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.

Changes in the abdominal wall after anterior, posterior, and combined component separation

KEY MESSAGE

Knowledge of the changes that occur in the abdominal wall after component separation (CS) is essential for understanding the mechanisms of action of the various CS techniques, the changes observed on computed tomography images, and, perhaps most importantly, the anatomic and physiologic changes observed in patients who have undergone CS. Purpose Component separation (CS) techniques are essential adjuncts during most abdominal wall reconstructions. They allow the fulfillment of most modern abdominal wall reconstruction principles, especially primary closure of defects and linea alba restoration under physiologic tension. Knowledge of the post-CS abdominal wall changes is essential to understanding the mechanism of action of the various types of CS, the changes observed on computed tomographic images, and, perhaps most importantly, the anatomic and physiologic changes following CS techniques. Methods A systematic review of the literature was conducted using the PubMed database and other sources to identify articles describing abdominal wall changes after CS Results After excluding non-pertinent articles, 14 articles constituted the basis for this review.  Conclusions After reviewing the literature on post CS abdominal wall changes, we conclude the following: (1)The external oblique muscle is significantly displaced laterally after anterior CS, the transversus abdominis muscle shifts very little after posterior CS, and muscle trophism is generally maintained after both techniques. These findings are consistent for both open and minimally invasive CS. (2) The anatomy and physiology of abdominal wall muscles are preserved mainly by the muscles' overlapping function and their ability to undergo compensatory trophism after midline restoration (reloading). (3) Well-performed CS techniques have a low risk of producing bulging and semilunar line hernias. (4) Anterior and posterior CS techniques probably have different mechanisms of action. (5) Current studies on how the nutritional status and postoperative conditioning can alter abdominal wall changes after CS and the mechanisms of the actions involved in anterior and posterior CS are underway.

Changes in the lateral abdominal wall following endoscopic subcutaneous anterior component separation

PURPOSE

Although changes in lateral abdominal wall musculature after posterior component separation with transversus abdominis release have been investigated, the effects of endoscopic subcutaneous anterior component separation (ES-ACS) on postoperative muscle anatomy have not been evaluated. The purpose of this study was to evaluate changes in the lateral abdominal muscles after ES-ACS.

METHODS

Computed tomography (CT) images of patients who underwent ES-ACS were retrospectively evaluated. Lateral abdominal wall thickness and external oblique displacement were measured at the level of fixed retroperitoneal structures. Measurements on the ES-ACS side were compared with those on the contralateral undivided side or with preoperative images in patients with bilateral procedures.

RESULTS

Fifteen patients met the criteria for study inclusion. Most patients (n = 13, 86.7%) underwent unilateral ES-ACS. The most commonly performed procedure was laparoscopic intraperitoneal onlay mesh-plus hernia repair (n = 12, 80.0%; the remaining patients underwent open repair). The Mean defect width was 8.4 cm (range 6-15 cm). There was no difference in the thickness of the lateral abdominal musculature between ES-ACS and undivided sides. There was a significant lateral displacement of the external oblique muscle from the lateral edge of the rectus abdominis on the ES-ACS side (mean distance 3.7 cm; p = 0.0006). No midline hernia recurrences, iatrogenic linea semilunaris hernias, or lateral eventrations were observed during a mean follow-up period of 2.6 years (range 0.5-7.4 years).

CONCLUSION

ES-ACS resulted in no atrophy of the lateral abdominal muscles in long-term CT follow-up. The procedure is a safe and effective adjunct to complex hernia repair in selected patients.

Técnica extraperitoneal comparada con IPOM plus: Análisis de costos evitados para optimizar el manejo de la hernia ventral por laparoscopia

Introducción. Analizamos los costos en el reparo extraperitoneal de la hernia ventral por laparoscopia, desde la perspectiva del sistema general de salud de Colombia, con el fin de mostrar los beneficios de dicho abordaje y su impacto económico, al compararlo con la técnica más implementada, el IPOM plus. Métodos. Se realizó un análisis económico de costo-beneficio, desde la perspectiva del Sistema General de Seguridad Social en Salud (SGSSS) de Colombia, comparando los costos del reparo de hernia ventral con la técnica extraperitoneal, TAPP o TEP, versus el IPOM plus. Se tomaron como costos de referencia lo establecido en el manual tarifario de Instituto de Seguros Sociales. Los datos fueron analizados con Stata V.15    Resultados. Se recolectó y analizo información de 109 procedimientos; 59 del grupo extraperitoneal TAPP/TEP y 50 del grupo IPOM plus, realizados durante los años 2015 a 2018, por el grupo de pared abdominal de Clínica Colsanitas, identificando un ahorro del 69,8 % o resultados de costo-beneficio a favor del grupo extraperitoneal. Discusión. El abordaje extraperitoneal en el reparo de hernia ventral se consideró una estrategia de alto costo-beneficio para el sistema de salud, validado por la experiencia del grupo de pared abdominal de Clínica Colsanitas, al compararla con el abordaje habitual. Teniendo en cuenta que los insumos utilizados para la disección no cambian, la prótesis utilizada para cada una de las técnicas representa un costo importante a considerar, tanto para el sistema como para las instituciones de salud

e-TEP Retromuscular Repair for Recurrent Incisional Hernias: Report of Three Cases

Introduction

Recurrent incisional hernias are difficult to treat. There are many factors involved in the recurrence, and due to extensive dissections, the planes are fused with adhesions, and we may need a new plane for dissection and placement of meshes.

Case Report

We report here three cases of recurrent incisional hernias which were dealt by a relatively new method to laparoscopy: the enhanced view totally extraperitoneal repair (e-TEP) retromuscular technique. There were three patients: one after an open onlay repair of lower midline incision, another after an onlay mesh repair of a subcostal incision for open cholecystectomy followed by an intraperitoneal onlay mesh hernioplasty (IPOM) repair, and another after IPOM repair of epigastric hernia. They were treated with the abovementioned technique with satisfying short-term results.

Conclusion

The e-TEP technique is a relatively new method of providing minimal access surgery to these patients utilizing the previously unaccessed retromuscular (Rives and/or preperitoneal) space for the repair of these recurrent incisional hernias.