in c/a Cord, c/a Sup, Y2, and the superior perimeter of the abdomen, confirmed with Bonferroni corrections, were noted between bulging (5 patients) and non-bulging groups (25 patients). There was a notable disparity between patient perceptions and objective outcomes.

CONCLUSION

The eTEP RS procedure improved abdominal contour in most patients from a selected cohort. The Ellipse 9 tool was valuable for the objective analysis of these changes. The cause of bulging post-eTEP RS is probably multifactorial. Notably, there was often a discrepancy between patient perceptions of bulging and objective clinical findings.

Minimally invasive approach to incisional hernia in elective and emergency surgery: a SICE (Italian Society of Endoscopic Surgery and new technologies) and ISHAWS (Italian Society of Hernia and Abdominal Wall Surgery) online survey

Minimally invasive abdominal wall surgery is growing worldwide, with a constant and fast improvement of surgical techniques and surgeons' confidence in treating both primary and incisional hernias (IH). The Italian Society of Endoscopic Surgery and new technologies (SICE) and the ISHAWS (Italian Society of Hernia and Abdominal Wall Surgery) worked together to investigate state of the art in IH treatment in elective and emergency settings in Italy. An online open survey was designed, and Italian surgeons interested in abdominal wall surgery were invited to fill out a 20-point questionnaire on IH surgical procedures performed in their departments. Surgeons were asked to express their points of view on specific questions about technical and clinical variables in IH treatment. Preferred approach in elective IH surgery was minimally invasive (59.7%). Open surgery was the preferred approach in 40.3% of the responses. In emergency settings, open surgery was the preferred approach (65.4%); however, 34.5% of the involved surgeons declare to prefer the laparoscopic/endoscopic approach. Most respondents opted for conversion to open surgery in case of relevant surgical field contamination, with a non-mesh repair of abdominal wall defects. Among those that used the laparoscopic approach in the emergent setting, the majority (74%) used the size of the defect of 5 cm as a decisional cut-off. The spread of minimally invasive approaches to IH repair in emergency surgery in Italy is gaining relevance. Code-sharing through scientific societies can improve clinical practice in different departments and promote a tailored approach to IH surgery.

Enhanced-view totally extraperitoneal access for repair of ventral hernias: Advantages and liabilities

The concept of enhanced-view totally extraperitoneal (eTEP) access was developed while exploring ways to facilitate the TEP approach for inguinal hernia repair. Surgeons soon noticed that the surgical space was ideal for repair of other abdominal hernias. The "crossover" maneuver, designed as a technique to cross from one retrorectus space to the other, permitted application of eTEP access to most hernias. eTEP access has the general advantage of working in the extraperitoneal space and the specific advantage of hernia repair allowing implementation of the modern principles of ventral hernia reconstruction and providing flexibility to address different types of hernias in different locations. The technique requires formal training and has inherent complications and limitations. The remarkable widespread acceptance and encouraging early results of this complex technique emphasize the responsibilities of proper training, judicious use, and evaluation of our own and others' results.

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.

eTEP-RS for incisional hernias in a non-robotic center. Is laparoscopy enough to perform a durable MIS repair of the abdominal wall defect?

INTRODUCTION

Incisional hernias can complicate up to 25% of laparotomies, and successful repair remains a significant clinical challenge for surgeons. Recently, the surgical technique of ventral hernia repair (eTEP-RS) has been introduced. The method was presented relatively recently and continues to evolve. The use of a robotic platform in eTEP-RS resulted in a significant improvement in ergonomics. Therefore, the questions arise as to whether the laparoscopic technique might still be feasible for such long procedures. The objective of this study is to present our early results in the treatment of patients with incisional ventral hernias using eTEP-RS and to discuss key technical aspects.

PATIENTS AND METHODS

A prospective case-controlled study was conducted for all incisional ventral hernia patients (hernia orifice between 4 and 10 cm) who underwent eTEP-RS between March 2019 and December 2021. Demographic data were recorded; and perioperative and postoperative results were analyzed.

RESULTS

We performed 34 eTEP-RS procedures. The mean duration of the surgery was 211 min (145-295). The mean width of the defect was 6.8 cm and the defect area was 42.5 cm². The mean mesh size was 498 cm² (270-625). After an average follow-up of 16 months (2-30), there was no recurrence or major complication.

CONCLUSIONS

The eTEP-RS is a safe alternative to open ventral hernia repair in selected cases and allows for the placement of a large piece of mesh in accordance with current recommendations, even in non-robotic centers. Excellent knowledge of the detailed anatomy of the abdominal wall is essential for safe and effective hernia repair. Compliance with certain rules of the laparoscopic eTEP-RS facilitates improved ergonomics for this procedure even in non-robotic centers.

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.

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.

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.