Analysis of ‘enhanced-view totally extra-peritoneal’ (eTEP) approach for ventral hernia: Early results

Abstract

Introduction: Laparoscopic ventral hernia repair is undergoing a paradigm shift with the introduction of numerous new techniques to improve the outcomes. Enhanced-view totally extra-peritoneal (eTEP) is a novel approach for the repair of ventral herniae introduced by Belyansky et al. The key innovation lies in placing the mesh in a large retrorectus–pre-peritoneal space contrary to the widely practiced intra-peritoneal placement. This approach can be easily coupled with a component separation in the form of transversus abdominis release (TAR) for large herniae. We conducted a midterm analysis of ‘eTEP’ approach to ventral hernia at a high-volume tertiary care centre and present our results of over 3 years of employing this technique. Methodology: A retrospective study of 150 cases of ventral hernia repaired using eTEP approach from January 2018 to February 2021 at a tertiary care centre by a team of three surgeons. The procedures were performed by a single team of three members headed by the first author. Results: Out of total 150 cases, incisional hernia occurred in 73 cases (48.7%), primary hernia occurred in 48 cases (32%) and recurrent hernia in 29 cases (19.3%). Although the majority of incisional (87.7%) and recurrent (79.3%) ventral hernias occurred in female, the incidence of primary ventral hernia was equal at 24 cases in both genders. The majority of the cases (80.7%) underwent eTEP RS procedure, and the rest were W3 hernias, which were managed by including a component separation in the form of eTEP TAR. The operating time for eTEP TAR (222.24 min ± 32.56) compared to eTEP RS (124.33 ± 23.68) was significantly longer. The mean length of stay was significantly shorter for primary hernias (3.75 days ± 1.62) compared to recurrent (5.21 days ± 2.51) and incisional hernias (4.36 days ± 2.19) (F = 4.376) (P = 0.014). The peri-operative period was uneventful in majority of the cases. We experienced a seroma rate of 5.8% in our series. At follow-up of 1 year, 3.3% of patients complained of discomfort/bulge in the upper abdomen. There were no other surgical site occurrences (SSO) in the form infection, posterior rectus sheath disruption and skin necrosis. We observed no recurrences till date with a minimum follow-up of 1 year. Conclusion: eTEP approach to ventral hernia is a promising abdominal wall reconstruction technique. It is safe and offers good functional outcomes with restoration of abdominal wall dynamics. It is a reproducible and safe technique for tackling various types of ventral hernia. It is specifically useful in managing unusual lateral hernias, incisional and recurrent hernias with ease.

Outcomes after ventral hernia repair using the extended totally extraperitoneal approach: Initial experience from the Philippines

“…16 A 3-year (2018-2021) single-center experience from India with a total of 150 patients showed a mean operative time of 124.3 ± 23.6 and 222.2 ± 32.5 min, respectively. 17 The longer operative time is one drawback of the eTEP procedure. This also reflects our learning curve, which can be improved over time with experience and further standardization of our technique.…”

“…Other reported SSOs include (1) dehiscence of the plicated linea alba/anterior fascia resulting in upper abdominal bulging and (2) disruption of the PRS/peritoneum resulting in bowel herniation and/or obstruction. 8,17,25,26 The first randomized controlled trial (RCT) in 2022 comparing eTEP (30) and IPOM (30) for ventral hernia showed that the former was more cost-effective and associated with lower seroma rates, postoperative pain scores, and earlier return to activity. 27 In 2023, another RCT (29 eTEP vs. 27 IPOM) also showed lower postoperative pain scores with eTEP but was associated with higher surgeons' workload.…”

“…eTEP repair is also considered more economical especially in a low/middle-income setting because it allows usage of a cheaper regular uncoated mesh without needing to use mesh fixation devices. 8,17 Although laparoscopic IPOM is still the most commonly performed minimally invasive ventral hernia repair worldwide, the adoption of complex/advanced ventral hernia repair such as eTEP ± TAR remains a challenge in the Philippines. Some of the identified challenges as reported by Faylona et al 2 include the possible limitation of local advanced MIS curriculum to IPOM for ventral hernia repair, limited hernia specialists, and hernia training centers.…”

“…A preliminary Turkey experience for incisional hernias ( n = 30) showed a mean operative time of 203.5 and 291.5 min for eTEP‐RS and eTEP‐TAR, respectively 16 . A 3‐year (2018–2021) single‐center experience from India with a total of 150 patients showed a mean operative time of 124.3 ± 23.6 and 222.2 ± 32.5 min, respectively 17 . The longer operative time is one drawback of the eTEP procedure.…”

“…Any type of fixation may be unnecessary during eTEP repair. The fundamentals of a Rives–Stoppa repair allow for anatomical fixation of the mesh within a well‐vascularized flap aided by the radially acting intraabdominal forces 17 . However, a pragmatic approach to use fibrin glue to fixate the mesh to the PRS may be applied if only a minimum mesh–defect overlap is achieved and extra space is evident beyond the edges of the mesh in relation to the dissected area (especially when TAR is performed).…”