Extended totally extraperitoneal repair (eTEP) for ventral hernias: Short-term results from a single centre.

INTRODUCTION: There has been a surge of innovative procedures in the field of abdominal wall hernias. Works of pioneers such as Dr. Yuri Novitsky, Dr. Jorge Daes and Dr. Igor Belyansky have started a new era in the field of hernia surgery. Conventional and popular surgeries for ventral hernias are open onlay mesh hernioplasty, open retromuscular mesh hernioplasty (Rives-Stoppa procedure) and laparoscopic intraperitoneal mesh hernioplasty. Evidence seems to suggest that retromuscular mesh hernioplasty has advantages over other procedures regarding recurrence and surgical site occurrences. An alternative strategy has been developed for this setting where a mesh is placed in retromuscular space by minimal access technique of the extended Totally Extraperitoneal approach (eTEP).
METHODS: We have retrospectively analysed the data of 21 patients who underwent an eTEP procedure with a minimum follow-up of 2 months. Their data were analysed for operative details, intra-operative and post-operative complications.
RESULTS: For a total of 21 patients, we have recorded a total of two surgical site occurrences (1 seroma and 1 linea alba dehiscence) and one recurrence. One patient had chronic pain. There was no surgical site infection.
CONCLUSION: Judging from our short-term results, we suggest that the eTEP technique can be adapted in centres with advanced laparoscopic skills with the careful patient selection.

INTRODUCTION

Extended totally extraperitoneal repair (eTEP) is a novel technique that was first introduced by Jorge Daes in 2012 to address difficult inguinal hernias.[1] The principle is to create a larger space than what is done in TEP to tackle large groin hernias.

Some surgeons have extended the indication to ventral hernias with the purpose to place the mesh in the retromuscular space, as suggested by Rives and Stoppa (RS).[2] This has been called Extended Totally Extraperitoneal RS repair (eTEP RS). When the defect is too wide to be closed without tension, a component separation procedure is added. Generally, the posterior component separation technique (PCST) in the form of Transversus abdominis release (TAR) as described by Dr. Novitsky et al.[3] is preferred with the eTEP technique since the plane of dissection is the same. This is called eTEP TAR. It is believed that mesh placement in retromuscular space translates into vascularisation of the mesh from both sides, less recurrence, fewer issues of fixation, less pain and fewer chances of bowel adhesions in addition to being economical due to the deployment of a cheaper mesh as composite mesh with anti-adhesion barrier is not needed.[4] However, the technique has a steep learning curve. In this article, we present how we perform this procedure and the short-term results of our experience.

METHODS

Case selection

The case selection depends primarily on the width of the defect although a host of other factors such as obesity, location, previous mesh and surgery, skin scars, sinus tracts and redundancy also play a role in decision-making.

Currently, we use intra-peritoneal onlay mesh hernioplasty with the closure of fascial defect (IPOM plus) for patients with defect size 4 cm and less.

We select all hernias that have a defect >4 cm for eTEP in our practice.

Defects that cannot be closed without tension necessitate a TAR. We have been able to manage eTEP TAR for hernia defects as wide as 12 cm. We have employed open surgery for hernias larger than 12 cm.

Exclusion criteria

Defect width >12 cm

Poor skin condition

Sinus tract

Previous retro-rectus mesh placement.

Technique

We follow the same technique as described by Dr. Belyansky et al.[2] with a few modifications.

Positioning of patient and ports

The patient is placed supine with arms tucked by the side and extended at the hips to enable instrumentation without hindrance from the pelvis and thighs.

The port positions are shown in Figure 1. For umbilical, infra-umbilical and suprapubic hernias, [Figure 1a] the TV monitor is placed at the foot end. We place the camera initially in the upper left port (A) until the midline is crossed and both retro-rectus spaces are dissected. Thereafter, the camera is shifted to the right upper port (D) for further dissection and suturing the defect.

Figure 1

Port positions. (a) for umbilical and infraumbilical hernia; (b) for supraumbilical hernia

For epigastric and subxiphoid hernias, we initially create one of the retro-rectus spaces like in lower hernias; thereafter, lower ports at the infra-umbilical region are made as shown in Figure 1b. Two monitors are needed, one at the foot end for initial space creation, and another at the head end that is used for the rest of the surgery.

Entering the retro-rectus space

We start with a 15-mm incision below the left costal margin at the left mid-clavicular line. Retro-rectus space is created with a PDB spacer balloon (Medtronic). A 10-mm telescope is inserted into this space that is further dissected with an energy source. The dissection proceeds caudally until the pubic bone is completely visualised. The lateral limit of the dissection is carefully maintained keeping medial to the linea semilunaris to prevent any inadvertent injury to the neurovascular bundle [Figure 2a].

Figure 2

(a) Creation of retro-rectus space. Note the neurovascular bundles - black arrow, Linea Semilunaris - yellow arrow, posterior rectus sheath - blue arrow (b) intraperitoneal dissection and taking down hernia contents (c) crossing the midline. Note the falciform pad of fat

Crossing the midline

Two more 5-mm ports are made in the retro-rectus space medial to the linea semilunaris at the midclavicular line at a distance of 5 cm from each other (B and C). The telescope is shifted to the lower port (C) to visualise the cranial end of the space and the left posterior rectus sheath is incised at its medial margin with a diathermy hook or scissors. The yellow pad of fat is seen that represents the falciform ligament [Figure 2c]. This is dissected down from the roof to cross the midline and visualise the right posterior rectus sheath. Here, we have modified the technique for our ease. We create the right retro-rectus space at the beginning of surgery and inflate it with carbon dioxide that helps in identifying and placing the incision on the right posterior rectus sheath. We also use a needle to guide us in incising posterior rectus sheath. The camera is shifted to the right upper port (D) for further dissection. The left upper ports (A and B) are then used as working ports.

For epigastric and subxiphoid hernias

Initial entry is from a left paraumbilical port. In these cases, we cross the midline from below. This is technically easier since the extraperitoneal space blends into the retro-rectus spaces cranially.

Entering the peritoneal cavity

The dissection is continued caudally until we reach umbilicus. The peritoneum is opened with an energy source at a safe distance from hernia sac to enter the peritoneal cavity [Figure 2b]. The contents are inspected and dissected down carefully with sharp dissection and judicious use of energy source, especially in the presence of a bowel.

Closure of the linea alba

The defect is closed at a lower insufflation pressure with a 45-mm taper cut 1 polypropylene or a 1-0 or 2-0 barbed non- absorbable sutures [Figure 3a]. The posterior rectus sheath is closed with absorbable barbed suture or 2-0 PDS [Figure 3b].

Figure 3

(a) Closure of linea alba. Rectus abdominis are marked with white arrows (b) closure of posterior rectus sheath

Transversus abdominis release

If a TAR is required in the event of inability to approximate the defect edges or posterior rectus sheath, an incision is made on the posterior rectus sheath in upper abdomen where the TA fibres are fleshy, medial to the linea semilunaris, preserving the neurovascular bundles. The TA fibres are identified and divided with a hook diathermy [Figure 4]. Plane is developed between the TA fibres and transversalis fascia using the principle described by Belyansky et al.[2] and Novitsky et al.[3] in their original papers. The procedure is unilateral or bilateral depending on the amount of release required.

Figure 4

Transversus abdominis release. TA fibres are marked with black arrow

Placement and fixation of the mesh

The mesh size depends on the defect size and the space created. Generally, a 20 cm × 25 cm is used for eTEP RS [Figure 5] where the mesh is placed flat from one linea semilunaris to another and from epigastrium to pubis, but there is significant inter-individual variation. For eTEP TAR, we use 30 cm × 30 cm mesh to cover from one axillary line to another. Our personal preference is to use a medium weight macroporous polypropylene mesh.

Figure 5

Mesh placement. Pubic bone is marked with an arrow

We prefer to fix the mesh with the fibrin glue or no fixation at all.

The gas insufflation is then stopped and space is deflated under vision taking care that the mesh is flat. If there is any folding of mesh noted during deflation, carbon dioxide is introduced again and the mesh is deployed properly.

Atypical sited hernias

We have performed four cases of atypically sited hernias with the eTEP technique (2 lumbar, 1 subcostal and 1 Pfannensteil). We have employed TAR on the ipsilateral side and RS on the opposite side for subcostal and lateral pfannensteil hernias. For lumbar hernias, ipsilateral TAR was sufficient for adequate overlap of the mesh.

Post-operative care

We allow clear liquids 6–8 h after surgery and oral feeds the morning after. Drains are usually not given. Analgesics are used in the first 5 days routinely. Patients are usually discharged within 48–72 h of the procedure.

RESULTS

We have done a total of 21 cases of eTEP until December 2017.

Patient characteristics

The mean age was 54.67 years. 6 were male and 15 were female. Mean BMI was 28.57 kg/m2. Three patients were diabetic, four were hypertensives and one had CAD, and one had a history of CVA. Out of 21, 3 patients had a primary hernia, and 18 had an incisional hernia. 5 had a recurrent hernia [Table 1].

Table 1

Patient characteristics (n=21)

Patient characteristics	n (%)
Age (years)
Mean	54.67
Median	54
SD	13.05
BMI (kg/m2)
Mean	28.57
Median	29
SD	4.14
Gender
Males	6 (28)
Females	15 (72)
Smoker	0
Diabetic	3 (14)
Hypertensive	4 (19)
CAD	1 (4.7)
CVA	1 (4.7)
Recurrent hernia	5 (23.8)

SD: Standard deviation, BMI: Body mass index, CAD: Coronary artery disease, CVA: Cerebrovascular accident

Periopertive characteristics

9 were eTEP RS and 12 were eTEP TAR. The mean operating time was 176.48 min and ranged from 138 to 310 min. We have seen that with increasing expertise, our operative time has gone down. Mean defect width was 6.65 cm and defect area was 45.33 cm2. The mean mesh size was 535 cm2. We tend to use 30 cm × 30 cm mesh for eTEP TAR and 20 cm × 25 cm mesh for eTEP RS, however, it varies depending on the patient's build and defect size. Initially, our preferred method of fixation was a single tacker to the pubic bone with or without glue, slowly we have moved to using no fixation at all. In one patient with an epigastric hernia, we have used a single trans fascial suture in the subxiphoid region for fixation. All the patients are ambulated on post-operative day (POD) 1 except one patient who had an anterior dehiscence and needed to undergo a secondary suturing on POD 1. Most of the patients are discharged on POD 2 or 3 with a mean time from surgery to discharge being 2.67 days and range being 2–5 days. We have used a flat suction drain in only one patient which was taken out at 48 h after surgery. In this patient, after dissection and mesh placement, the raw surface looked ‘oozy’. Placing the drain was a subjective decision [Table 2].

Table 2

Perioperative details

Intraoperative parameters	Values
eTEP-RS (n)	9
eTEP-TAR (n)	12
Operative time (min)
Mean	176.48
Median	178
SD	40.95
Defect width (cm)
Mean	6.65
Median	6
SD	1.95
Defect area (cm2)
Mean	45.33
Median	40
SD	22.38
Mesh size (cm2)
Mean	535
Median	500
SD	193.35
Fixation
None	7
Single tacker to the pubic bone	9
Single tacker to the pubic bone + glue	3
Glue alone	1
Single transfascial suture	1
Drain (%)
Yes	1 (4.7)
No	20 (95.3)
Time to ambulation
Mean	1.05
Median	1
SD	0.22
POD 1 pain score (VAS)
Mean	3.48
Median	3
SD	0.87
Time to discharge after surgery (days)
Mean	2.67
Median	3
SD	0.79

TAR: Transversus abdominis release, SD: Standard deviation, POD: Post-operative day, VAS: Visual analog scale, eTEP-RS: Extended Totally Extraperitoneal Repair- Rives Stoppa

Outcomes

One patient developed a suture dehiscence in POD 1 that could be palpated clinically. There had been a technical difficulty in suturing the anterior abdominal wall in this case due to ergonomic reasons. We had to re-operate with a limited laparotomy to close the defect. The patient did well thereafter. One patient who had undergone an eTEP TAR developed a seroma that could be observed after 10 days of surgery. Since it was painful and was causing extreme discomfort, we decided to drain it. It needed single aspiration and a tight corset for a month to which it responded satisfactorily. There was one recurrence at 3 months follow up. There were no SSI. One patient had significant pain at 1 month follow up [Table 3].

Table 3

Post-operative complications

Complications	n (%)
Surgical site occurrence
Seroma	1 (4.7)
Hematoma	0
Linea alba dehiscence	1 (4.7)
Surgical site infection	0
Systemic complications	0
Mortality	0
Recurrence	1 (4.7)
30-day readmission	0
Pain	1 (4.7)

DISCUSSION

With increasing evidence suggesting better results in the outcome (recurrence and SSO) with the retro-rectus mesh for ventral hernias, many surgeons have tried to use this space with minimal access.

The eTEP technique was initially devised to tackle large groin hernias by Dr. Jorge Daes. The eTEP procedure involves opening of retro-rectus spaces along with the preperitoneal spaces of Retzius and Bogros at the groin level. This has led surgeons to explore the possibility of using the retro-rectus space for ventral hernia repair.

eTEP technique for ventral hernias was developed by Dr. Belyansky et al.[2] and the author was fortunate to have observed with the innovator at his centre. It is a novel and ingenious technique that involves developing the retro-rectus space bilaterally and connecting them, with minimal access method, to duplicate the open RS repair. For larger defects, the same plane can be utilised to perform PCST (TAR), as described by Dr. Yuri Novitsky, to enable tension-free closure of hernia gap and achieving a greater mesh overlap.

Currently, we have used the technique for hernias with a width of 4–12 cm. It is difficult for us to suture defects wider than this. We prefer to use IPOM-plus for smaller defects because of its ease and less operative time.

Our technique is the same as the innovator except for one difference. We create both retro-rectus spaces initially by open technique and inflate it. This helps us in identifying and entering the opposite space more easily.

We have used TAR for closing large defects, allowing closure of posterior rectus sheath and non-midline hernias. We have noticed wide inter individual variability of distance between the two linea semilunaris. Sometimes (n = 3), we had to do limited right TAR for tension-free closure of posterior rectus sheath.

In our series, there was 1 recurrence in the short to medium term follow-up. This recurrence was probably due to misjudgement of mesh size required. After finding that, the mesh size inserted was too large for the space in a case of eTEP right TAR, we cut the mesh intracorporeally. It may have led to a mesh size that was actually smaller than needed.

The complications-linea alba dehiscence and recurrence- reflect our learning curve that can be avoided in future with experience and practice.

Although we did not have a controlled trial comparing the pain scores between our IPOM and eTEP patients, we found that the latter had lower requirement of analgesics. This may be due to the fact that no/minimal fixation was used in these cases.

The steep learning curve and the longer operative time are the main drawbacks of the procedure. The suturing of the linea alba is both technically demanding and a critical step to prevent dislodgement of the mesh.

CONCLUSION

With all its limitations, eTEP is an attractive option for selected cases because of improved outcome. There is a need to perform RCT between eTEP and IPOM/IPOM plus in these settings to have an evidence-based answer.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.