Aims Ventral hernias are a frequent pathology in general surgery.Its association with rectus abdominis diastasis and groin hernias is not uncommon. Currently, the minimally invasive approach of these pathologies is becoming more frequent.The retromuscular-preperitoneal approach is a good technique because of more anatomical position of the mesh, <complications and recurrences.We present the usefulness of the e-TEP approach to treat different types of hernias (ventral and groin hernias)&rectus abdominis diastasis in the same surgical procedure. Methods Video-case. Results 58-year-old man.Physical examination: umbilical hernia(4cm), rectus diastasis(4cm) and left groin-hernia.We decided to perform a laparoscopic-extraperitoneal technique(eTEP). We use 4ports(2×12mm,2×5mm).The surgery begins dissecting the left retromuscular space using a dissector-balloon.We perform the supraumbilical cross-over transecting the left posterior sheath and then the right posterior sheath and complete the dissection of the other retromuscular space. The dissection continues reducing the hernial content and after that dissecting down to the pubis, then dissecting the left groin space.After that we continue closing the anterior sheath using Stratafix (barbed suture) & posterior sheath using 2-0 V-lock suture.We placed a 3D-PVDF-mesh for left groin hernia and another 18×35cm PVDF-mesh fixed with fibrin and without drainage. The patient presented a satisfactory evolution without complications and was discharged in 1°POD. Conclusions The minimally invasive eTEP-approach is an effective and good option in cases of ventral hernias associate with inguinal hernias and rectus abdominis diastasis,without increasing the incidence of postoperative complications and with better postoperative recovery,less postoperative pain,shorter LOS,lower rates of recurrence,faster return to routine activities and working life,and lower healthcare costs.
Objective The possibility of new approaches allows dissecting wide retroperitoneal spaces with minimal tissue damage, make the laparoscopic approach a developing technique. Our purpose is to show how the extended-view totally extraperitoneal (eTEP) approach can be used for giant hernia repair in obese patients. Material and Methods 34-year-old man, with a history of laparotomy due to traumatic perforation of the colon and BMI: 39.18, presented hernia M2–5W3. Preoperative botox is performed 1 month before. Results laparoscopic approach was performed: dissector balloon in the left hypochondrium, 5mm trocars in the right hypochondrium and flank. And 10mm trocar on the right flank. Dissection of the left retrorectal space. Crossover in upper third. Dissection of the right retrorectal space. Hernial sac opening during dissection. Section of the right transverse muscle is completed and that space is released. Plication of the anterior fascia and hernial sac. Closure of the posterior fascia. Measurement and placement of 37×25 cm CICAT mesh fixed with tissucol. Conclusion Minimally invasive surgery allows more and more extensive surgeries to be performed, with less aggression to patients and faster recovery. With the technical improvements and the combinations of different tools, we're capable of performing laparoscopic repair of giant hernias. In our case, the preoperative application of botox, eTEP technique, and the combination of one-sided TAR allowed safe and uncomplicated repair of an M2-5W3 hernia defect. eTEP is a safe and reproducible technique that can be used in association with hemi TAR or bilateral TAR for the solution of giant hernias.
Aims Lumbar hernias are very rare defects of the posterior abdominal wall.They can be classified as Grynfelt in the upper lumbar space(it is the most frequent) and Petit in the lower lumbar triangle. Its treatment can be performed by open approach, or by laparoscopic approach(TAPP or TEP), observing a lower incidence of recurrences and postoperative pain by laparoscopy. Methods Video-case. Results 78-year-old female who attended the clinic presenting a lump that had been increasing in size and was causing pain in the left upper lumbar region. Surgical histories: open lumbar hernioplasty(2018). Physical examination: recurrent left-lumbar hernia(Grynfelt).CT-scan: left-lumbar hernia(defect:45mm) with colon into the hernial sac and a large paraesophageal hiatal hernia. Since the hiatal hernia also needs to be treated, we decided to perform a laparoscopic TAPP-approach to treat the lumbar hernia.The patient was placed in the right lateral decubitus. We use 3 ports(1×12mm,2×5mm) to perform the surgery and place a 10×15cm PVDF mesh fixed with Tisseel and closed the peritoneum with V-Lock 3-0.The patient presented a satisfactory evolution without complications and was discharged in 1°POD. No recurrence. Conclusion Lumbar hernias are a disease with a very low incidence, so there is no clear consensus on the best surgical treatment.Our group think the laparoscopic approach in this type of hernia, whether through the transabdominal(TAPP) or extraperitoneal(TEP) approach, is the most appropriate, since it offers the advantages of minimally invasive surgery(less postoperative pain, shorter LOS) and <postoperative complications related to the surgical site and a lower incidence of hernia recurrence have been reported.
Aim Ventral hernias are a pathology with a high incidence within general surgery.Repair techniques have been evolving, and the minimally invasive approach to this type of pathology is currently on the rise due to the advantages of the MIS. Material & Methods We analyzed our database of patients with ventral hernias undergoing laparoscopic-eTEP approach,August-2021 to December-2022. We present our short-term outcomes. Results A total of 31 patients(men:54.8%,age:64(RIQ:43–73years)). LOS:1.48±0.62days. Pathological history:diabetes mellitus(19.4%),arterial hypertension(45.2%),dyslipidemia(51.6%), smoking(25.8%), alcohol consumption(13.3%), cardiovascular disease(12.9%). ASA Classification:I(32.3%), II(45.2%), III(22.6%). BMI:30.6±4.68kg/m2. Overweight:11(35.5%) and obesity:17(54.8%). Primary hernias:4(26.7%) and incisional hernias:19(61.3%).Location:midline(100%), supraumbilical:58.1%,umbilical:87.1% and infraumbilical:25.8%.Hernia width (EHS classification): W1:12.9%, W2:80.6% and W3:6.5%, transverse hernia diameter: 5.5±2.1cm, hernia length size:6.1±4.4cm. Associated with diastasis:24(77.4%),diastasis width:4.9±1.7cm. Associated with inguinal hernia:6(19.4%). Type of laparoscopic surgical technique performed:Rives-Stoppa: 24(77.4%), unilateral TAR:5(16.1%), bilateral TAR:2(6.5%).Number of trocars used by procedure:4(RIQ:4–5). Preoperative botulinum toxin:7(22.6%). Posterior sheath closure:23(74.2%). Mesh fixation type:Glutack 5(16.1%), Tisseel 19(61.3%), no fixation 7(22.6%). Mesh type used: Low density wide-pore polypropylene 11(35.5%),PVDF-Mesh 18(58.1%), PVDF-IPOM mesh 2(6.5%). Mesh size: width 18(RIQ:16–22cm) and length 28(RIQ:25–30cm). Drainage: 3(9.7%). Surgical time:200(RIQ:180–300min). Global and serious complications (CD≥III): 4(12.9%) and 1(3.2%), Re-IQ due to incarcerated hernia due to posterior sheath dehiscence: 1 (3.2%). No intraoperative complications. Clinical seroma:3(9.7%).No cases of hematoma or surgical wound infection.No recurrence. Conclusions The laparoscopic eTEP approach of ventral hernias has a low rate of global complications,despite being our first cases performed. It also has low rates of postoperative pain and shorter LOS.We can conclude that in our Hospital the laparoscopic eTEP approach is a safe, efficient and effective technique.
Aims Ventral hernias are a frequent pathology in general surgery.Its association with rectus abdominis diastasis and groin hernias is not uncommon.Currently, the minimally invasive approach of these pathologies is becoming more frequent.We present the usefulness of the e-TEP-approach to treat different types of hernias and diastasis at the same surgical-procedure. Methods Video-case presentation. Results 73-year-old-man,surgical-histories:umbilical-hernioplasty with onlay-mesh and lap-sigmoidectomy. Physical-examination:midline ventral-hernia(M2–3W2:8cm),diastasis(6cm) and right groin hernia. CT-scan: midline ventral-hernia with small-bowel into the hernial-sac and small defect(15mm) in the right flank(L2).We decided to perform a laparoscopic-extraperitoneal-technique(eTEP). We use 4 ports(2×12mm, 2×5mm).The surgery begins dissecting the left and right retromuscular space using a dissector balloon.We continue with the supraumbilical cross-over transecting the left posterior-sheath and then the right posterior-sheath and complete the dissection of the other retromuscular space.The dissection continues down to the pubis, dissecting the right groin space.We continue with the right-TAR,at this area we observe the lateral defect and continue the dissection on the preperitoneal-space.After that we continue with the closure of the posterior-sheath using 2–0 V-lock and the anterior-sheath using Monomax-loop-1.We placed a 3D-PVDF-mesh for right groin-hernia and 30×40cm-PVDF-mesh fixed with glue and left a drainage.The patient had a satisfactory evolution and was discharged in 2°POD. Conclusions The enhanced view totally-extraperitoneal approach (eTEP) is an effective and safe option in cases of ventral hernias associate with groin hernias and rectus abdominis diastasis,as in the case presented.Posterior component separation-techniques(TAR) allow us to achieve a correct and tension-free closure of the abdominal wall and place a wide mesh covering all hernial-defects.
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