eTEP Technique Research Articles

Inguinal Hernia Repair: Comparative Study between TEP versus Extended Totally Extraperitoneal.

Inguinal hernia repair is a common surgical procedure, with laparoscopic techniques offering advantages over open surgery. The extended Totally Extraperitoneal (eTEP) technique provides a larger working space compared to the traditional Totally Extraperitoneal (TEP) approach, potentially improving outcomes. A prospective study was conducted comparing eTEP and TEP techniques for inguinal hernia repair at Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune. Forty patients (20 in each group) aged 15-65 with uncomplicated inguinal hernias were included. Surgical procedures were performed based on patient preference. Data on surgical duration, pain scores, hospital stay, and complications were collected and analyzed using statistical methods. eTEP surgery had a significantly shorter mean duration (48.70 ± 7.505 minutes) compared to TEP surgery (74.20 ± 7.78 minutes; P = 0.00). Patients undergoing eTEP experienced lower mean pain scores (3.75 ± 0.55) compared to those undergoing TEP (5.15 ± 0.745; P = 0.00). Hospital stay following eTEP surgery was shorter (1.70 ± 0.657 days) than following TEP surgery (3.65 ± 1.137 days; P = 0.00). eTEP had lower incidences of hematoma and surgical emphysema but higher seroma complications. TEP surgeries were associated with more post-operative complications and a higher likelihood of requiring conversion to open surgery. The eTEP technique offers several advantages over TEP, including shorter surgical duration, less post-operative pain, and shorter hospital stays. However, TEP had more complications related to seroma. Individual patient factors and surgeon experience should guide the choice of technique. The eTEP technique appears to be a promising option for inguinal hernia repair, offering advantages over TEP in terms of surgical outcomes. However, further studies are needed to evaluate long-term outcomes and complication rates comprehensively.

"Fully endoscopic preperitoneal ascending suprapubic approach for minimally invasive repair of anterior and lateral abdominal wall hernias".

The aim of this work is to describe the rational, feasibility and clinical and Quality-of-life improvement results of a fully endoscopic preperitoneal repair for midline and lateral abdominal wall hernias, starting from the space of Retzius in a "bottom-to-up" approach. An observational prospective data-collected and quality of life study is performed in selected patients with less than 10cm. in diameter midline and lateral abdominal wall hernias. A suprapubic upward e-TEP technique from a previously dissected Retzius space, is performed in all cases. The surgical goal is to perform a total free-tension abdominal wall reconstruction followed by a prosthetic hernioplasty. Clinical Data is classified in preoperative, intraoperative, and postoperative variables, including a quality-of-life clinical evaluation based on an improvement of HerQLes score. A total of 30 patients underwent this approach from September 2017 to October 2022 in a single-surgeon practice. A total restoration of the previous abdominal wall anatomy and a prosthetic repair were achieved in all cases. The mean operative time was 142.53min, with a significant shorter time in lateral hernias approach. Minor complications (Clavien-Dindo I) were collected in 10% of the patients. Major complications (Clavien-Dindo IIIb) occurred in 6.66% of the patients. The mean pain at discharge was 1.83 VAS, with a significant lower pain in M-eTEP approach for lateral hernias. The mean hospital stay was 42.4h. No seroma, hematoma, chronic pain, or recurrence was observed in the mean follow-up (20.33months). A clinical and quality of life improvement was found in 92.9% of the patients, measured by a minimal clinical important difference (MCID) between preoperative and postoperative HerQLes score. Despite being a technically demanding approach, the results obtained by this approach are compatible in safety and feasibility with other minimally invasive preperitoneal hernia repair techniques, in addition to obtaining a significant improvement in the quality of life of patients.

Prospective randomized study comparing mesh displacement in enhanced-view totally extraperitoneal versus totally extraperitoneal laparoscopic inguinal hernia repair without mesh fixation.

In laparoscopic inguinal hernia repair, it is thought that the mesh can be displaced more in the enhanced-view totally extraperitoneal (eTEP) technique. The aim of this study was to compare eTEP and totally extraperitoneal (TEP) techniques without mesh fixation in terms of mesh displacement and hernia recurrence. Between December 2022 and April 2023, 60 consecutive patients with unilateral inguinal hernia were randomized into two groups; eTEP group (n = 30) and TEP group (n = 30). There was without mesh fixation in both groups. Study was registered at http://Clinicaltrials.gov (NCT06070142). The mesh was marked with three radiopaque clips. Pelvic radiographs were performed to evaluate the displacement of the mesh. The primary outcome of this study was mesh displacement. In addition, this is the first study in the literature to compare eTEP and TEP techniques in terms of mesh displacement without fixation in laparoscopic inguinal hernia. There was no significant difference between the groups in terms of mesh displacement, recurrence, postoperative VAS scores, length of hospital stay, hematoma, and seroma formation. The operation time was higher in the eTEP group and was statistically significant. Without mesh fixation, the eTEP technique does not increase the risk of mesh displacement and recurrence. The eTEP technique can be safely applied without mesh fixation in laparoscopic inguinal hernia repairs. ClinicalTrials number: NCT06070142.

ROBOT-ASSISTED EXTRAPERITONEAL VENTRAL HERNIA REPAIR—EXPERIENCE FROM THE FIRST 160 CONSECUTIVE OPERATIONS WITH LATERAL eTEP AND eTAR TECHNIQUES

Abstract Background As in various other surgical domains, robotically assisted procedures have become integral in the management of ventral hernias in recent years. The employment of robotic technology enables the integration of minimally invasive techniques with retromuscular mesh placement. Beyond the conventional transabdominal approach, these surgical interventions can alternatively be executed in a total extraperitoneal fashion. The objective of this study is to demonstrate that robotic total extraperitoneal management of abdominal wall hernias is safe and efficient. Method A retrospective analysis encompassing all patients who underwent robotic surgery for ventral hernia repair utilizing the extraperitoneal eTEP technique with a lateral approach was conducted. The study period spanned from December 2019 to December 2023. Results Over the study period, a total of 160 patients underwent surgical intervention utilizing the lateral robotic eTEP technique. Among these cases, 43 patients required a lateral extension of retro-rectal dissection through extraperitoneal transversus abdominis release (eTAR) due to either the hernia size or lateral hernia localization. In every instance, an uncoated synthetic mesh was positioned in the retromuscular location, accompanied by complete fascial closure. The median hernia defect area was 25 cm² (2.25–375 cm²). The median mesh size was 540 cm² (225–1350 cm²). The median mesh defect ratio (MDR) was 21 (2.3–150). Two conversions (1.72%) were necessary. One intraoperative and seven postoperative complications were encountered (5%) out of which two required reoperations (1.72%). Conclusion The robotic extraperitoneal eTEP technique enables a retromuscular mesh placement in a minimally invasive approach. With the possibility of combination with a transversus abdominis release, even complex findings can be treated using this technique.

The eTEP/eTEP-TAR Repair of Ventral Hernias a Study From One Center/ One Surgeon-The First Five Years of Experience.

Objective: The objective of this study is analyze the outcomes of retro-muscular repair techniques for ventral hernias performed by a single surgeon in a renowned hernia surgery center. Method: This study involved 197 patients who underwent surgery between May 2016 and December 2021 under the care of a single surgeon (VR). Respecting the indication/contraindications of the eTEP procedure, 197 of 212 patients with ventral hernias underwent eTEP/eTEP-TAR surgery during this period. The cohort consisted of diverse hernia types, including median, lateral, and multiple-site defects. The safety of this approach was evaluated based on postoperative occurrences, where the number of complications accounted for 5% of the cases. Results of the study indicated that there was a significant improvement in the quality of life of patients following the procedure. The assessment, which measured postoperative pain, normal activity, and aesthetics on a 0-10 scale, showed improvement at 2 weeks and 3 months after surgery compared to the preoperative level. However, after a mean of 51.11 months, only one case of recurrence was reported. This recurrence occurred on top of the mesh, 18 months after the initial operation. The follow-up period lasted between 24 and 90 months. Patient monitoring was conducted either in person or over the phone, focusing on quality of life, postoperative pain, and the occurrence of recurrence. In conclusion, the laparo-endoscopic retro-muscular repair of ventral hernias, whether primary or incisional, has shown to yield excellent results in medium and long-term follow-up. The eTEP technique combines the benefits of the Rives-Stoppa technique (considered the gold standard in open ventral hernia repair) with the advantages of minimally invasive surgery.

Impact of cadaver training for learning abdominal wall reconstruction: our early experience.

Assess the utility of a hands-on cadaver workshop for teaching abdominal wall reconstruction (AWR) using components separation technique. Over a year, from June 2022 to July 2023, 112 surgeons participated in seven training courses focused on the eTEP technique for inguinal and ventral hernias. The workshops covered theoretical learning sessions followed by hands-on training using frozen human cadavers. An online survey was used to know the influence of our workshop on the clinical practice of the attendees. Out of 112 total participants, 70% (78) participants completed the survey. Among them, 58% (45) surgeons had over 10years of experience. The workshop resulted in approximately 85% (66) of participants successfully adapting to eTEP. Confidence levels significantly increased for all steps of the technique after the workshop (p < 0.001, Rank-Biserial Correlation = -1.000). Participants expressed high satisfaction with the course. The cadaver model training program was found to be effective in reducing the learning curve and being replicable. This suggests its potential for widespread implementation as an introductory training model for learning the anatomy of abdominal wall and adapting this for treating hernias requiring AWR.

A study to compare outcomes in patients undergoing intraperitoneal onlay mesh plus and eTEP repair for ventral wall and incisional hernia

Background: The introduction of minimally invasive surgery in the early 1990s enabled the possibility of laparoscopic ventral or incisional hernia repair in 1993. At present IPOM Plus (intraperitoneal onlay mesh) is the most frequent technique used for laparoscopic ventral hernia repair, and the mesh is placed just under the peritoneum and enhanced view totally extraperitoneal repair. A relatively new approach based on TEP repair for inguinal hernia has also shown to be safe and effective. our study is primarily aimed at assessing and comparing outcomes of lap IPOM plus and eTEP, in terms of operative time, postoperative pain, length of hospital stay. Methods: This is a retrospective cohort study. Data were collected from successive patients who have undergone minimally invasive ventral hernia repair from January 2020 to June 2022, in Global hospital Hyderabad). Data were entered into a prospectively maintained database and retrospectively analysed. Pateints were distributed into two groups IPOM plus and eTEP. Perioperative data were analysed using statistical tests. Results: In this study, a total of 76 patients with ventral and incisional hernias were included, with 40 patients undergoing IPOM plus repair and 36 patients undergoing eTEP repair. Both groups were similar in terms of risk factors, types of hernias, defect size. The duration of surgery was significantly shorter in the IPOM plus group (85.6 minutes) compared to the eTEP group (121.6 minutes). Postoperative pain, according to the VAS score at postoperative day 1 and 3, was significantly higher in the IPOM plus group (7.5 and 5.6, respectively) compared to the eTEP group (3.8 and 1.6, respectively). However, at day 30, pain scores in both groups were not statistically significant (IPOM plus-1.2 vs. eTEP 1.1). The mean length of hospital stay in the IPOM plus group (5.3 days) was significantly longer than in the eTEP group (3.1 days). Conclusions: The eTEP technique exhibits significantly lower postoperative pain and results in a reduced length of hospital stay. However, it is worth noting that the eTEP procedure does require a longer operative time compared to IPOM Plus.

Learning curves of robotic extended totally extraperitoneal (eTEP) hernia repair among two surgeons at a high-volume community hospital: a cumulative sum analysis.

Robotic extended totally extraperitoneal hernia (eTEP) repair is a novel technique for minimally invasive ventral hernia repair with retromuscular placement of mesh. This study aimed to evaluate the learning curve for robotic eTEP hernia repair using risk-adjusted cumulative sum (RA-CUSUM) analysis for two general surgeons-one with dedicated fellowship training in robotic eTEP technique (surgeon 2) and another without robotic eTEP-specific training (surgeon 1). We conducted a retrospective analysis of 98 patients undergoing robotic eTEP hernia repair from July 2020 to February 2022 for two surgeons. RA-CUSUM method was applied to the overall operative time (OT) in minutes, adjusting for transversus abdominis release (TAR). Figures 3 (surgeon 1) and 4 (surgeon 2) illustrate the three phases in the RA-CUSUM graphs of OT. For surgeon 1, the cases for each phase were determined: phase 1 (1 to 12), phase 2 (13 to 24), and phase 3 (25 to 51). For surgeon 2, the three phases were similarly determined as 1 to 8, 9 to 32, and 33 to 47, respectively. A significant (p = 0.017) difference existed for the OTs between phases 1 (262 ± 69) and 3 (192 ± 63.0) for surgeon 1. OT compared to the risk-adjusted value stabilized after case 12 and decreased after case 24 for surgeon 1; it began to decrease after case 8 for surgeon 2. The initial learning curve for surgeon 1 reached its plateau after 12 cases, shorter than comparable studies. This was likely due to the surgeon's intentional focus on learning this technique through courses, proctoring, and active mentorship. The flat learning curve seen in surgeon 2's series illustrates the value of experience gained during fellowship training. Our data support that, given the right resources and support, a short learning curve for eTEP is attainable for community surgeons without prior training in the technique.

P-027 Enhanced view totally extraperitoneal technique (e-TEP) for laparoscopic retromuscular inguinal hernia repair- our experience

Abstract The best approaches to repair inguinoscrotal hernias are still debated. Extended totally extraperitoneal repair technique (e-TEP) represents a modification of the traditional TEP method. The role of this technique is to overcome the limitations of the classical technique (limited dissection space), while still keeping the main advantages. The e-TEP technique allows an additional dissection space, a large surgical field and a very flexible trocarization, adaptable to many clinical situations and also good tolerance to pneumoperitobeum Our team uses the e-TEP technique to repair most cases of inguinal hernias. Between May 2017 and January 2023, we performed 102 operations, using the e-TEP technique. I used macroporous polypropylene mesh 15/12, fixed with cyanoacrylate. For a total of 102 cases, we registered a total of 6 self-limiting seromas, two cases were converted to open surgery, one wound infection and three recurrences. Patients were followed up one week, three months and one year, postoperatively. One patient presented with chronic pain one year postoperatively. The operating time was about 60–90 minutes. Conclusions Our experience with the e-TEP procedure has been satisfactory. We had no major complications, neither intra, or post-operatively, and the functional results were excellent. The operating time was found to be longer than usual at the beginning of the use of this technique, attributed to the novelty of the technique, the longer laryngeal curve and the complexity of the cases.

V-039 Combination of Botox &amp; eTEP &amp; hemi-TAR for giant hernia repair in an obese patient

Abstract Objective The possibility of new approaches allows dissecting wide retroperitoneal spaces with minimal tissue damage, make the laparoscopic approach a developing technique. Our purpose is to show how the extended-view totally extraperitoneal (eTEP) approach can be used for giant hernia repair in obese patients. Material and Methods 34-year-old man, with a history of laparotomy due to traumatic perforation of the colon and BMI: 39.18, presented hernia M2–5W3. Preoperative botox is performed 1 month before. Results laparoscopic approach was performed: dissector balloon in the left hypochondrium, 5mm trocars in the right hypochondrium and flank. And 10mm trocar on the right flank. Dissection of the left retrorectal space. Crossover in upper third. Dissection of the right retrorectal space. Hernial sac opening during dissection. Section of the right transverse muscle is completed and that space is released. Plication of the anterior fascia and hernial sac. Closure of the posterior fascia. Measurement and placement of 37×25 cm CICAT mesh fixed with tissucol. Conclusion Minimally invasive surgery allows more and more extensive surgeries to be performed, with less aggression to patients and faster recovery. With the technical improvements and the combinations of different tools, we're capable of performing laparoscopic repair of giant hernias. In our case, the preoperative application of botox, eTEP technique, and the combination of one-sided TAR allowed safe and uncomplicated repair of an M2-5W3 hernia defect. eTEP is a safe and reproducible technique that can be used in association with hemi TAR or bilateral TAR for the solution of giant hernias.

OC-030 COMPARISON OF OUTCOMES OF THE EXTENDED-VIEW TOTALLY EXTRAPERITONEAL RIVES-STOPPA (ETEP-RS) AND THE INTRAPERITONEAL ONLAY MESH WITH DEFECT CLOSURE (IPOM-PLUS) FOR W1-W2 MIDLINE INCISIONAL HERNIA REPAIR

Abstract Aim This study aimed to compare the outcomes of the eTEP-RS and IPOM-plus procedures in W1 and W2 midline incisional abdominal wall hernia (IAWH) repairs performed by the same surgeon. Material and Methods Prospectively collected data of laparoscopic abdominal wall repairs performed on 61 patients with eTEP between November 2018 and April 2022 and on 67 patients with IPOM-plus between January 2016 and April 2022 were retrospectively analyzed. A total of 74 out of 128 patients, 30 in the eTEP-RS group and 44 in the IPOM-plus group, who underwent W1-W2 midline incisional hernia repair were included in the study. The mean follow-up was 24 months in the eTEP-RS group and 45 months in the IPOM-plus group. Results There was no statistically significant difference between the groups regarding age, sex, BMI, ASA score, or active smoking. The mean mesh area (MMA) and mesh/defect (M/D) ratio were higher in the eTEP-RS group (p &amp;lt;0.001 and p =0.004). In the eTEP-RS group, the hospital length of stay (LOS) (1.48 days vs. 2.58 days, p &amp;lt;0.001) and pain on the first and 10th postoperative days were significantly lower (p &amp;lt;0.001), while the operative time was significantly longer (p &amp;lt;0.001). There was no significant difference in terms of intraoperative complications (p =0.56), seroma formation (p =0.83), or recurrence (p =0.83). Conclusions The eTEP-RS technique has advantages over the IPOM-plus approach, such as a shorter LOS and less early postoperative pain with W1-W2 midline IAWH repair. However, the eTEP technique has a longer operative time.

P-013 No recurrence after 15 years prospective long-term follow-up of open Total ExtraPeritoneal / TransInguinaI PrePeritoneal (oTEP/TIPP) inguinal hernia repair

Abstract Aim Evaluation of long-term follow-up results after open transinguinal preperitoneal (TIPP) technique with preformed lightweight mesh (PLM). Method This unicentric study included all consecutive 102 patients(10 women, 92 men; 93 primary, 9 recurrent hernias) operated for a groin hernia by the same surgeon using the same technique between June 2008 – September 2009. All patients were postoperatively followed-up with a control after 1 month and a survey follow-up between 40 and 54 months after surgery with subsequent clinical control if something abnormal appeared in the survey in January 2013. Results up until January 2023 were retrieved from the Swedish Hernia Register. Results 102 hernia repairs - 54 in general, 48 in local anesthesia. Clinical control after 1 month: There was no infection of the mesh, no clinical recurrence. -No reoperations were required. Questionnaire follow-up: -95 patients (93%) were followed-up. Slight, not permanent pain in 8.8% of patients who did not require the consumption of systematic painkillers and are not limited in their activities. No reoperations have so far been recorded in the Swedish Hernia Register with 81 patients still alive in long-term follow-up . Discussion -No recorded recurrences after 15 years of follow-ups is encouraging. -This technique consisted of the placement of a patch in the preperitoneal space, which combines the benefits of the anterior approach (i.e., easy and safe technique, short learning curve, local anesthesia, low cost) and the preperitoneal placement of the mesh (less recurrence, less pain). This procedure is a good alternative to eTEP technique. PLM=PolysoftMesh/Bard

V-012 MADRID-PCS. STEP BY STEP E-TEP APPROACH

Abstract Aim To show the steps involved in the Madrid Modification of posterior component separation (PCS) by e-TEP approach. Material and Methods We present a case of a patient with a lateral incisional hernia (L3W1) associated with primary umbilical hernia and ipsilateral groin hernia. The repair that allows treatment of all defects and wide prosthetic coverage with wall reinforcement is PCS, performed in this case according to the Madrid modification. Due to the presence of risk factors for surgical site occurrences such as obesity, we decided to perform a totally extraperitoneal minimally invasive approach (e-TEP) and the step-by-step procedure is shown. Conclusions Minimally invasive surgery has become the standard approach in many abdominal wall pathologies. Since the description of the e-TEP technique in 2017, its growth and development has been exponential, progressively expanding for large defects and other locations; being especially indicated versus open surgery for patients with risk factors for surgical site events. Likewise, the technique of PCS described in 2012 by Novitsky has been extended in recent years and is now the gold standard in the treatment of complex abdominal wall hernias. From the Madrid group, modifications to this technique have been proposed. We present a video that combines this modification with minimally invasive surgery, visualizing the steps of this technique using the e-TEP approach.

Social and economic aspects of treatment of patients with medium (W2) and large (W3) postoperative ventral hernias

The article describes social and economic aspects of the treatment of patients with medium and large postoperative ventral hernias . The study was based on the results of treatment of 181 patients operated by endovideosurgical and open methods for postoperative ventral hernias . The stratification of patients was carried out on the basis of the mod ern classification of postoperative hernias of the EHS approved in the national clinical guidelines . The first main group of patients who underwent laparoscopic hernioplasty using the IPOM+ technique ( intraperitoneal onlay mesh ) consisted of 47 people . The second main group included 12 patients operated using the preperitoneal eTEP technique ( extended total extraperitoneal plasty ). The control group consisted of 122 patients with postoperative ventral hernias who underwent traditional ( open ) hernioplasty : using the techniques of onlay – 35 patients , inlay – 12, sublay – 75. Preoperative examination before planned minimally invasive hernioplasty included routine laboratory and instrumental examinations . The exceptions were patients with stage II and III obesity , as well as large postoperative ventral hernias , patients who underwent computed tomography with abdominometry . The economic efficiency of the treated patients was calculated using standardized formulas . It has been established that the complete e- TEP operation statistically reliably allows to get a significant economic effect compared to the laparoscopic IPOM surgery . IPOM endovideohernioplasty can be used in patients with a combined surgical disease of the abdominal organs in the case of simultaneous intervention . Traditional hernioplasty in patients with large and giant hernias with reduction of abdominal volume are the operations of choice and significantly increase the economic efficiency of the medical hospital . A modern surgical hospital should be able to perform any variants of both traditional and endovideosurgical hernioplasty in order to provide effective medical care and achieve optimal economic performance in any of the existing health insurance systems .

Researching extended-view totally extraperitoneal (eTEP) approach for the treatment of inguinal hernia: two case reports

Currently, mesh placement laparoscopic surgery is a first-line procedure for the repair of an inguinal hernia. Extended-view totally extraperitoneal (eTEP) technique for inguinal hernia repair has many advantages, such as the creation of an enlargement view, flexible port setup adaptability, and possible tolerance of pneumoperitoneum. Besides, it also repaired an incisional hernia. To contribute to the study and evaluation of the results of the eTEP technique for inguinal hernia repair, we reported the first two cases performed eTEP technique approach for the treatment of an inguinal hernia at our department: a 79-year-old male and a 62-year-old male referred to hospital for indirect inguinal hernia on the right side. Initial results were effective and safe. However, we need to research and follow up on the long-term outcomes to assess the advantages of this technique. Key words: inguinal hernia, inguinal hernia repair, Laparoscopic hernia repair, eTEP.

Comparison of outcomes of the extended-view totally extraperitoneal rives-stoppa (eTEP-RS) and the intraperitoneal onlay mesh with defect closure (IPOM-plus) for W1-W2 midline incisional hernia repair-a single-center experience.

The eTEP technique is a new approach that has recently gained popularity in abdominal wall hernia surgery. This study aimed to compare the outcomes of the eTEP-RS and IPOM-plus procedures in W1 and W2 midline incisional abdominal wall hernia (IAWH) repairs performed by the same surgeon. Prospectively collected data of laparoscopic abdominal wall repairs performed on 61 patients with eTEP between November 2018 and April 2022 and on 67 patients with IPOM-plus between January 2016 and April 2022 were retrospectively analyzed. A total of 74 out of 128 patients, 30 in the eTEP-RS group and 44 in the IPOM-plus group, who underwent W1-W2 midline incisional hernia repair were included in the study. The mean follow-up was 24months in the eTEP-RS group and 45months in the IPOM-plus group. There was no statistically significant difference between the groups regarding age, sex, BMI, ASA score, or active smoking. No difference was seen between the two groups in terms of the mean defect area (MDA, 28.17cm2 vs. 27.41cm2, p = 0.84), but the mean mesh area (MMA) and mesh/defect (M/D) ratio were higher in the eTEP-RS group (404.11cm2 vs. 267.85cm2, p < 0.001 and 20.96 vs. 12.36, p = 0.004). In the eTEP-RS group, the hospital length of stay (LOS) (1.48days vs. 2.58days, p < 0.001) and pain on the first and 10th postoperative days were significantly lower (p < 0.001), while the operative time was significantly longer (204.07min vs. 88.33min, p < 0.001). There was no significant difference in terms of intraoperative complications (p = 0.56), seroma formation (p = 0.83), or recurrence (p = 0.83). The eTEP-RS technique has advantages over the IPOM-plus approach, such as a shorter LOS and less early postoperative pain with W1-W2 midline IAWH repair. However, the eTEP technique has a longer operative time.

Inside to outside puncture following endoscopic localization-A novel technique to insert ports and create retromuscular space in eTEP for ventral hernias.

Enhanced-view totally extraperitoneal plasty (eTEP) has been used worldwide to repair ventral hernias. This study aimed to describe a novel technique to insert ports and create retromuscular space in more detail. From 2020 to 2022, 23 consecutive ventral hernia repairs were performed using the eTEP technique. In all cases, inside-to-outside puncture following endoscopic localization was utilized to insert ports and create retromuscular space. All cases were completed with the eTEP technique, and no cases with conversion to open repair or IPOM technique. There were no epigastric vessel injuries and posterior sheath tears due to puncture. In addition, no postoperative hematoma cases were reported. Inside-to-outside puncture following endoscopic localization to insert ports and create retromuscular space is a safe, feasible, reproducible technique in eTEP for ventral hernia repair.

Endoscopic Mini-or Less-Open Sublay Operation (E/MILOS) in ventral hernia repair: a minimally invasive alternative technique.

The ideal ventral hernia surgical repair is still in discussion1. The defect closure with a mesh-based repair is the base of surgical repair, in open or minimally invasive techniques2. The open methods lead to a higher surgical site infections incidence, meanwhile, the laparoscopic IPOM (intraperitoneal onlay mesh) increases the risk of intestinal lesions, adhesions, and bowel obstruction, in addition to requiring double mesh and fixation products which increase its costs and could worsen the post-operative pain3-5. The eTEP (extended/enhanced view totally intraperitoneal) technique has also arisen as a good option for this hernia repair. To avoid the disadvantages found in classic open and laparoscopic techniques, the MILOS (Endoscopically Assisted Mini or Less Open Sublay Repair) concept, created by W. Reinpold et al. in 2009, 3 years after eTEP conceptualization, allows the usage of bigger meshes through a small skin incision and laparoscopic retro-rectus space dissection, as the 2016 modification, avoiding an intraperitoneal mesh placement6,7. This new technique has been called E-MILOS (Endoscopic Mini or Less Open Sublay Repair)8. The aim of this paper is to report the E-MILOS techniques primary experience Brazil, in Santa Casa de Misericórdia de São Paulo.

ETEP technique for inguinal and ventral hernias: approach being simplified

Background: Enhanced view totally extra peritoneal (eTEP) approach for inguinal and ventral hernias repair is becoming the preferred technique. Initially the technique was described by Jorge Daes for inguinal hernia repair and later Igor Belyansky applied this technique for ventral and incisional hernia repair. Since it does not penetrate the peritoneal cavity, the major advantage of this approach is in reducing the risk of intestinal and vascular injuries as well as herniation at the trocar sites. This eTEP approach provides scope for flexible port placement and wide coverage by the prosthetic mesh in the retromuscular space with hardly any transfascial fixation. Here we bring forward the technical benefits and avoidable hurdles encountered which might render this as most sought approach. Patients and Methods: 72 patients with mean age of 44 yrs underwent eTEP repair between July 2018 and June 2022. The data was analysed for standardising the surgical steps of eTEP approach, operative time taken, technical advantages in this approach and hurdles encountered Results: All 72 patients underwent laparoscopic repair successfully. There were six conversions to alternate laparoscopic hernia repair techniques. The operative time improved with the subsequent surgeries though initially it was prolonged. Conclusion: Our clinical experience with eTEP approach has been convincing. With improved technical steps, adjunct hybrid manoeuvres &amp; hurdles overcome; eTEP is becoming a favourable approach for laparoscopic inguinal and ventral hernias repair in our practice. We believe this technique makes a striking presence among all the types of surgical approaches for laparoscopic hernia repair.

Robot-assisted extraperitoneal ventral hernia repair-Experience from the first 61 consecutive operations with eTEP and eTAR techniques

As in many other fields of surgery, robotically assisted surgical procedures have been established in the treatment of ventral hernias in recent years. The use of the robot can combine the demands of a minimally invasive approach and retromuscular mesh placement. In addition to a transabdominal approach, these procedures can also be performed using an extraperitoneal approach. The purpose of this study is to demonstrate that robotic total extraperitoneal management of abdominal wall hernias is safe and efficient. A retrospective analysis of all robotically operated patients on ventral hernia using extraperitoneal eTEP technique from September 2019 to May 2022 was performed. A total of 61 ventral hernias were operated on using the robotic eTEP technique during the study period. In 14 patients retro-rectal dissection was extended laterally by an extraperitoneal transversus abdominis release (eTAR) because of the hernia size or a lateral hernia localization. In all cases, an uncoated synthetic mesh was placed in the retromuscular position with complete closure of the hernia defects. The median hernia defect area was 30 cm² (4-308 cm²). The median mesh size was 540 cm² (300-1350 cm²). The median mesh defect ratio (MDR) was 17.78 (3.06-145). One intraoperative and three postoperative complications were encountered. Neither conversion nor reoperation were required. The robotic extraperitoneal eTEP technique enables the required retromuscular mesh placement in a minimally invasive approach. With the possibility of a combination with a transversus abdominis release, even complex findings can be treated using this technique.