Endoscopic totally extraperitoneal approach (TEA) technique for primary ventral hernia repair

Abstract

Background: Up to now the totally extraperitoneal (TEP) technique is limited to the treatment of inguinal hernias. Applying this anatomical repair concept to the treatment of other abdominal wall hernias, we developed an endoscopic totally extraperitoneal approach (TEA) to treat primary midline ventral hernias, including umbilical and epigastric hernias, in which for mesh placement, an anatomical space is developed between the peritoneum and the posterior rectus sheath in the ventral part of the abdominal wall (preperitoneal space).

Methods: Between September 2017 and December 2019 according to the selection criterions, 28 consecutive primary midline ventral hernias were repaired using TEA. After extensive endoscopic development of the midline extraperitoneal plane, which was started in the suprasymphysic area, and reduction of the hernia sac, the hernia defect was closed and a large mesh was placed in the preperitoneal position to enforce the anterior abdominal wall.

Results: All operations were successfully performed without conversion to open surgery. The mean operation time was 103.3 min (range 85-145 min). Patient-reported postoperative pain was qualitatively mild with a mean pain visual analogue scale score of 1.9 on postoperative day 1. The average hospital stay was 1.9 days (range 1-3 days). Three patients developed minor complications and were treated with no long-term adverse effects. Readmissions within 30 days or hernia recurrences were not observed with a mean follow-up period of 18 months (range 10-27 months).

Conclusion: In selected cases, TEA is a safe and feasible minimally invasive alternative in treating primary ventral hernias. This technique preserves the anatomical and physiological structure of the abdominal wall and may significantly reduce trauma and postoperative complications. Additionally, anti-adhesion-coated meshes and fixation tackers are not required, thus being cost-effective. Further studies are necessary to proof the true clinical efficacy in comparison to well-known alternative techniques.

Keywords: Endoscopic repair; Epigastric hernia; Primary ventral hernia; Totally extraperitoneal approach; Umbilical hernia.

Fig. 1

Position of the patient on the operating table

Fig. 2

Primary extraperitoneal space establishment and port placement

Fig. 3

Identifying the posterior sheath and locating the correct extraperitoneal space

Fig. 4

Cord-like structures visualized in the extraperitoneal space of the lower umbilical margin

Fig. 5

An umbilical defect was revealed after hernia content reduction

Fig. 6

Extraperitoneal space in the subxiphoid area. The ligamentum teres hepatis is visualized

Fig. 7

Placement of a 15 × 9-cm² self-gripping mesh in the extraperitoneal space (a case of umbilical hernia)