Abdominal Wall Endoscopic Extraperitoneal Reconstruction Technique 
 in Patients with Primary Midline Hernias and Diastasis 
 of the Rectus Abdominis Muscles

Abstract

Introduction. The paper focuses on technical features of endoscopic extraperitoneal reconstruction (EER) of the anterior abdominal wall in patients with primary median hernias combined with diastasis of the rectus abdominis muscles, the nuances of the operating room equipment and preparation of patients for intervention.The aim of the study was to analyze the stages and features of the technique for performing endoscopic extraperitoneal reconstruction of the anterior abdominal wall to ensure safe and qualified implementation of the operation in clinical practice.Materials and methods. This research was a prospective study including 45 clinical cases of patients with primary median hernias of the anterior abdominal wall combined with diastasis of the rectus abdominis muscles, who were exposed to endoscopic extraperitoneal reconstruction. The study was performed in the surgical department of the private healthcare facility "Central Clinical Hospital Russian Railways-Medicine" in 2019-2020. The median follow-up was 14 months (8 - 18 months), there were no complications estimated higher than type I according to the Clavien-Dindo classification and relapses.Results and discussion. Successful EER requires thorough preoperative preparation: to connect a second monitor; to distance anesthetic equipment; to ensure the patient is in an extension position in the lumbar segment of the spinal column; to identify principle anatomical landmarks under ultrasound control. The main two stages of EER - mobilization and reconstruction - are performed extraperitoneally in a confined space, and therefore the localization of the ports must be anatomically validated. The major point at the stage of mobilization is to maintain the integrity of the parietal peritoneum, this solves visualization problems and helps to work in the required layer of the anterior abdominal wall. Adherence to the principles of open surgery, namely, orientation of the needle holder at an angle close to 0 to the suture line (white line), and the needles at a right angle; maintaining working angles between the instruments 30-60, - allows effectively performing the reconstructive stage.Conclusion. Thus, a topographic-anatomically based approach to each stage of the operation and adherence to a set of features of the surgical technique allows safely and effectively applying EER for the treatment of patients with primary midline hernias and diastasis of the rectus abdominis muscles.