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

Abstract

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.

Employing a Xiphoid-umbilicus Approach in an Endoscopic Totally Extraperitoneal Procedure for the Preperitoneal Repair of Midline Ventral Hernias

“…After access, the preliminary working space was obtained by blunt dissection with an index finger or the camera, which is familiar to surgeons with TES experience. Second, with a suprapubic approach, the preperitoneal space posterior to the posterior sheath and the retromuscular space anterior to the sheath was distinguished, [3][4][5]8 whereas the preperitoneal space was accessed directly after cutting the linea alba open in a xiphoid-umbilicus approach. Third, interference from the legs in a operation with suprapubic approach 4,8 was avoided when using the xiphoid-umbilicus approach.…”

“…M ore articles on endoscopic sublay repair (ESR) of ventral hernias have been published recently because ESR overcomes the disadvantages of open sublay repair, which has more surgical site events and avoids the risk of laparoscopic intraperitoneal onlay mesh placement. [1][2][3][4][5] There are 2 procedures for ESR, that is, totally extraperitoneal sublay (TES) [1][2][3][4] and transabdominal sublay. [5][6][7] In China, TES is implemented more frequently.…”

Preperitoneal space, is it an ideal layer for endoscopic sublay repair of ventral hernia?

“…We named this conception as "total visceral sac separation (TVS)". [3,5,6] However, the implementation of TVS is difficult because the separation is like peeling an eggshell along its shell membrane. Certainly, no case needs a complete TVS, but the concept is important because it provides us a new perspective on ESR repair.…”

“…Therefore, it is potential to separate the visceral sac as large as possible. We named this conception as “total visceral sac separation (TVS) ” [3,5,6] . However, the implementation of TVS is difficult because the separation is like peeling an eggshell along its shell membrane.…”