Extraperitoneal Approach Research Articles

Enhanced view totally extraperitoneal approach: A better alternative to transabdominal preperitoneal approach for irreducible inguinoscrotal and giant inguinal hernias!

The advantages of enhanced view totally extraperitoneal (eTEP) over TEP approach are well established in large inguinoscrotal, recurrent inguinal, patients with short pubis to umbilicus distance and in obese patients. Irreducible inguinoscrotal hernias (IISHs) and giant inguinal hernias (GIHs) pose a great challenge. GIHs are hernias which extend below the midpoint of the inner thigh with the patient in the standing position. Majority of these hernias are managed by open, hybrid or by transabdominal pre-peritoneal (TAPP) approach. TAPP was considered the optimal minimally invasive approach for these hernias as it provides a large working space and reduction of contents under vision. My practice of eTEP has been limited to IISH and GIH. I would like to share some technical tips to manage these cases by eTEP approach.

Extraperitoneal robot-assisted radical prostatectomy with the Hugo™ RAS system: initial experience of a tertiary center with a high background in extraperitoneal laparoscopy surgery.

The Hugo™ RAS system is a novel robotic platform with innovative features. However, there are currently no available data on extraperitoneal robot-assisted radical prostatectomy (RARP) performed using this system. The objective of this study is to describe the surgical setup and assess the safety and feasibility of the extraperitoneal approach in robotic radical prostatectomy with the Hugo™ RAS system. Sixteen consecutive patients diagnosed with localized prostate cancer underwent extraperitoneal RARP ± lymph node dissection at our institution, between March and May 2023. All RARP procedures were performed extraperitoneal with a modular four-arm configuration. The focus was to describe the operative room setup, trocar placement, tilt and docking angles and evaluate the safety and feasibility of this approach with this robotic platform. Secondary outcomes recorded included, total operative time, console time, estimated bleeding, intra- and postoperative complications, and length of stay after surgery. A descriptive analysis was conducted. We report on the first sixteen cases of extraperitoneal robot-assisted radical prostatectomy performed with the new Hugo™ RAS system. All procedures were completed, without the need for conversion or placement of additional ports. No intraoperative complications or major technical failures that would prevent the completion of surgery were recorded. The median operative time was 211min (IQR 180-277), and the median console time was 152min (IQR 119-196). The mean docking time was 4.6min (IQR 4.1-5.2). The median estimated blood loss and the median time to remove the vesical catheter were 200mL (IQR 150-400) and 8days (IQR 7-8), respectively. The median length of stay was 2 days (IQR 2-2). Only one minor complication was registered in the first 30days. This study provides evidence of the safety and feasibility of the extraperitoneal approach in RARP with the Hugo™ RAS system. The description of the surgical setup in terms of trocar placement, arm-cart disposition, tilt and docking angles offers valuable information for surgeons interested in adopting this surgical approach with the Hugo™ RAS platform.

Comparison of extra-peritoneal cesarean section with conventional trans-peritoneal cesarean section: An open label randomized controlled trial.

To ascertain whether extra-peritoneal approach is superior to conventional trans-peritoneal approach of cesarean section in terms of fetus delivery time, intra-operative and postoperative outcomes, including return of bowel activity and pain. An open-label randomized controlled trial conducted over one year and six months at a tertiary care center in India. As per sample size calculation, 68 women enrolled in the study; 34 underwent extra-peritoneal, and another 34 underwent trans-peritoneal cesarean section after randomization. Statistical analysis was done with independent sample 't' test, chi-squared test, and fisher's exact test. Baseline characteristics were comparable in both groups. Fetus delivery time was significantly higher in extra-peritoneal than trans-peritoneal cesarean section (14.26±1.26 vs. 9.38±1.83min; p=<0.001). Total operation time was also higher in extra-peritoneal than trans-peritoneal approach (63.24±12.74 vs. 57.41±8.62min; p=0.027). Whereas average blood loss was comparable in both groups (733.82±219.06 vs. 694.12±351.57ml; p=0.063). Postoperatively, return of bowel activity was significantly earlier in extra-peritoneal than trans-peritoneal approach (4.59±0.56 vs. 8.65±1.23h; p=<0.001). Mean time taken for passage of flatus was also significantly less in extra-peritoneal cesarean section (8.56±0.99 vs. 12.76±2.05h; p=<0.001). Pain score at 6, 12, and 18h was significantly lower in extra-peritoneal approach. No patient in extra-peritoneal approach had nausea, vomiting, and abdominal distension. Whereas 11.8 % of patients had nausea, 5.9 % had constipation, and 14.7 % had abdominal distension in trans-peritoneal cesarean section. Requirement of injectable antibiotics and analgesics, and hospital stay was less with extra-peritoneal approach. Extra-peritoneal cesarean section is associated with better postoperative outcomes with respect to return of bowel functions, pain, and requirement of injectable analgesics and antibiotics than the routine trans-peritoneal cesarean section. However, the significantly higher fetus delivery time questions its feasibility in patients with acute fetal distress. Additionally, it is technically difficult and has a longer learning curve.

1119 A Scoping Review of Kidney Transplantation in Africa: How Far Have We Come?

Abstract Aim Kidney transplantation is a life-saving treatment for patients with end-stage kidney disease. However, the availability of kidney transplantation in Africa has lagged behind other regions of the world, leading to significant disparities in access to care. In this study, we sought to analyse indications for transplant, demographic characteristics, and outcomes of kidney transplantation in Africa from inception till date. Method The Preferred Reporting Items for Systematic Reviews and Meta-Analyses were used in conducting this study. PubMed, Google Scholar, and African Journal Online were searched. Data on procedure done, graft outcomes, donor, prophylaxis given for graft, post-op complications, and survival timelines were pooled together and analysed. Thirty-three studies fully satisfied the eligibility criteria and were used in this review. Results The most common causes of end-stage kidney disease requiring transplant included glomerulonephritis and Nephroangiosclerosis. Overall, open nephrectomy accounted for 95% of the surgical approach used. The other approaches documented were Hand-assisted Laparoscopic Nephrectomy (3.88%), Extraperitoneal approach (0.55%), and Simultaneous Unilateral native nephrectomy (0.12%). In total, 56.3% (4221) of all donors were living donors of which 68.5% were related to the recipient (living-related donor), while 43.7% (3280) patients received transplants from cadaveric donors. The commonest surgical complication was graft rejection (39.44%). In the follow-up period, 60.49% of patients who had a kidney transplant developed hypertension. Conclusions In conclusion, our study not only highlights the potential for kidney transplantation to improve the lives of patients in Africa, but also the need for further research and infrastructure development to make this a more widespread and successful option.

WTP4.1 Can Deep Stomal Fixation and Extraperitoneal Stoma Creation Improve Stoma Morbidity? Systematic Review and Meta-Analysis

Abstract Aim This systematic review evaluates the efficacy and safety of two operative techniques: deep stomal fixation (fixation of stoma to the sheath of abdominal wall muscles and/or peritoneum) and extraperitoneal approach of stoma creation. Method PubMed, Medline, Cochrane, and Google Scholar were searched for studies comparing stoma fixation to the sheath and/or peritoneum to the conventional skin-only fixation and extraperitoneal to transperitoneal approaches of stoma formation. Clinical endpoints included parastomal hernia (PSH), stoma prolapse, retraction and associated adverse effects. Results 2 randomised and 2 retrospective studies investigated deep stomal fixation. There was no statistically significant benefit of this technique in terms of PSH (OR 1.19, P=0.82), prolapse (OR 0.62, P=0.53) or retraction (OR 1.16, P=0.80). Some technical difficulties on stoma reversal were reported in one of the studies. As for extraperitoneal stoma creation, 2 randomised and 8 retrospective studies compared it to the conventional transperitoneal approach. A statistically notable reduction in PSH was identified in extraperitoneal stomas (OR 0.29, P=0.004). This technique showed statistically insignificant reduction in prolapse (OR 0.74, P=0.53) and retraction (OR 0.48, P=0.36). There was no significant difference in operative time (MD 3.45, P=0.71) or the associated risk of small bowel obstruction (OR 0.68, P=0.57). Conclusion Stoma fixation to the abdominal muscle sheath and/or peritoneum does not lower stomal complications, and conversely it may make stoma reversal technically challenging. Extraperitoneal approach minimises PSH occurrence with no remarkable adverse effects; yet more randomised trials are required for further evaluation.

Initial experience of laparoendoscopic single-site radical prostatectomy with a novel purpose-built robotic system

ObjectiveThis prospective single-arm clinical trial aimed to evaluated the feasibility and safety of the application of the SHURUI system (Beijing Surgerii Technology Co., Ltd., Beijing, China), a novel purpose-built robotic system, in single-port robotic radical prostatectomy. MethodsSixteen patients diagnosed with prostate cancer were prospectively enrolled in and underwent robotic radical prostatectomy from October 2021 to August 2022 by the SHURUI single-port robotic surgical system. The demographic and baseline data, surgical, oncological, and functional outcomes as well as follow-up data were recorded. ResultsThe mean operative time was 226.3 (standard deviation [SD] 52.0) min, and the mean console time was 183.4 (SD 48.3) min, with the mean estimated blood loss of 116.3 (SD 90.0) mL. The mean length of postoperative hospital stay was 4.50 (SD 0.97) days. Two patients had postoperative complications (Clavien-Dindo Grade II), and both patients improved after conservative treatment. All patients’ postoperative prostate-specific antigen levels decreased to below 0.2 ng/mL 1 month after discharge. The mean prostate-specific antigen level further decreased to a mean of 0.0219 (SD 0.0641) ng/mL 6 months after surgery. Thirty days postoperatively, 12 out of 16 patients reported using no more than one urinary pad per day, and all patients reported satisfactory urinary control without the need for pads 6 months after surgery. ConclusionThe SHURUI system is safe and feasible in performing radical prostatectomy via both transperitoneal and extraperitoneal approaches. Tumor control and urinary continence were satisfying for patients enrolled in. The next phase involves conducting a large-scale, multicenter randomized controlled trial to thoroughly assess the effectiveness and safety of the new technology in a broader population.

Extraperitoneal approach to left-sided colorectal resections (EXPERTS procedure).

Extraperitoneal approach to left-sided colorectal resections (EXPERTS procedure).

Robot-assisted oncologic pelvic surgery with Hugo™ robot-assisted surgery system: A single-center experience

ObjectiveTo report the outcomes of intra- and extra-peritoneal robot-assisted radical prostatectomy (RARP) and robot-assisted radical cystectomy (RARC) with Hugo™ robot-assisted surgery (RAS) system (Medtronic, Minneapolis, MN, USA). MethodsData of twenty patients who underwent RARP and one RARC at our institution between February 2022 and January 2023 were reported. The primary endpoint of the study was to report the surgical setting of Hugo™ RAS system to perform RARP and RARC. The secondary endpoint was to assess the feasibility of RARP and RARC with this novel robotic platform and report the outcomes. ResultsSeventeen patients underwent RARP with a transperitoneal approach, and three with an extraperitoneal approach; and one patient underwent RARC with intracorporeal ileal conduit. No intraoperative complications occurred. Median docking and console time were 12 (interquartile range [IQR] 7–16) min and 185 (IQR 177–192) min for transperitoneal RARP, 15 (IQR 12–17) min and 170 (IQR 162–185) min for extraperitoneal RARP. No intraoperative complications occurred. One patient submitted to extraperitoneal RARP had a urinary tract infection in the postoperative period that required an antibiotic treatment (Clavien-Dindo Grade 2). In case of transperitoneal RARP, two minor complications occurred (one pelvic hematoma and one urinary tract infection; both Clavien-Dindo Grade 2). ConclusionHugo™ RAS system is a novel promising robotic platform that allows to perform major oncological pelvic surgery. We showed the feasibility of RARP both intra- and extra-peritoneally and RARC with intracorporeal ileal conduit with this novel platform.

Experiences with an Extraperitoneal Transvesicoscopic Repair of a Vesicovaginal Fistula.

Purpose A vesicovaginal fistula (VVF) is a debilitating condition for women in terms of both its personal and social impacts. A reported transperitoneal laparoscopic approach to treatment has some limitations such as risk of intra-peritoneal organ injury and unnecessary bladder dissection. We here report on our experiences with an extraperitoneal transvesicoscopic approach to a VVF repair, which overcomes these drawbacks. Materials and Methods Seven VVF patients were treated using the transvesicoscopic approach. Under general anesthesia, patients were placed in the dorsal lithotomy position. The VVF orifice was obstructed via the vaginal canal using a Foley catheter. The bladder was then filled with normal saline under cystoscopic inspection, and a 5 mm trocar was inserted into it at the suprapubic area. The bladder wall was next fixed to the anterior abdominal wall. Thereafter, two 3 mm ports were punctured at the interspinous skin crease allowing the fistula margin to be cut and sutured in layers. Results Six of the study subjects in whom we attempted a transvesicoscopic repair of VVF had undergone a hysterectomy due to myoma and one had an intraabdominal abscess removal with Behcet's disease. One myoma patient who had a preexisting vesicoperitoneal fistula was converted to an open transabdominal VVF repair. The mean age of the 6 remaining patients was 46.0 ± 7.2 years (range, 35-57). The mean operation time was 273 ± 40.6 minutes (range, 223-323). There was no instances of significant pain or other immediate complications. Five patients showed no recurrence of the fistula during the follow-up period (8.7±5.1 months). Conclusion A transvesicoscopic approach is an effective modality for the repair of a VVF that is more minimally invasive and has a lower morbidity than a transabdominal procedure.

Low Risk of Postoperative Hernia Following Single-port Robot-assisted Radical Prostatectomy: A Report From the Single-port Advanced Research Consortium (SPARC)

To evaluate the risk of postoperative hernia following different approaches of single-port robot-assisted radical prostatectomy (SP-RARP). A retrospective review was performed on patients who underwent SP-RARP between February 2019 and December 2022. Demographic and clinical information was collected from the multi-institutional, prospectively-maintained Single-Port Advanced Research Consortium (SPARC) database. Data were analyzed using IBM Statistical Packaging for Social Sciences (SPSS) version 29.0 with descriptive statistics as presented. A total of 1103 patients were identified, consisting of 244 (22.1%), 712 (64.6%), and 147 (13.3%) cases performed via transperitoneal, extraperitoneal (EP), and transvesical (TV) approaches, respectively. During a median follow-up time of 11 months (interquartile range 5.7-17.1 months), only two cases of incisional hernia were reported. Both cases occurred following transperitoneal SP-RARP with one patient requiring surgical repair. There remains no evidence of postoperative hernia following EP and TV SP-RARP at the completion of our review. SP-RARP was associated with low risk for postoperative hernia. The risk was lower following TV and EP SP-RARP where the peritoneum is preserved.

Endovideoscopic urethra-sparing simple prostatectomy via an extraperitoneal approach as treatment of benign prostatic hyperplasia

Aim. To evaluate the efficacy of endovideoscopic urethra-sparing simple prostatectomy via an extraperitoneal approach (EUSP) for patients with benign prostatic hyperplasia.&#x0D; Materials and methods. In the period from January 2021 until September 2022 8 patients underwent EUSP. Initial clinical datas, perioperative and postoperative outcomes, implications, IPSS questionnaires, IIEF-5 and ejaculatory datas have been evaluated. The technique of the present method was adopted from Ping Wang, Dan Xia, SunYi Ye, DeBo Kong, Jie Qin, TaiLe Jing, YeQing Mao, HongZhou Meng, Shuo Wang (2018).&#x0D; Results. Seven (87.5%) patients underwent EUSP successfully, 1 (12.5%) patient needed conversion into open simple prostatectomy. Mean time of operation was 171 minutes (150–185), mean blood loss was 232 ml (180–300). In 2 (25%) cases urethral reconstruction after damage was needed. Mean catheterization time was 1.5 days (1–4). According to Clavien–Dindo classification (2004) such complications were found: low degree – 2 (1 or 2 group), 3а group – 1 (severe hematuria, when bladder infusion is needed). Mean management time was 8.4 months (6–11). Results from post-operative questionnaire IPSS (p0.1) и QoL (p0.1) significantly improved. Totally 4 patients had secure erectile function: 3 of them had normal erection, the last one (1) – retrograde ejaculation.&#x0D; Conclusion. EUSP is technically applicable for patients with benign prostatic hyperplasia. Patients have shorter time of catheterization, risk profile, significant improvement of urination и support of antegrade ejaculation.

Efficacy of extended view totally extra peritoneal approach versus laparoscopic intraperitoneal on lay mesh plus for abdominal wall hernias: a single center preliminary retrospective study

BackgroundLaparoscopic minimally invasive surgery has become the primary treatment for ventral hernias. The laparoscopic intraperitoneal on lay mesh (IPOM) plus approach for abdominal wall hernias is the most used procedure, while extended view totally extraperitoneal (e‑TEP) repair is a newer option. This study aimed to compare the effectiveness and complications of the 2 procedures for abdominal wall hernias repair.MethodsThis was a retrospective and comparative single-center study done at The Second Clinical Medical College, Jinan University Hospital (Shenzhen People’s Hospital), Shenzhen, China. The study included patients with a 2 to 6 cm abdominal wall defect who underwent hernia repair from January 2022 to December 2022. Patients’ baseline characteristics, hernia features, operative time, blood loss, postoperative pain level, and total hospitalization expenses were extracted from the medical records and compared between patients who underwent the IPOM plus and e-TEP repair.ResultsA total of 53 patients were included: 22 in the e-TEP group and 31 in IPOM plus group. Patient demographic characteristics were similar between the 2 groups. The operation time of the e-TEP groups was significantly longer than the IPOM plus (98.5 ± 10.7 min vs. 65.9 ± 7.3 min, P < 0.01). Postoperative pain levels (VAS; visual analog scale) (4.2 ± 0.9 vs. 6.7 ± 0.9, P < 0.01), analgesic requirements (Tramadol) (25.0 ± 37.0 mg vs. 72.6 ± 40.5 mg, P < 0.01), length of hospital stay (1.2 ± 0.5days vs. 2.2 ± 0.6days, P < 0.01), and total hospitalization expenses (19695.9 ± 1221.7CNY vs. 35286.2 ± 1196.6CNY, P < 0.01) were significantly lower in the e-TEP group. The mean intraoperative blood loss was similar between the 2 groups. No postoperative complications were observed in either group.ConclusionThe e-TEP approach for abdominal wall hernias appears to be better than IPOM plus with respect to postoperative pain levels(VAS: 4.2 ± 0.9 vs. 6.7 ± 0.9, P < 0.01), analgesic requirements(25.0 ± 37.0 mg vs. 72.6 ± 40.5 mg, P < 0.01), length of hospital stay(1.2 ± 0.5days vs. 2.2 ± 0.6days, P < 0.01), and hospitalization costs (19695.9 ± 1221.7CNY vs. 35286.2 ± 1196.6CNY, P < 0.01).

A randomised control trial study of early post-operative pain and intraoperative surgeon workload following laparoscopic mesh repair of midline ventral hernia by enhanced-view totally extraperitoneal and intraperitoneal onlay mesh plus approach.

The aim of this study was to compare the peri-operative outcomes, especially intraoperative surgeon workload and early post-operative pain, following midline ventral hernia repair by laparoscopic enhanced-view totally extraperitoneal (eTEP) approach and laparoscopic intraperitoneal onlay mesh plus (IPOM plus) approach. This single-centre randomised control trial study was conducted from January 2020 to June 2022. A total of 60 adult patients undergoing elective ventral hernia surgery with small- and medium-sized midline defects were included. Intraoperative surgeon workload and early post-operative pain were systematically recorded and analysed for each procedure. Out of 30 patients assigned to each group, 29 patients underwent eTEP mesh repair and 27 patients underwent successful IPOM plus repair. The intraoperative surgeon's workload, especially mental demand, physical demand, task complexity and degree of difficulty as reported and felt by the operating surgeon, was significantly higher in the eTEP mesh repair group compared to IPOM plus group (P < 0.001) with comparable operating room distractions (P = 0.039). The mean overall post-operative pain score on post-operative day 1 was slightly less in eTEP mesh repair (4.28 ± 1.12) group compared to IPOM plus group (4.93 ± 1.17), which was statistically insignificant (P = 0.042). The eTEP group had significantly longer operative time and length of hospital stay compared to the IPOM plus group. Our study revealed significantly longer operative time, higher surgical workload and increased length of hospital stay in the eTEP group with comparable early post-operative pain in both groups, thus making eTEP mesh repair a more difficult and challenging procedure.

Initial experience and short-term outcomes of single-port extraperitoneal transvesical robot-assisted radical prostatectomy: a two-center study.

This study presents the procedure of single-port extraperitoneal transvesical approach to robot-assisted radical prostatectomy (SETvRARP) on the da Vinci Xi platform coupling with a 4-channel single port and evaluated the short-term outcomes in the first 72 prostate cancer (PCa) patients. Seventy-two patients with localized PCa were enrolled. Each operation was conducted by the same single robotic surgery group in two centers using the da Vinci Xi system. The median operation time was 150 min, and the median estimated blood loss was 50 mL. All operations were successfully carried out without open conversion or transfusion. No ≥ Grade II complications were noted. Urethral catheters were routinely removed on postoperative day 7. Sixty-eight (94.4%) patients recovered to immediate urinary continence after surgery, with 72 (100%) patients achieving full continence on postoperative day 14. A positive surgical margin was observed in 15 (20.8%) patients. Postoperative urodynamic studies regarding peak urinary flow, bladder capacity, and residual urine were not statically different from the preoperative results. No biochemical recurrence was noted in all patients within the follow-up period. Postoperative erectile function was not statistically different from the preoperative results (P=0.1697). SETvRARP using the da Vinci Xi system coupling with a 4-channel single port is a valid radical prostatectomy technique in well-selected PCa patients, resulting in superior postoperative recovery of urinary continence. Meanwhile, the outcomes in functional protection and cancer control need to be further investigated with a long-term follow-up duration.

V-002 Robotic suprapubic eTEP retrorectus repair for incisional hernia

Abstract Aim A retrorectus mesh position is often considered the most suitable for the repair of a midline incisional hernia. The minimal invasive extraperitoneal approach is gaining popularity. Material &amp; Methods A 56-year-old female patient, who had a laparoscopic deroofing of a bile cyst in her history, presented with an incisional midline hernia (EHS M2-M3, width 6.6 cm). Preoperative optimization via dietary instructions reduced her BMI from 40 kg/m2 to a BMI of 35 kg/m2. Results A robotic extraperitoneal approach via suprapubic docking was performed. The patient is positioned supine and flexed for 15° at the level of the spina iliaca. An intraperitoneal trocar is placed to explore the abdomen for adhesions. Three trocars are placed in the suprapubic position in the extraperitoneal plane whereafter the robot is docked. A dissection in the cranial direction is performed in the retrorectus plane by incising both posterior rectus fascia in a symmetric way. A preperitoneal plane behind the linea alba is created. At the level of the hernia defect the hernia sac is opened, and adhesions are freed. Once the retrorectus space is dissected up to the xyphoid, the linea alba is reconstructed with a barbed suture size 0. A self-fixating mesh is placed in the retrorectus position. The posterior layer of the peritoneum is closed. The postoperative course was uneventful. Conclusions We present an extraperitoneal minimal invasive approach to the retrorectus plane allowing for an adequate retrorectus dissection and mesh placement like in a classical Rives-Stoppa repair.

OC-033 SHORT-TERM OUTCOMES OF MINIMALLY INVASIVE RETROMUSCULAR VENTRAL HERNIA REPAIR USING AN ENHANCED VIEW TOTALLY EXTRAPERITONEAL (ETEP) APPROACH: SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract Background The enhanced view totally extraperitoneal (eTEP) approach is becoming increasingly more widely accepted as a promising technique in the treatment of ventral hernia. However, evidence is still lacking regarding the perioperative, postoperative and long-term outcomes of this technique. The aim of this meta-analysis is to summarize the current available evidence regarding the perioperative and short-term outcomes of ventral hernia repair using eTEP. Study Design A systematic search was performed of PubMed, EMBASE, Cochrane Library and Web of Science electronic databases to identify studies on the laparoscopic or robotic enhanced view totally extraperitoneal (eTEP) approach for the treatment of ventral hernia. A pooled meta-analysis was performed. The primary endpoint was focused on short-term outcomes regarding perioperative characteristics and postoperative parameters. Results A total of 13 studies were identified involving 918 patients. Minimally invasive eTEP resulted in a rate of surgical site infection of 0% [95% CI 0.0–1.0%], a rate of seroma of 5% [95% CI 2.0–8.0%] and a rate of major complications (Clavien-Dindo III-IV) of 1% [95% CI 0.0–3.0%]. The rate of intraoperative complications was 2% [95% CI 0.0–4.0%] with a conversion rate of 1.0% [95% CI 0.0–3.0%]. The mean hospital length of stay was 1.77 days [95% CI 1.21–2.24]. After a median follow-up of 6.6 months (1–24), the rate of recurrence was of 1% [95% CI 0.0–1.0%]. Conclusion Minimally invasive eTEP is a safe and effective approach for ventral hernia repair, with low reported intraoperative complications and good outcomes.

V-019 Spiegel hernia repair using eTEP approach

Abstract Objective Spiegel hernia is a rare entity that accounts for less than 1% of operated hernias. Its clinical diagnosis is difficult and its treatment is varied. The objective of this work was to show the eTEP approach for the treatment of this pathology. Methods Despite the fact that this entity accounts for less than 1% of all hernia outbreaks, we had three probable cases of Spigelian hernia in the last quarter. The last of them was resolved with Extended Totally Extraperitoneal (eTEP) Approach for Hernia Repair. Results We show a 62-year-old man, previously operated on for bilateral inguinal hernia and Spiegel hernia on the right side by TAPP laparoscopic approach. He presents a left Spiegel hernia now, for which a totally extraperitoneal approach is proposed. The surgery was uneventful and the patient was discharged the day after the intervention. At two months of follow-up, the patient is asymptomatic. Conclusions Spiegel hernia is a rare hernia, difficult to diagnose and can present itself as complicated. It can be treated with various approaches. Laparoscopic Spiegel hernia repair is gaining popularity for its safety and patient benefits. The eTEP approach is useful tool in the management of the abdominal wall and, as demonstrated in our case, for the treatment of Spiegel hernia.

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.

P-046 NOVEL TECHNIQUE TO DISSECT RETRORECTAL SPACE DURING ETEP APPROACH FOR SUPRAUMBILICAL HERNIAS

Abstract Aim Present a modification for the retrorectal dissection during the performance of enhanced view totally extraperitoneal (eTEP) approach for the treatment of supraumbilical hernia associated with rectus diastasis. Material and methods During eTEP, a new approach to access both retrorectal spaces was performed through an infraumbilical incision. First, we made a 2 cm section in the anterior fascia spanning both sides of the linea alba. Therefore, both retrorectal spaces were dissected with the assistance of a balloon trocar. After this maneuver, a structural trocar was inserted, and CO2 was inssuflated. Then 3 suprapubic trocars were inserted: one at the midline, and the other two medial to both semilunaris lines. After trocar placement, and prior to the inferior crossover the anterior rectus fascia of the infraumbilical incision was closed. The surgery was then performed according to the technique described by Daes and Belyansky. Results We have performed this approach in 2 consecutive patients with supraumbilical hernia (M3W1 and M3W2) associated with rectus diastasis. We achieve a complete dissection of the retro-muscular spaces in only one step and from the same location, facilitating the crossover. There were no associated intraoperative or postoperative complications. Conclusion The presented modification of the retrorectal dissection during laparoscopic eTEP for supraumbilical hernias represents a time-saver, safe and feasible alternative for the dissection of retrorectal space during eTEP.

OC-041 TOTALLY EXTRA-PERITONEAL REPAIR VERSUS TRANS-ABDOMINAL PRE-PERITONEAL REPAIR FOR THE LAPAROSCOPIC SURGICAL MANAGEMENT OF SPORTSMAN'S HERNIA: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract Aim Open and laparoscopic modalities are employed for treatment of sportsman's hernia, with totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal (TAPP) laparoscopic approaches both currently being utilised. At present, neither subtype has demonstrated superiority for sportsman's hernia repair. The aim of this review was to evaluate current evidence to ascertain whether there was a difference in laparoscopic techniques following sportsman's hernia repair. Material &amp; Methods A systematic literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. Databases searched included PubMed, Scopus and Web of Science to identify all randomised controlled trials (RCTs) and observational studies. Risk of bias was assessed using the Cochrane risk of bias tool and Newcastle-Ottawa scale for RCTs and observational studies, respectively. The assessed outcomes included median time to return to sporting activity, complications and the degree of postoperative pain reduction within three months. Random effects model was used to calculate pooled proportion data where feasible. Subgroup analyses were also performed. Results 28 studies were identified including 2 RCTs and 26 observational studies. No significant differences were observed between techniques in the primary or secondary outcomes. Significant heterogeneity was observed in all outcomes. This was signficant for return to sporting activity; thus meta-analysis was not feasible in this domain. Median time to return to sporting activity was 28 days for both techniques. Conclusions There is no difference in the primary and secondary outcomes in either technique. An RCT comparing TEP and TAPP repair is needed to provide definitive data.