Essential anatomical landmarks in placement of an adequate size mesh for a successful ventral hernia repair

eTEP-RS for incisional hernias in a non-robotic center. Is laparoscopy enough to perform a durable MIS repair of the abdominal wall defect?

INTRODUCTION

Incisional hernias can complicate up to 25% of laparotomies, and successful repair remains a significant clinical challenge for surgeons. Recently, the surgical technique of ventral hernia repair (eTEP-RS) has been introduced. The method was presented relatively recently and continues to evolve. The use of a robotic platform in eTEP-RS resulted in a significant improvement in ergonomics. Therefore, the questions arise as to whether the laparoscopic technique might still be feasible for such long procedures. The objective of this study is to present our early results in the treatment of patients with incisional ventral hernias using eTEP-RS and to discuss key technical aspects.

PATIENTS AND METHODS

A prospective case-controlled study was conducted for all incisional ventral hernia patients (hernia orifice between 4 and 10 cm) who underwent eTEP-RS between March 2019 and December 2021. Demographic data were recorded; and perioperative and postoperative results were analyzed.

RESULTS

We performed 34 eTEP-RS procedures. The mean duration of the surgery was 211 min (145-295). The mean width of the defect was 6.8 cm and the defect area was 42.5 cm². The mean mesh size was 498 cm² (270-625). After an average follow-up of 16 months (2-30), there was no recurrence or major complication.

CONCLUSIONS

The eTEP-RS is a safe alternative to open ventral hernia repair in selected cases and allows for the placement of a large piece of mesh in accordance with current recommendations, even in non-robotic centers. Excellent knowledge of the detailed anatomy of the abdominal wall is essential for safe and effective hernia repair. Compliance with certain rules of the laparoscopic eTEP-RS facilitates improved ergonomics for this procedure even in non-robotic centers.

An Evaluation of the Evidence Guiding Adult Midline Ventral Hernia Repair

Purpose:  Several guidelines have been published in recent years to guide the clinician in ventral hernia repair. This review distils this advice, critically assesses their evidence base, and proposes avenues for future study. Methods:  A PUBMED search identified four guidelines addressing midline ventral hernia repair published by major surgical societies between 2016 and 2020. The studies used to inform the advice have been critically appraised, including 20 systematic reviews/meta-analyses, 10 randomized controlled trials, 32 cohort studies, and 14 case series. Results:  Despite a lack of randomized controlled trials, case heterogeneity, and variation in outcome reporting, key themes have emerged. Preoperative computed tomography scan assesses defect size, loss of domain, and the likely need for component separation. Prehabilitation, frailty assessment, and risk stratification are beneficial in complex cases. Minimally invasive component separation techniques, Botox injection, and progressive pneumoperitoneum represent novel techniques to promote closure of large fascial defects. Rives-Stoppa sublay mesh repair has become the "gold" standard for open and minimally invasive repairs. Laparoscopic repair promotes early return to functional status. The enhanced-view totally extraperitoneal approach facilitates laparoscopic sublay mesh placement, avoiding mesh contact with viscera. Robotic techniques continue to evolve, although the evidence at present remains immature. Synthetic mesh is recommended for use in clean and clean-contaminated cases. However, optimism regarding the use of biologic and biosynthetic meshes in the contaminated setting has waned. Conclusions:  Surgical techniques in ventral hernia repair have advanced in recent years. High-quality data has struggled to keep pace; rigorous clinical trials are required to support the surgical innovation.