eTEP-RS for Ventral Hernia

Dr Rounak Mehrotra
• Daes introduced the eTEP for inguinal Hernia

• Belyansky in 2017 devised the same retrorectus space

• Emerging technique
• Indications: Similar to other endoscopic methods
• Additional TAR can be performed for larger defects
• Polypropylene mesh: low cost
Open RS
• Midline Laparotomy
• Division of medial border of PRS prior it forms Linea Alba B/L.
• Creating Retro-rectus space upto Linea Semilunaris.
• Suturing peritoneum just to isolate mesh.
Proper flexion
of OR table

• To maximize
sterno pubis
disctance
• Port position and placement (by open method) and Development of
Retro-rectus space by blunt camera dissection
Lamppost sign- NV medial to LS. Limit of Lateral dissection
Division of I/L PRS->Crossover->Division of C/L PRS

• Through Falciform lig. Dissecting space of retzius

C/L Retro rectus
dissection(electrocautery & • Both the Retrorectus spaces is linked by the preperitoneal bridge of
FL
blunt by port on other side)
Volcano sign
• Reduction of sac (adhesionolysis)
• Rents utilized for intraperitoneal inspection and reduction
Frenulum sign - B/L PRS and Xiphoid
• Division of this PRS
from xiphoid in M1&
M2 hernias.
Closure of the Post. defect and Restoration of linea alba
Non-resorbable barbed 0 sutre
Any smallest post defect closed 5-6 mmof Hg
No suturing of PRS, as only barrier layer Closes dead space
Large defects(˜10/12 cm) might require TAR
Carbonell’s algorithm

The sum of the bilateral rectus muscle width (RW) is at least twice the maximal
defect width(DW)
Mesh placement
The mesh size depends on the the
space created b/w two Semilunaris.
20 cm × 25 cm is used
Fixation usually not required ±
glue

Slow exsufflation
Check insufflation
Pros and Cons – eTEP
Pros Cons
• No intra abdominal mesh related • Prolonged operative time
complications • Steep learning curve
• Less cost • Need of advanced laparoscopic
• Less pain skills
• Sublay position - superior quality • Difficulty in crossover to the
of postoperative connective other side in large defect with
tissue formation previous incision
• TAR can be combined
Reversed TEP
Bittner proposed modification of
the TEP method
First optical trocar in umbilicus

Retromuscular space - similarly to

the TEP technique in inguinal hernia
repair
Dissection in the cranial direction,
analogously to the eTEP method.
n RS = 38 TAR = 41 79

Avg defect width(cm) 6.2 ± 3.7 11.1 ± 7.6

Average defect area (cm2) 70.1 ± 43.3 205.3 ± 164.6 132 ± 134.2

Average mesh area (cm2) 634.4 ± 319.7

Length of hospital stay 1.0 ± 0.7 2.7 ± 1.3 1.8 ± 1.8

• Multicentric and retrospective
• n= 79
• Average mesh area- 634.4 cm2
• Average defect area- 132.1 cm2
• Length of hospital stay- 1.8 days
• Seroma- 2
• Conversion - 2
• Recurrence- 1 (after 1 year)
• Follow-up- 332 ± 122 days
• Comparison of mean pre- and postoperative QOL(CCS) scores found significant
improvements in pain (68%,p<0.007) and movement limitations (87%, p<0.004)
at 6-month follow-up.
• Single centre & prospective
• N= 60 , incisional = 61.7% , median = 80%
• eTEP-RS(63.3%) , eTEP-TAR(30%) , IPOM (1(1.7%)), open 3(5%)
• Intraop complications=4(6.6%) LS disruptionTAR ; Perf – 1
• Readmission – 1 SBO d/t tension in post.
• Improvement in QOL wrt pain, activity,aesthetics
• Chronic pain= 1/57
• 15mnth recurrence 0
• Single centre & retrospective
• N= 21 , incisional = 18/21 , median = 80%
• eTEP-RS 9/21 , eTEP-TAR12/21 ,
• Mesh fixed and flat drain used
• SSI 1/21
• LA dehiscence d/t ergonomics 1/21
• Recurence 1/21 @ 3 months
• n = 92, 46 in each group
• Operative time - significantly higher for e-TEP,
• Postoperative pain (VAS), analgesic requirement, and postoperative hospital stay -
significantly less as compared to IPOM Plus.
• Seroma in 6 patients in e-TEP
• 2 cases (4.35%) of e-TEP had recurrence within 6 months but none in IPOM Plus
group.
THANK YOU