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PURPOSE: The extended totally extraperitoneal technique (eTEP) is a relatively new laparoscopic approach to address ventral hernias. Since this technique is not widely used yet, the literature regarding its efficacy and safety is limited, especially when compared to more established surgical techniques like intraperitoneal onlay mesh (IPOM). This study aimed at contributing to the expanding body of evidence for eTEP, by comparing the early outcomes of eTEP and IPOM surgeries for ventral hernias. METHODS: This monocentric, retrospective cohort study compared patients with ventral hernias that were treated with eTEP or IPOM from 2019 to 2023. RESULTS: A total of 123 patients were analysed. 92 underwent eTEP and 31 IPOM respectively. Both groups were overall comparable. The IPOM group had a higher proportion of incisional hernias (61,29% vs. 21,74%, p < 0,001). This was taken into account for in a subgroup analysis of only primary hernias. The IPOM group had a significantly longer admission time (eTEP: 3 days, IPOM: 4 days, p < 0,001). The subgroup analysis revealed a statistically significant shorter surgery time in IPOM (median of 66,5 min vs. 106,5 min; p = 0,043) and a lower rate of postoperative complications in eTEP (eTEP: 4,17%, IPOM: 25%. p = 0,009). The eTEP group reported lower postoperative pain, yet without statistical significance. CONCLUSION: eTEP for ventral hernia repair appears to be non-inferior to IPOM. Compared to IPOM it leads to shorter postoperative hospital stay and a potentially lower complication rate, despite a longer operation time.

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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.

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PURPOSE: To present a novel technique of preperitoneal cross-over for eTEP VHR. METHODS: Patients who underwent robotic eTEP with mesh utilizing a preperitoneal cross over technique were identified using a single-institution hernia database. This novel technique involves minimally invasive access to the retro-rectus space on one side with midline cross over into the preperitoneal space on the contralateral side. Baseline demographics of the patients were obtained, and intra-operative and post-operative outcomes were reported. RESULTS: Nine VHR patients underwent robotic eTEP with mesh using a preperitoneal crossover technique. Five patients were male, mean age was 53 ± 18.4 years, and mean BMI was 32.5 ± 4.2 kg/m2. Two patients were diabetic and 2 were previous smokers. Two of the hernias were recurrent. The average hernia defect was 96.9 ± 45.5 cm2 and the average mesh size was 593.3 ± 168.2 cm2. Four patients underwent a unilateral TAR, while five patients did not require any component separation. All cases were CDC Class 1 wounds. All patients met discharge criteria on post-operative day 1. There was one post-operative wound occurrence which was a seroma. There were no infectious complications and no hernia recurrences. The average follow up was 1.4 ± 1.2 months. CONCLUSIONS: Preperitoneal cross-over during eTEP ventral hernia technique is a safe technique that allows placement of a large extra-peritoneal mesh. Early patient outcomes are favorable. Larger sample size and follow-up are needed to truly assess postoperative outcomes.

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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.

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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.

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BACKGROUND: Laparoscopic hernia repair in recent times has gained the most acceptance among both the surgical community and the patient groups, as it has proven benefits of lesser postoperative hospital stay and less pain scores. The incidence of both inguinal and ventral hernias has increased significantly in the present days. Various methods have been postulated by different surgical groups for repairing the same but no there is no standard consensus on managing concomitant inguinal and ventral hernias. The conventional e-TEP requires an extensive dissection with increased operative time. We present our experience in managing cases with both inguinal and primary M2/M3 and W1 ventral hernias with or without divarication of recti using a modified up to down approach for inguinal hernia followed by down to up approach for the ventral hernia, from a tertiary care center in South India. MATERIALS AND METHODS: We managed 16 cases with simultaneous incidence of inguinal and primary M2/M3 and W1 ventral hernias with or without divarication of recti between January 2022 and November 2023. Institute ethical committee clearance and informed consent was obtained from all the 16 patients. They were all subjected to an extra peritoneal repair of both the hernias. All the demographic data, intraoperative data, postoperative complications and follow up were digitally stored. All patients were followed up for six months after surgery. RESULTS: Out of 16 patients, 15 were males and 1 was female. The mean age was 48 years and the mean BMI of all the patients was 29.2 kg/m2. The postoperative recovery was smooth in all patients and being discharged within 24 h after surgery. The pain scores of all patients were significantly lower than patients who underwent intraperitoneal repair. CONCLUSION: e-TEP hernia repair is gaining popularity and has amused the hernia surgical community. Our method of e-TEP RS repair in cases with concomitant inguinal and primary M2/M3 W1 ventral hernias with or without divarication helps in addressing both the hernias in the extra-peritoneal space. Our technique reduces the area of dissection needed for mesh placement and preserves the integrity of abdominal musculature in the upper abdomen when compared with the conventional technique. It further allows extension of the e-TEP inguinal space into the Rectro rectus space without much alteration in the port arrangement allowing simultaneous repair of groin and umbilical hernias. Good knowledge of anatomy and laparoscopic skills are pertinent for safe and effective hernia repair by this technique.

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Objective: The objective of this study is analyze the outcomes of retro-muscular repair techniques for ventral hernias performed by a single surgeon in a renowned hernia surgery center. Method: This study involved 197 patients who underwent surgery between May 2016 and December 2021 under the care of a single surgeon (VR). Respecting the indication/contraindications of the eTEP procedure, 197 of 212 patients with ventral hernias underwent eTEP/eTEP-TAR surgery during this period. The cohort consisted of diverse hernia types, including median, lateral, and multiple-site defects. The safety of this approach was evaluated based on postoperative occurrences, where the number of complications accounted for 5% of the cases. Results of the study indicated that there was a significant improvement in the quality of life of patients following the procedure. The assessment, which measured postoperative pain, normal activity, and aesthetics on a 0-10 scale, showed improvement at 2 weeks and 3 months after surgery compared to the preoperative level. However, after a mean of 51.11 months, only one case of recurrence was reported. This recurrence occurred on top of the mesh, 18 months after the initial operation. The follow-up period lasted between 24 and 90 months. Patient monitoring was conducted either in person or over the phone, focusing on quality of life, postoperative pain, and the occurrence of recurrence. In conclusion, the laparo-endoscopic retro-muscular repair of ventral hernias, whether primary or incisional, has shown to yield excellent results in medium and long-term follow-up. The eTEP technique combines the benefits of the Rives-Stoppa technique (considered the gold standard in open ventral hernia repair) with the advantages of minimally invasive surgery.

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BACKGROUND: The evolution of midline ventral hernia repair has progressed from the open Rives-Stoppa technique to minimally invasive robotic approaches, notably the trans-abdominal retromuscular (TARM) and enhanced-view Totally Extraperitoneal (eTEP) methods. This study compares these two robotic techniques in repairing medium-sized midline ventral hernias. METHODS: A retrospective comparative study of electronic medical records from 2015 to 2021 was conducted on patients undergoing robotic TARM or eTEP at NYU Langone Hospital-Long Island. Data on demographics, comorbid conditions, surgical history, intraoperative details, hernia characteristics, and postoperative outcomes were analyzed. RESULTS: Both eTEP and TARM groups exhibited comparable outcomes regarding operative duration, hernia defect size, and overall complications. However, notable differences were observed in patients' BMI, implanted mesh area, mesh composition, and fixation techniques across the groups. The TARM group required a longer hospital stay (median: 1 day) in contrast to the eTEP group (median: 0 days). Additionally, eTEP patients indicated reduced postoperative pain scores (median: 2) compared to TARM (median: 3), with both differences being statistically significant (p < 0.001). CONCLUSION: The robotic eTEP approach is associated with lower post-operative pain scores, decreased hospital length of stay, and larger areas of mesh implantation as compared to the TARM approach. Other variables are largely comparable between the two techniques. LEVEL OF EVIDENCE: Level III.

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Background Primary ventral hernias are abnormal protrusions of abdominal viscera through the areas of weakness in the fascia of the abdominal wall. The aim of this study was to compare the benefits and complications, and the overall outcome in the Extended-View Totally Extraperitoneal Rives-Stoppa (eTEP-RS) repair versus Intraperitoneal Onlay Mesh (IPOM Plus) repair in the management of primary ventral hernias. Methods After obtaining institutional ethical committee clearance, this prospective comparative study between IPOM Plus and eTEP-RS was conducted in a tertiary care hospital from December 2020 to January 2022. A total of 50 patients presenting with primary ventral hernias were included in the study, of whom 25 underwent IPOM Plus and 25 underwent eTEP-RS repairs. Group selection was done by simple randomization using the lottery method. Patients more than 18 years of age with primary ventral hernias presenting with a hernial defect width less than 6 cm, consenting to the study, were included in the study. Patients who did not fulfill the inclusion criteria, strangulated/obstructed hernias, recurrent/incisional hernias, connective tissue disorders, skin infections, enterocutaneous fistulas, pregnancy, morbid obesity, and parastomal hernias were exclusion factors. Results The mean intraoperative duration in the eTEP-RS group (192.3 ± 16.20 min) was significantly higher than in the IPOM Plus group (102.6 ± 16.78min, p=0.001). The mean duration of hospital stay in the IPOM Plus group (5.9 ± 2.19 days) was longer than in the eTEP-RS group (4.6 ± 3.17 days, p=0.02). The mean postoperative pain scores, from the Visual Analogue Scale (VAS), on days 1, 7, and 90 were 3.2 ± 1.11, 2.64 ± 1.11, and 1.68 ± 1.46 in the IPOM Plus group and 1.84 ± 0.688, 0.76 ± 0.66 and 0.08 ± 0.40 in the eTEP-RS group, respectively (p=0.001). Conclusion Despite being a technically easy procedure requiring less intraoperative time, IPOM Plus had several disadvantages, such as increased postoperative pain, longer duration of hospital stays, higher chances of wound site seromas, and higher rates of postoperative paralytic ileus. On the other hand, eTEP-RS was a more challenging procedure requiring more intraoperative time; however, it had several advantages: less postoperative pain, less duration of hospital stay, early recovery, and fewer chances of seromas and paralytic ileus. However, more robust data is required to compare and validate the differences between both procedures' short- and long-term outcomes.

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BACKGROUND: This article aims to share the initial experience of the preperitoneal eTEP approach and its potential benefits in a selected group of patients. The eTEP Rives-Stoppa is a proven minimally invasive surgical technique for the treatment of ventral midline and off-midline hernias that has shown to be a solid, durable, and reproducible repair. The preperitoneal eTEP repair is a surgical technique that brings together the extraperitoneal access surgery with a preperitoneal repair for primary midline hernias avoiding posterior rectus sheath division and preservation of the retrorectus space while being able to treat simultaneous diastasis recti. METHODS: The analysis included 33 patients operated with the preperitoneal eTEP approach from September 2022 to September 2023 in patients with primary small to medium (< 4 cm) midline hernias, single or multiple defects with or without diastasis recti. Age, gender, hernia characteristics, operative time, and surgical site occurrences will be discussed, as well as fine details and landmarks in the operative technique. RESULTS: 33 consecutive patients were operated, 19 female (57.5%) and 14 males (42.5%) between 32 and 63 years of age, the most common comorbidity found was obesity (BMI > 30). In 70% of the cases, operative time was 90 min ± 25 min. The average hospital stay was one day, while 12 went home the same day, and so far, no reoccurrences have been reported. CONCLUSIONS: We believe the preperitoneal eTEP approach for small to medium primary midline hernias is an effective and solid repair that combines excellent features of proven surgical techniques and eliminates the need for posterior rectus sheath division while saving the retrorectus space, among other benefits that will be discussed. The reproducibility of the technique remains to be proven.

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OBJECTIVE: To review the first robotic hernia repairs performed at the Ilyinsky Hospital, evolution of this technology, learning curve and early outcomes. MATERIAL AND METHODS: There were 17 procedures at the Ilyinskaya Hospital between 2021 and 2023 (13 men and 4 women). Mean age was 60 years, body mass index 28 kg/m2. ASA grade 1 was observed in 1 patient, grade 2 - 14 ones, grade 3 - 2 patients. Ventral, inguinal and umbilical hernias were diagnosed in 7, 8 and 2 cases, respectively. Ventral hernias required IPOM+ procedure in 3 cases, eTEP-RS procedure in 2 cases and eTEP-RS-TAR procedure in 2 cases. Patients with inguinal hernia underwent transabdominal preperitoneal hernia repair. In case of umbilical hernia, TARUP procedure was performed in 1 case and vTAPP procedure in 1 case. RESULTS: Mean surgery time was 2 hours 38 min (min 1 hour 35 min, max 10 hours 11 min). There was one intraoperative complication (bleeding from epigastric artery). The follow-up period ranged from 3 months to 3 years. There were no recurrent hernias. Postoperative complications were noted in 2 cases. One patient was diagnosed with epididymitis after TAPP, 1 patient - with seroma after eTEP-RS procedure. All complications were relieved by conservative treatment. Bleeding from a. epigastrica inferior was diagnosed after removal of the trocar at the end of surgery. This event required suturing. CONCLUSION: Robotic hernia repair appears to be technically feasible and safe. This approach provides favorable results regarding quality of life and recurrence rate.

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video width="640" height="480" controls controlsList="nodownload" poster="https://www.revistachirurgia.ro/pdfs/video/Victor_Gheorghe_Radu_L3W3_Incisional_Hernia.jpg" style="margin-top: -20px;" source src="https://www.revistachirurgia.ro/pdfs/video/Victor_Gheorghe_Radu_L3W3_Incisional_Hernia.mp4" type="video/mp4" Your browser does not support the video tag. /video Introduction: The Rives-Stoppa procedure has emerged as the preferred method for ventral hernia repair, and the principles of this technique are similarly applied in minimally invasive surgery using the eTEP (enhanced view totally extraperitoneal) approach. It appears that the eTEP approach offers excellent outcomes in terms of less post-operative pain, faster recovery, and shorter hospital stays for patients undergoing abdominal wall reconstruction (AWR). It's important to note that there are some contra-indications of this procedure. In general, laparoscopic eTEP may not be suitable for cases with large hernias and loss of domain where the working space is limited. In such cases, alternative approaches, such as using a robotic platform, may be considered to ensure an adequate working space for abdominal wall reconstruction (AWR). A robotic platform can create a working space by using the robotic arms as a "laparo-lift," enabling the AWR to be performed. Case Report: In this case, we have a 65-year-old female patient with a BMI of 28.5 who presents with a large incisional hernia with LOD. This hernia is located on the right flank and occurred after a Jalaguier incision. The CT scan provided valuable information regarding the size of the hernia, the remaining volume of the abdominal cavity, and the content of the hernia sac. Based on these radiological details, the LOD diagnosis was confirmed using the Sabbagh equation, which revealed that the hernia volume accounted for 46.47% of the total peritoneal volume. Based on the location, size of the defect, and the EHS classification for incisional hernias, the diagnosis for this case is a Complex incisional hernia of L3 right W3 with LOD. The protocol for optimization in this case involves chemo-relaxation, which refers to the injection of botulinum toxin A (BTA) into the large lateral muscles of the abdomen. This is done approximately 6 weeks before the surgery. Based on the successful reduction of the hernia during the consultation, the decision has been made to perform the Abdominal Wall Reconstruction (AWR) procedure using the robotic eTEP-TAR technique. Conclusion: The post-operative course was favorable, with the patient experiencing early active mobilization, reduced pain, and early return of bowel movement. The patient was discharged the day after the surgery.

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BACKGROUND: Though robotic adoption for eTEP surgery has decreased technical barriers to minimally invasive repairs of large ventral hernias, relatively few studies have examined outcomes of robotic-specific eTEP surgery. This study evaluates safety, feasibility, and early outcomes of ERAS/same-day discharge protocols for robotic eTEP ventral hernia repairs. METHODS: A retrospective chart review was performed for all robotic eTEP hernia surgeries at a single institution between 2019 and 2022. Analysis included patient demographics, hernia characteristics, intraoperative data, and post-operative outcomes at 30 days. ERAS protocol included: judicious use of urinary catheters with removal at end of case if placed, bilateral transversus abdominus plane (TAP) blocks, post-operative abdominal wall binder, and opioid-sparing perioperative analgesia. Patients were discharged same day from post-anesthesia care unit (PACU) if they lacked comorbidities requiring observation post-anesthesia and demonstrated stable vital signs, adequate pain control, ability to void, and ability to ambulate. Hospital length of stay (LOS) was considered 0 for same-day PACU discharges or hospitalizations < 24 h. RESULTS: 102 patients were included in this case series. 69% (70/102) of patients were discharged same-day (mean LOS 0.47 ± 0.80 days). Within 30 post-operative days, 3% (3/102) of patients presented to the ER, 2% (2/102) were readmitted to the hospital, and 1% (1/102) required reoperation. There was 1 serious complication (Clavien-Dindo grade 3/4) with an aggregate complication rate of 7.8%. CONCLUSIONS: Our initial experience with ERAS protocols and same-day discharges after robotic eTEP repair demonstrates this approach is safe and feasible with acceptable short-term patient outcomes. Compared to traditional open surgery for large ventral hernias, robotic eTEP may enable significant reductions in hospital LOS as adoption increases.

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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.

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BACKGROUND: Posterior component separation with transversus abdominis release (TAR) is considered to be the optimal technique for large incisional ventral hernia repair. Endoscopic TAR (eTAR) that gets all the benefits of minimally invasive surgery (MIS) gives a possibility to enhance results of the treatment. The aim of our study was to make the comparison between open and endoscopic TAR procedures with an emphasis on frequency and severity of postoperative complications in comparable groups. MATERIALS AND METHODS: All patients had midline incisional hernia and underwent either open (open TAR group) or endoscopic (eTAR group) Rives-Stoppa repair in combination with bilateral transversus abdominis release in Moscow City Hospital №1 from January 2018 to December 2022. A propensity score matching (PSM) was used to make groups comparable. Postoperative complications were classified according to Clavien-Dindo Classification, and Comprehensive complication index was calculated. RESULTS: We performed 133 open and endoscopic TAR separation for midline incisional hernia. After PSM analysis 51 patients were matched to each group. Overall surgical morbidity in the open TAR group (56.9%) was statistically significantly higher than in the eTAR group (29.4%) (p = 0.009). There were more severe complications (Clavien IIIa-V) in the open TAR group (11.8% vs. 0%, p = 0.027). Length of hospital stay after surgery was shorter in eTAR group (p < 0.001). The Comprehensive complication index in the open TAR group was significantly higher than in eTAR group, 8.7 (0-20.9) vs. 0 (0-8.7) (p = 0.011). CONCLUSION: Based on the data from our study, the entire MIS procedure including endoscopic TAR is a safe and optimal technique for surgery of midline incisional ventral hernia, requiring TAR separation in terms of reducing the rate of postoperative complications, their severity and hospital length of stay, compared to open TAR procedure.

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Minimally invasive extended totally extraperitoneal (eTEP) technique is revolutionising ventral hernia repairs. Robotic-assisted eTEP has been gaining popularity due to better visual clarity and greater dexterity provided by the robotic systems, compared to laparoscopy. Despite growing number of papers being published each year, so far, no study has explored intraoperative complications in robotic-assisted eTEP. The aim was to perform a systematic literature review on the incidence of intraoperative complications in robotic-assisted eTEP ventral hernia repairs. The study protocol was preregistered with PROSPERO, registration number CRD42023450072. Twelve categories of intraoperative complications were defined by the authors. A search of PubMed and Embase was conducted on 16/08/2023, for articles pertaining to robotic-assisted eTEP operations in ventral hernias in adults. Articles were critically appraised and data were extracted using predefined extraction templates. No data were suitable for statistical analysis and a narrative synthesis was performed instead. Ten studies fulfilled the inclusion criteria, of which four studies reported intraoperative complications. Of the 12 categories of intraoperative complications, only 5 were reported. Three studies encountered adherent bowel inside the hernia sac. One reported linea alba injury with subsequent anterior layer dehiscence. There was one case of unrecognised intraoperative retromuscular bleeding and one case of insufflation injury with subcutaneous emphysema. There is a paucity of literature on the incidence of intraoperative complications in robotic-assisted eTEP ventral hernia repairs. Available studies suggest complication rates are low. More robust studies using prospective data from hernia registries are required before further conclusions can be drawn.

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INTRODUCTION: Newer extraperitoneal techniques of laparoscopic ventral/incisional hernia repair (LVIHR) have been continually introduced since the popularity of the laparoscopic intraperitoneal onlay mesh technique began in 1993. One of which is the extended totally extraperitoneal (eTEP) approach allowing wide mesh augmentation, concurrent repair of diastasis recti, and performance of transversus abdominis release (TAR) for large/complex hernias. However, minimally invasive/laparoendoscopic ventral hernia repair is not yet widely adopted in the Philippines. We aim to share our preliminary experience with LVIHR using the eTEP approach. METHODS: This was a retrospective review of all consecutive eTEP repairs for ventral hernia between January 2019 and September 2023. The clinical profiles of all patients were gathered. Hernia characteristics, operative profile, and postoperative outcomes were reported. RESULTS: Thirty-five patients were included in the study with a mean age of 54.7; 60% were incisional hernias, and the most common hernia location was the umbilical area. A defect size between 4 and 10 cm was reported in 54.3%. eTEP-TAR was necessary in 12 patients. At a median follow-up of 16 months, two patients developed seroma, one hematoma, and two surgical site infections. All were successfully managed conservatively. Only one patient developed recurrence. CONCLUSION: eTEP approach is safe and feasible for repairing ventral hernias. Our preliminary experience showed acceptable outcomes similar to the published literature. Surgeons interested in this technique should be familiar with the abdominal wall anatomy, carefully select patients during preoperative planning, and undergo mentorship with hernia surgeons experienced with the technique to shorten the learning curve.

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PURPOSE: Assess the utility of a hands-on cadaver workshop for teaching abdominal wall reconstruction (AWR) using components separation technique. METHODS: Over a year, from June 2022 to July 2023, 112 surgeons participated in seven training courses focused on the eTEP technique for inguinal and ventral hernias. The workshops covered theoretical learning sessions followed by hands-on training using frozen human cadavers. An online survey was used to know the influence of our workshop on the clinical practice of the attendees. RESULTS: Out of 112 total participants, 70% (78) participants completed the survey. Among them, 58% (45) surgeons had over 10 years of experience. The workshop resulted in approximately 85% (66) of participants successfully adapting to eTEP. Confidence levels significantly increased for all steps of the technique after the workshop (p < 0.001, Rank-Biserial Correlation = -1.000). Participants expressed high satisfaction with the course. CONCLUSION: The cadaver model training program was found to be effective in reducing the learning curve and being replicable. This suggests its potential for widespread implementation as an introductory training model for learning the anatomy of abdominal wall and adapting this for treating hernias requiring AWR.

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The trend to minimally invasive surgery has also made its way into the surgical treatment of incisional hernias. Unlike other areas of visceral surgery, recent years have seen a resurgence of open sublay repair in incisional hernia procedures, primarily due to the recognition of the retromuscular layer as the optimal mesh placement site. Additionally, with the growing availability of robotic systems in visceral surgery, these procedures are increasingly being offered in the form of minimally invasive procedures. These methods can be categorized based on the access routes: robotic-assisted transperitoneal procedures (e.g., r­Rives, r­TARUP, r­TAR) and total extraperitoneal hernia repair (e.g., r­eTEP, r­eTAR). Notably, the introduction of transversus abdominis muscle release enables the robotic-assisted treatment of larger and more complex hernia cases with complete fascial closure. With respect to the comparison with open surgery required in retromuscular hernia treatment, the currently available literature on incisional hernia repair seems to show initial advantages of robotic-assisted surgery in the perioperative course. New technologies create new possibilities. In the context of surgical training the use of surgical robot systems with double consoles opens up completely new perspectives. Furthermore, the robot enables the implementation of models of artificial intelligence and augmented reality and could therefore open up novel dimensions in surgery.

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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.

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