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Enhanced View Totally
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Extraperitoneal (eTEP) Repair
for Midline Hernia
VictorG.Radu
15.1 Introduction
The eTEP technique in laparoscopic ventral hernia repair was published 5years ago by Dr. Igor
Belyansky, as a paradigm-changing technique,
that involved closing the defect, using uncoated
mesh placed outside of the abdominal cavity, and
minimizing the mesh xation [1].
The underlying principle is to connect three
spaces [2]—the preperitoneal space, the retrorectus spaces, and the pre-transversalis spaces crossing over the midline anterior to the falciform
ligament or anterior to the umbilical ligament
depending on hernia location. In this way, a large
space is achieved for placing a retro-muscular
mesh (Fig.15.1).
15
Fig. 15.1 Connection of the retro-muscular spaces: (1)
preperitoneal space (1a—falciform ligament, 1b—umbilical ligament); (2) retrorectus spaces; (3) pre-transversalis
spaces
Supplementary Information The online version contains supplementary material available at [https://doi.org/
10.1007/978-981-19-5248-7_15].
V. G. Radu (*)
Life Memorial Hospital—Medlife,
Bucharest, Romania
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
S. J. Baig et al. (eds.), Newer Concepts and Procedures in Hernia Surgery - An Atlas,
https://doi.org/10.1007/978-981-19-5248-7_15
135
136
15.2 Indications and
Contraindications
The indications for this procedure are: primary
ventral hernias, incisional ventral hernias, and
also complex incisional hernias with multiple site
defects [3].
The eTEP is contraindicated in cases with
mesh infection, entero-cutaneous stula, loss of
domain, and ulcerated skin [4]. A recurrence
after a previous retro-muscular repair can also be
considered a relative contraindication of this
procedure.
The width of the defect is another subject of
discussion regarding the contraindications.
Depending on the compliance of the abdominal
wall (with or without preoperative preparation
with botulinum toxin), eTEP is efcient even in
closing defects larger than 15cm width [5].
Also, morbid obesity, uncontrolled diabetes
mellitus, and active smoking are contraindications, in general [2].
15.2.1 Instruments
In the eTEP procedure, I use regular laparoscopic
instruments (trocars 5 and 10 mm, 30-degree
scope, graspers, hook monopolar cautery,
scissors, needle-driver) and some specic instruments (balloon trocar or optic port, advanced
energy devices as Harmonic or Ligasure grasper).
15.2.2 Position ofthePatient
The bed is exed up to 30 degrees. In this position, the distance between the iliac crest and the
costal margin is increased allowing an optimal
ports placement. Also, it avoids the conict
between the surgeon’s hands and the patient’s
thighs (Fig.15.2).
A Foley catheter can be useful, especially during a long time surgery and/or if the hernia is
located in the inferior part of the abdomen (M4,
M5).
The procedure is performed under general
anesthesia with good muscular relaxation.
V. G. Radu
Fig. 15.2 Position of the patient
15.2.3 Team Setup
The right-handed surgeon sits on the left of the
patient if the hernia is situated in the lower part of
the abdomen, and on the right side of the patient
if the hernia is located in the upper part of the
abdomen respectively; conversely, the assistant
sits on the opposite side to the surgeon.
15.2.4 Key Steps
15.2.4.1 For Hernias Located
intheLower Part
oftheAbdomen
The crossing over of linea alba is performed
above the umbilicus, in front of the falciform
ligament, connecting both retrorectus spaces in
the epigastrium (Fig.15.3).
The rst step is the development of the left ret-
rorectus space.
– An optic port is placed just below the left costal
margin, penetrating the subcutaneous tissue,
the anterior rectus sheath, and the rectus muscle
to reach the retrorectus space. This space is dissected gently, using the scope; the insufator is
connected for the beginning, and the pressure
of insufation is set to 15mmHg, high ow.
15 Enhanced View Totally Extraperitoneal (eTEP) Repair for Midline Hernia
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The crossing over of the midline is performed by dissecting the fatty tissue anterior
to the falciform ligament (called the “fatty triangle”) without penetrating the peritoneal
cavity. It is very important to identify the contralateral PRS, to maintain the integrity of
linea alba.
– The contralateral (right) PRS is cut just lateral
to the linea alba, and the right retrorectus
space is dissected gently as wide as possible
(Fig.15.6).
– The fourth port (to be used for camera port
subsequently) is placed just below the right
costal margin.
At this point, the team setup is changed: the
surgeon sits on the left of the patient, using the
upper left trocars, and the assistant handles the
camera placed on the right-side port.
– The retro-muscular dissection progresses
Fig. 15.3 Ports placement and planning to cross over the
midline in hernia located in the lower part of the
abdomen
from cranial to caudal, between the semilunar
137
Fig. 15.5 Cutting the medial aspect of the posterior rectus sheath
Fig. 15.4 Development of the left retrorectus space
It is necessary to identify and protect some
anatomical structures: the inferior epigastric
vessels, and the last six pairs of intercostal
neurovascular bundles (Fig.15.4).
– The second and the third ports are placed
under direct vision, medially to the linea
semilunaris.
The scope is moved to the left lower trocar,
and a monopolar cautery hook is placed
through the left upper trocar.
The next step is the incision of the medial
aspect of the left posterior rectus sheath (PRS)
Fig. 15.6 Cross over the midline
(Fig.15.5).
138
V. G. Radu
lines. The connection of both retrorectus
spaces, cutting the medial aspects of the PRSs,
creates a common retro-muscular compartment [6] (Fig.15.7).
– The medial aspects of the PRSs become the
edges of the defect. While approaching the
hernia neck, the PRS with the hernia sac
resembles the edges of a volcano. The edges
on both sides with the intervening yellow falciform ligament and hernia content resemble an
erupting volcano—“volcano sign” (Fig.15.8)
The contents of the hernia are gently
reduced. In incarcerated hernias, it is necessary to cut the hernia ring. Often, this involves
opening the peritoneal cavity with a small
incision to check the contents of the hernia
sac, reduce them, and perform adhesiolysis.
During this phase, the eTEP becomes a
laparoscopic procedure. In incisional hernias,
the penetration into the peritoneal cavity
occurs more frequently due to the scar on the
hernia neck. However, in my experience, the
risk of bowel injury is not higher than in classical laparoscopic ventral hernia repair
(IPOM). This is because there is always a
small transparent area of the peritoneum that
can be found to enter the abdominal cavity and
check the content of the hernia sac and/or the
adhesions, and perform adhesiolysis if necessary. Then, the hernia contents are reduced
under direct vision.
– Measurement of the defect.
After the hernia content is reduced, it is
necessary to measure the dimensions of the
defect—the width and the length. This should
be done at a lower intra-abdominal pressure of
6mmHg. After measurement of the defect, we
can decide the necessity of TAR using
Carbonell’s algorithm:
“When the width of the defect closely
approximates or exceeds two times the rectus
widths, TAR is needed” [7] (Fig.15.9).
Fig. 15.7 Connection of retrorectus spaces cutting the
medial edges of posterior rectus sheaths
Fig. 15.8 Hernia neck—“volcano sign”
15.2.4.2 For Hernias Located
intheUpper Part
oftheAbdomen
Unlike the superior crossover in lower midline
hernias, in upper midline hernias the crossing
over of linea alba is performed below the umbilicus, anterior to the fat of the umbilical ligament
[5] (Fig.15.10).
Fig. 15.9 Measurement of the defect
15 Enhanced View Totally Extraperitoneal (eTEP) Repair for Midline Hernia
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Fig. 15.11 Ports placement to cross over the midline in
hernia located in the upper part of the abdomen
139
Fig. 15.10 Planning to cross over the midline in hernia
located in the upper part of the abdomen
The rst step is to develop the right retrorectus
space. An optic port is placed through the right
rectus muscle above the level of the umbilicus
penetrating the subcutaneous tissue, the anterior
rectus sheath, and the right rectus muscle into the
retrorectus space. This space is dissected in the
same manner as described on the left side.
– The second and the third ports are placed
under direct vision, medial to the linea semi-
lunaris at the level of linea arcuate
(Fig.15.11).
The dissection progresses caudally, toward
the Retzius space, and medially, crossing over
the midline, anterior to the umbilical ligament.
The fourth port—for the scope—is placed in
the left lower quadrant
– Connection of both retrorectus spaces is real-
ized by cutting the medial aspects of the posterior rectus sheaths and the retro-muscular
Fig. 15.12 Connection of the retrorectus spaces from
caudal to cranial
dissection progresses from caudal to cranial,
between both semilunaris lines, and creating a
common retro-muscular compartment as
described before (Fig.15.12).
15.3 Transversus Abdominis
Release (TAR)
One of the advantages of the eTEP approach is
that the retro-muscular dissection can be enlarged
laterally to the linea semilunaris by performing
TAR.This decision can be done during the surgery, without any preoperative preparation.
140
Fig. 15.13 Landmarks
of right TAR
Before describing how the TAR is performed
laparoscopically, it is necessary to highlight
some anatomical details/landmarks. The neurovascular bundles must be recognized and protected. The incision for the TAR on the PRS will
be placed medially to the linea semilunaris, at
least 5mm medially to the nerves. For the righthanded surgeon, it is easier to perform TAR on
the right side from cranial to caudal (Novitsky
way) [2] (Fig.15.13).
V. G. Radu
15.4 Division oftheTransversus
Abdominis
After the posterior lamella of the internal oblique
muscle is incised, the transversus abdominis
muscle belly is visible which is then cut. Then the
release is carried down caudally till the arcuate
line is reached. This gives a good release of the
fascial ap (Fig.15.14).
Fig. 15.14 Right TAR
15.5 Development ofthe
Pre- transversalis/
Retro-Muscular Space
The pretransversalis space is developed as lateral
as possible and also as cranial as necessary to
obtain a large overlap of the defect, depending on
the hernia location.
15 Enhanced View Totally Extraperitoneal (eTEP) Repair for Midline Hernia
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It is important to be sure that the dissection
progresses in the correct anatomical plane.
One way of being sure of this is to ensure that
there are no muscular bers on the “oor.”
Also, it is important to know that the diaphragm is located in the same anatomical plane
as the transversus abdominis; the bundery
between them is represented by a thin fatty tissue—the “yellow line,” a constant landmark. In
this anatomical plane, the dissection can be
enlarged cranially up to the central tendon of
Fig. 15.16 Landmarks for the left TAR
the diaphragm, when a subxiphoid hernia is
repaired (Fig.15.15).
TAR on the left side is performed starting
from caudal to cranial (bottom-up).
First, the landmarks—linea semilunaris and
the neurovascular bundles—are identied.
The TAR begins from the arcuate line, by
incising the posterior lamella of the internal
oblique and then the transversus abdominis. The
retro-muscular dissection is performed similarly
as described on the right side (Figs. 15.16 and
15.17).
141
Fig. 15.15 TAR.Retro-muscular dissection
Fig. 15.17 Left TAR
15.6 Closure ofthePosterior
Layer
This is performed using an absorbable barbed
suture 2/0.
The Achilles heel of this procedure is the tension in the suture line of the posterior layer. If this
closure is under tension, it may result in a rupture
and occurrence of a postoperative intraparietal
hernia [8] (Fig. 15.18). Therefore, achieving a
tension-free closure of the posterior fascia is crucial to a successful procedure.
142
Fig. 15.18 Closing of
the posterior layer
15.7 Restoration oftheLinea Alba
This is performed next using a nonabsorbable
barbed suture 0 or 1/0. This suture should also
incorporate bites on the pseudosac so as to avoid
a dead space that might lead to postoperative
seroma formation (Fig.15.19).
V. G. Radu
Fig. 15.19 Restoration of the linea alba
15 Enhanced View Totally Extraperitoneal (eTEP) Repair for Midline Hernia
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143
15.8 Mesh Placement
A medium-weight, macroporous polypropylene
mesh is placed into the retro-muscular space, tailored to the entire dissected area after its measurement. If the defect is correctly closed and the
landing zone for the mesh is large enough to
ensure a correct overlapping of the defect, it is
not necessary to x the mesh (Fig.15.20).
The hemostasis must be as perfect as possible.
Even at the expense of spending some extra time,
the operative eld should be clean and dry. It is
not necessary to place drains if meticulous hemostasis has been obtained.
15.9 Complications
andManagement
– Injury of linea alba may happen during the cross-
ing over. This should be detected intraoperatively,
sutured, and/or covered with the mesh. Failure to
do this entails a high risk of recurrence.
– Postoperative intraparietal hernia is due to the
rupture of the posterior layer. It occurs when
the posterior layer is sutured under tension.
Once this occurs in the postoperative period,
patients usually present with features of intestinal obstruction. It is managed frequently
with redo laparoscopic surgery.
– Retro-muscular hematoma. The Rives-Stoppa
space is very well vascularised and hematomas
can be a side effect. Meticulous hemostasis is the
key to prevention, and treatment may involve
reexploration.
Fig. 15.20 Mesh placement
144
V. G. Radu
References
1. Belyansky I, Zahiri HR, Park A.Laparoscopic transversus abdominis release, a novel minimally invasive
approach to complex abdominal wall reconstruction.
Surg Innov. 2016;23:134–41.
2. Novitsky YW, editor. Hernia surgery. Cham: Springer
International Publishing; 2016. http://link.springer.
com/10.1007/978- 3- 319- 27470- 6
3. Radu VG, Lica M. The endoscopic retromuscular
repair of ventral hernia: the eTEP technique and early
results. Hernia. 2019;23:945–55.
4. Belyansky I, Daes J, Radu VG, Balasubramanian R,
Reza Zahiri H, Weltz AS, etal. A novel approach using
the enhanced-view totally extraperitoneal (eTEP)
technique for laparoscopic retromuscular hernia
repair. Surg Endosc. 2018;32:1525–32.
5. Radu VG.Laparoscopic retromuscular repair of ventral
hernias: eTEP and eTEP-TAR.In: Guttadauro A, editor.
Techniques and innovation in hernia surgery. London:
IntechOpen; 2020. https://www.intechopen.com/
books/techniques- and- innovation- in- hernia- surgery.
6. Ramana B, Arora E, Belyansky I. Signs and landmarks in eTEP Rives-Stoppa repair of ventral hernias.
Hernia. 2021;25:545–50.
7. Carbonell AM. 9th annual abdominal wall reconstruction summit. In: Robotic TAR. Big Sky, Montana;
2018.
8. Carbonell AM. Rives-Stoppa retromuscular repair.
In: Hernia surgery. Cham: Springer International
Publishing; 2016. p. 107–15. http://link.springer.
com/10.1007/978- 3- 319- 27470- 6_12.
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