The endoscopic retromuscular repair of ventral hernia: the eTEP technique and early results

Abstract

Purpose
The aim of this article is to describe the technique and early follow-up results of abdominal wall reconstruction (AWR) by minimally invasive surgery (MIS); it concerns the already described endoscopic (retromuscular) Rives procedure (e-Rives) and posterior component separation with transversus abdominis release (TAR) by endoscopic approach (eTEP-TAR).

Method
This is a prospective study which consists of 60 patients operated on between May 2016 and December 2017 by a single surgeon and monitored until July 2018. This is a heterogenic cohort with different hernia types (lateral, median, combined) which were also treated with different meshes. This material includes physiological and biomechanical issues related to the abdominal wall, the key stages of the operation including port placement strategy.

Results
The group of patients are 55% male, having a mean age of 53.3 years old, mean BMI of 29.3 and median ASA score of 1.83. The majority of the hernia types is represented by incisional hernia (61.7%) located especially on the median side of the abdomen (80%); more than half of them (60%) are reducible. There were 6 (10%) intraoperative complications that lead to four conversions to open or traditional laparoscopic techniques. Postoperative re-admission—two cases: one case with small bowel obstruction, solved by laparoscopic surgery and one case with hemorrhagic gastritis because of non-steroidal anti-inflammatory treatment that required only medical treatment. Quality of life (assessed on a 0–10 scale) evaluating the postoperative pain, normal activity and aesthetics, shows a significant improvement after 2 weeks and 3 months postoperatively compared to the preoperative level. 93.3% of the patients have been monitored and no recurrences after a mean of 15 months have been reported.

Conclusion
A thorough understanding of the anatomy and surgical technique is mandatory. The eTEP approach is a feasible and safe option in MIS ventral hernia repair.

Full text

Vol.:(0123456789)
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https://doi.org/10.1007/s10029-019-01931-x
ORIGINAL ARTICLE
The endoscopic retromuscular repair ofventral hernia: theeTEP
technique andearly results
V.G.Radu1· M.Lica1
Received: 10 October 2018 / Accepted: 17 March 2019
© Springer-Verlag France SAS, part of Springer Nature 2019
Abstract
Purpose The aim of this article is to describe the technique and early follow-up results of abdominal wall reconstruction
(AWR) by minimally invasive surgery (MIS); it concerns the already described endoscopic (retromuscular) Rives proce-
dure (e-Rives) and posterior component separation with transversus abdominis release (TAR) by endoscopic approach
(eTEP-TAR).
Method This is a prospective study which consists of 60 patients operated on between May 2016 and December 2017 by
a single surgeon and monitored until July 2018. This is a heterogenic cohort with different hernia types (lateral, median,
combined) which were also treated with different meshes. This material includes physiological and biomechanical issues
related to the abdominal wall, the key stages of the operation including port placement strategy.
Results The group of patients are 55% male, having a mean age of 53.3years old, mean BMI of 29.3 and median ASA score
of 1.83. The majority of the hernia types is represented by incisional hernia (61.7%) located especially on the median side of
the abdomen (80%); more than half of them (60%) are reducible. There were 6 (10%) intraoperative complications that lead
to four conversions to open or traditional laparoscopic techniques. Postoperative re-admission—two cases: one case with
small bowel obstruction, solved by laparoscopic surgery and one case with hemorrhagic gastritis because of non-steroidal
anti-inflammatory treatment that required only medical treatment. Quality of life (assessed on a 0–10 scale) evaluating the
postoperative pain, normal activity and aesthetics, shows a significant improvement after 2weeks and 3months postopera-
tively compared to the preoperative level. 93.3% of the patients have been monitored and no recurrences after a mean of 15
months have been reported.
Conclusion A thorough understanding of the anatomy and surgical technique is mandatory. The eTEP approach is a feasible
and safe option in MIS ventral hernia repair.
Keywords eTEP· Ventral and incisional hernia· Abdominal wall repair· Retromuscular mesh placement· TAR
Purpose
The gold-standard procedure in ventral hernia repair by open
approach is, by general opinion, the Rives operation [1, 2].
Its principle is the restoration of the linea alba and mesh
placement under the rectus muscles.
The minimally invasive techniques have been improved
due to significant changes of the paradigm in AWR: from
the “bridged-IPOM” of Leblanc in the 1990s to “IPOM
plus” 20years later—a concept introduced by J.F. Kukleta,
representing a huge step for AWR, restoring the abdominal
wall functionality and decreasing the rate of recurrences and
other complications (postoperative seroma, bulging etc.) [3,
4].
A new, interesting idea occurred: pushing the mesh out-
side of the abdominal cavity. Miserez and Penninckx [5]
repaired a ventral hernia placing the mesh pre-peritoneally
and Wolfgang Reinpold placed the mesh under the rectus
muscles by trans-hernial access (MILOS technique) [4–6].
Belyansky etal. [7] published a new technique combining
the eTEP access described by Jorge Daes with the principles
of TAR described by Novitsky [7–10]. The result (eRives/
eTEP-TAR) is very promising and the technique has the
potential to become one of the best solutions in laparoscopic
ventral hernia repair (LVHR) [8].
* V. G. Radu
dr.victor.radu@gmail.com
1 Life Memorial Hospital, Bucharest, Romania

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An important improvement has been noticed in com-
plex AWR: the principles of magistral component sepa-
ration—anterior component separation (ACS)—Ramirez
and Novitsky’s TAR are applied in MIS operations: eACS
(Rosen) and eTEP-TAR (Belyansky) [11, 12].
One of the biggest advantages of this approach is the
possibility to extend the retro-rectus dissection laterally to
the semilunaris lines, performing TAR, or eTAR, respec-
tively; in this way, large defects in the abdominal wall can
be repaired. Sometimes the decision to perform a TAR can
be made during the surgery.
Methods andpatients
The biomechanics oftheabdominal wall
andabdominal cavity
Due to the tone of the abdominal wall muscles, the pres-
sure inside the abdominal cavity is 5–7mmHg [13].
According to Laplace’s law, this pressure acts equally
on the abdominal wall, determining the tension.
So the “tension-free” concept, which Lichtenstein imple-
mented in inguinal hernia repair in 1984, is not available if
restoration of AW functionality is the aim.
The new surgical techniques have changed the attitude
from tension-free repair to restoration under physiological
pressure when the aim is the restoration of architecture and
functionality of the abdominal wall; the focus of these pro-
cedures is the reconstruction of the linea alba, the “central
tendon” of the abdominal wall [12] (Fig.1).
The most useful preoperative imaging exploration is the
CT scan. It allows us to locate the defect, measure it, and
establish the strategy for the surgery.
For example, in our practice, the Rives–Stoppa technique
alone is enough when the sum of the bilateral rectus mus-
cle width (RW) is at least twice the maximal defect width
(DW)—Fig.2, confirming Carbonell’s algorithm, presented
at 9th Annual Abdominal Wall Reconstruction Summit, Mon-
tana US, 2018: additional myofascial release (TAR) may be
necessary if the maximal defect width closely approximates
or exceeds twice the rectus width—Fig.3.
Before explaining the key stages of the surgery, it is
important to first mention exclusion criteria of the patients:
all the patients presenting mesh infection and/or fistula have
an absolute contraindication to eTEP and MIS; the patients
Fig. 1 Law of Laplace [14]

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with dystrophic or ulcerated skin, the patients with loss of
domain, the patients with previous pubo-xiphoidian incision
and also the patients with a previous retromuscular ventral
hernia repair have a relative contraindication to eTEP.
There are no contraindications related to the width of
the defects. As in open retromuscular surgery, the eTEP
approach can be used to repair all varieties of ventral her-
nias, from small umbilical hernias to large and complex
ventral hernias.
The key stages of the eRives and eTEP-TAR procedures
are:
1. Development of the retro-rectus space and port place-
ment.
2. Cross-over of the midline.
3. Connection of both retro-rectus spaces, left and right.
4. 3* TAR (when needed [8]).
5. Closure of the defect and restoration of linea alba.
6. Mesh placement.
7. Exsufflation.
1. Development of the retro-rectus space and port place-
ment.
Conversely to the traditional laparoscopic approach, the
ports have to be placed medially to the semilunaris lines
for ergonomic reasons. The linea semilunaris is the most
important landmark for port placement.
As a rule, the ports have to be placed opposite to the side
of the abdomen related to the hernia location:
• Hernia located in the lower part of the abdomen: the
ports will be placed above the umbilicus (Fig.4a, left).
• Hernia located in the upper part of the abdomen: the
ports will be placed below the umbilicus (Fig.4a, right).
• Hernia located laterally (hypochondrium, flank, lateral
lower quadrant or lumbar): consider ports placement lat-
erally, on the opposite side of the abdomen (Fig.4b).
Port placement must also take the previous scar into
consideration (in incisional hernia); the midline has to be
crossed over, preferably in a virgin part of the abdomen,
where the subjacent ligament (falciform or umbilical,
respectively) is untouched and can protect against the acci-
dental penetration of the peritoneal cavity.
The first step is developing the retro-rectus space. We can
do that using an optic port or a balloon trocar.
After dissecting the retro-rectus space we inflate using
CO2 and then we insert the ports just medially to the semi-
lunaris line (Fig.5).
Important! Introducing the ports laterally to the semilu-
naris line (outside of the rectus sheath) results in penetration
of the (uninflated) peritoneal cavity and carries major risk
of injury to the viscera!
2. Cross-over of the midline should be done in the virgin
part of the wall, on the opposite side to where the defect
is located (Fig.6).
Crossing the midline to the contralateral retro-rectus
space must be totally extraperitoneal (TEP), anterior to the
falciform ligament, when we start from left to right (if the
defect is in the lower abdomen) and, respectively, anterior to
the umbilical ligament, when the crossing starts from right
to left, inferiorly to the umbilicus (if the defect is in the
upper abdomen).
3. Connection of both retro-rectus spaces, left and right
Dissecting both retro-rectus spaces (left and right) and
connecting them by incising the posterior sheaths on their
medial edges conducts to a common large retromuscular
space (the left retro-rectus space connected to the right
Fig. 2 Carbonell’s algorithm: 2xRW:DW ≥ 2 : 1
Fig. 3 Carbonell’s algorithm: 2xRW:DW ≤ 2 : 1

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Fig. 4 a Port placement, b port
placement
Fig. 5 Development of the retro-rectus space Fig. 6 Crossing over the linea alba

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retro-rectus space). This space is linked by the preperito-
neal bridge represented by the falciform ligament and/or
umbilical ligament. The retro-rectus dissection is limited
laterally by the semilunaris lines, where the neurovascular
bundles pass through the posterior sheath to the rectus
muscles (Fig.7).
The dissection should be done preperitoneally as far as
possible; opening the peritoneum at the level of the hernia
neck is almost unavoidable. This step must be performed
carefully, delicately and using sharp dissection to avoid
injury to the bowel—if it is herniated in the sac. Keeping
the sac will assist with the closure of the posterior defect.
3*. TAR. For more challenging defects that require
large mesh placement, the TAR procedure is added. The
incorporation of TAR was found beneficial in cases with a
wide defect (10cm), tension on the posterior layer, narrow
retro-rectus space (< 5cm) or when dealing with a poor
compliant abdominal wall [8].
If we decide to perform TAR, it is important to iden-
tify the semilunaris lines, marked by the neuro-vascular
bundles.
Incision of the posterior lamella of the internal oblique
fascia 1cm medially to the semilunaris line exposes the
transversus abdominis (TA) muscle (Fig.8).
This step can be done from “bottom to top” (first it is
necessary to identify the arcuate Douglas line) or from “top
to bottom” (Fig.9).
The transection of the TA muscle and a posterior com-
ponent separation (Fig.10), which can be done laterally
up to the psoas muscle, allows medial mobilization of the
musculo-fascial edges.
4. Closure of the defect and restoration of linea alba
Closure of the defect in the posterior layer (if the perito-
neum was opened) is necessary to keep a barrier between
the mesh and the viscera. This layer is not a resistance layer
(Fig.11).
Restoration of the linea alba is done by suturing the ante-
rior sheaths of the rectus muscles on the midline. This step
is performed using a non-resorbable barbed 0 (zero) suture.
This suture is possible if we reduce the pressure of insuffla-
tion to 5–6mmHg when we pull the stitch (Fig.12).
Fig. 7 Retromuscular dissection: connecting both retro-rectus spaces
Fig. 8 TAR: cutting the posterior lamella of the internal oblique fas-
cia
Fig. 9 TAR bottom-top (Courtesy of Dr. Igor Belyansky)
Fig. 10 Posterior component separation

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5. The mesh placement into the retro-rectus space will be
done after measurement of the entire area to be covered
by the mesh (Fig.13).
Important! The surface covered by the mesh is not the
surface of the defect; it is the entire dissected area.
The mesh has to be completely flat on the posterior
layer.
In our practice, after correct dissection and thorough
hemostasis, we do not consider drainage necessary.
6. Slow exsufflation, under direct vision, allows us to
ensure the mesh remains in the correct position.
Methods
We consider all the medical records of patients with ven-
tral hernias (primaries or incisional) who underwent lapa-
roscopic eTEP repairs between May 2016 and December
2017. The procedure is performed by the same surgical
team within Life Memorial Hospital, Bucharest, Romania.
All the hernias are classified according to EHS criteria
[15].
The main parameter regarding the postoperative evolu-
tion is hernia recurrence, which is systematically assessed
at every clinical follow-up or by asking five questions in
the event of telephone follow-up. Other measured param-
eters are: length of stay, surgical site occurrence (seroma,
hematoma and infection), 30-day post-op readmission and
any other medical or surgical complications during the
period of follow-up.
The quality of life is measured by a scale derived from
EuraHS Quality of Life Scale: there are three questions
addressed to the patients on admission (before surgery),
on the 1st postoperative day and at the 1st and 2nd clinical
follow-up. These three questions evaluate the pain in rest-
ing position (lying down), the restriction of daily activi-
ties (walking, climbing stairs) and the cosmetics related
to the abdomen and hernia site. The answers are reported
numerically on a scale of 0–10.
Chronic pain is defined as pain which persists for
more than 3 months postoperatively and influences daily
activities.
The data are added to an electronic database and statistics
are performed by SPSS 20.
Patients
This study includes 60 consecutive patients (33 male, 27
female) operated on between May 2016 and December 2017.
The demographics are presented in Table1.
The most frequent type of hernia is incisional (61.7%) and
the most frequent hernia site is the median site of the abdo-
men (80%). Over half of them are reducible (60%).
The hernia characteristics are presented in Tables2 and 3.
The median defect area is 99.5cm2 (min 6cm2–max
375cm2) and the median width is 5.5cm (min 1cm–max
17cm), but there are important variations according to the
type of hernia and these are detailed in Table4.
Fig. 11 Closure of the posterior layer (Courtesy of Dr. Igor Belyan-
sky)
Fig. 12 Restoration of linea alba (Courtesy of Dr. Igor Belyansky)
Fig. 13 Mesh placement

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The diastasis recti associated withtheventral hernia
Diastasis recti is an abdominal wall deformity, which has
numerous definitions and three major classifications, which
are not the subject of this article. In our practice we have
adhered to Rath’s classification, which states that any
enlargement over 27mm of the linea alba at the level of the
umbilicus is considered a diastasis [16].
Diastasis recti is associated with the majority of primary
ventral hernias (22 cases out of 25–88%) but also with
incisional hernias (5 cases out of 28–17.8%). According to
literature, correction of the umbilical hernia alone without
correction of the diastasis is often associated with recur-
rence due to the poor quality of the surrounding tissue [17].
We have expanded on this to include all ventral and inci-
sional hernias. Therefore, no matter the case, the linea alba
is restored by suturing the anterior sheaths and reinforcing
the suture line by placing an adequate-sized mesh into the
retro-rectus space. In our data, the size of the weakness is
considered to be the actual “diastasis defect” and not only
the hernia defect (for example in a small umbilical hernia
of 2 by 2cm and a diastasis recti of 5cm width and 20cm
length, we consider the area of the defect 100cm2 and the
mesh should be at least 30cm in length; the width of the
mesh in this case is shaped to fit into the retro-rectus space
between the two semilunaris lines). In cases involving dia-
stasis the mean length of the defect was 18cm (min 10cm
to max 25cm) and the mean length of the mesh was 28cm
(min 10cm to max 30cm). Regarding the diastasis’ width,
it measures a mean of 5cm (min 3cm to max 9cm) and the
mesh is mean 17cm width (min 10cm to max 25cm), to
cover the entire dissected area.
Table 1 Patient demographics
All patients n = 60
Age (years) 53.3 ± 12.4 (SD)
Male/female 55%/45%
ASA score 1.83 ± 0.5 (SD)
BMI 29.3 ± 5.8 (SD)
Smoker 20%
Lipid disorders 63.3%
Hypertension on meds 48.3%
Diabetes 15%
Coronary disease 6.7%
Cancer history 18.3%
Table 2 Hernia characteristics n (%)
Hernia type
Incisional 37 (61.7%)
Ventral 21 (35%)
Traumatic 1 (1.7%)
Mixed 1 (1.7%)
Hernia site
Median 48 (80%)
Lateral 5 (8.3%)
Multiple sites 7 (11.7%)
Hernia severity
Reducible n = 36 (60%)
Incarcerated n = 24 (40%)
Table 3 Hernia location according to EHS classification
2
12
3
5
19
9
0 10 20 30
4
M5
M4
M3
M2
M1
1
3
5
3
0 2 4
L4
L3
L2
L1

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Comments
Multiple site hernias are particular cases that involve
at least two distinctive sites of hernia. In our series we
encountered 7 such cases: two associating median and
inguinal hernias, two median and former-stoma site inci-
sional hernias, one case of double incisional hernia post
laparoscopic cholecystectomy (umbilical and right flank),
one case of subcostal incision spreading from epigastric
to right flank region and one complex case with complete
left semilunar line destruction and epigastric hernia. In
these particular situations it is difficult to assess the correct
defect area and the technical solutions usually need two
meshes so we consider that they do not fit into our defect/
mesh size analysis table.
Procedures
We use the eTEP technique as first option for all of our
patients. Four patients needed conversion to open or lapa-
roscopic approach. The conversion was due to: respiratory
difficulties in two cases, intensive fibrosis in the retro-
rectus space in one case and bowel adhesions to a previous
mesh in another case (Table5).
Analyzing the cases that needed TAR we find out that it
was performed in 6 cases as unilateral TAR and in 13 cases
as bilateral TAR. Unilateral TAR was performed in four
cases of either lateral hernia (mean defect width of 7cm;
min 4cm to max 11cm) or multiple-sites hernia, but with
a lateral component (two cases). Regarding the lateral her-
nias which occurred in this study (subcostal—L1, flank—
L2 and iliac fossa—L3) the technique includes retro-rectus
dissection and unilateral (ipsilateral) TAR. The dissection
is enlarged as laterally as possible performing a posterior
component separation. In this way the retro-rectus space
and the pretransversalis space are connected obtaining
a large retromuscular space. After closure of the hernia
defect, the mesh is placed into this space, covering medi-
ally the posterior rectus sheath and, laterally, the perito-
neum and fascia transversalis and augmenting the suture
of the defect and reinforcing the abdominal wall.
Bilateral TAR was performed in ten cases of median her-
nia (mean defect width 7.9cm; min 6cm to max 15cm) and
in three cases of multiple-sites hernia.
The eTEP-RS procedure was performed in 38 cases of
median hernia with a mean defect width of 5.5cm (min 2cm
to max 10cm). Nevertheless, there is a statistically signifi-
cant difference between these two means (p = 0.006), but we
can notice a “gray” area between 6 and 10cm defect width
where TAR procedure may be needed or not—that is the
area where Carbonell’s algorithm may be applied (Fig.14).
In all cases, the restoration of the linea alba (the “cen-
tral tendon of the abdomen”) was achieved, as it represents
the goal of abdominal wall reconstruction; it improves the
isokinetic and isometric functions of the abdominal wall and
ultimately the quality of life [18].
Mesh andxation
The most frequently used mesh is Parietene Macroporous™
(55 cases, 91.7%), followed by self-fixating mesh (Pro-
Grip™) in two cases and a more rigid, heavy-weight mesh
(Assumesh®) in another two cases.
In 83.4% of the cases the mesh was fixated using
cyanoacrylate: 75% applying glue alone; in the rest of the
cases tackers or sutures were added if the defect was located
in the suprapubic area. In 16.6% of the cases the mesh was
placed into the retro-rectus space without any fixation. Mesh
fixation by cyanoacrylate is an established method [19]. The
first meshes were fixed by force of habit as we still do in
inguinal hernia repair. In time, as far as ventral hernia repair
Table 4 Defect type and site nDefect area (cm2),
mean (min–max)
Mesh area (cm2),
mean (min–max)
Mesh/defect ratio,
mean (min–max)
Incisional hernia—midline 23 109.4 (20–300) 605 (320–1350) 8.1 (2.5–27)
Ventral hernia—midline 3 24.3 (6–42) 204.7 (100–289) 10.8 (6.9–16.7)
Ventral/incisional hernia and
diastasis recti
22 91.8 (50–180) 480.5 (200–750) 5.6 (2.5–8)
Incisional hernia—lateral 5 62 (20–100) 416 (150–780) 6.5 (4.29–7.8)
Multiple-sites defects 7 NA (not applicable) NA NA
Table 5 Procedure n (%)
eTEP-RS 38 (63.3%)
eTEP-TAR 18 (30%)
Conversion
Open-RS 2 (3.3%)
Open-TAR 1 (1.7%)
IPOM 1 (1.7%)

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was concerned, mesh fixation was deemed unnecessary due
to the restrictive space and lack of orifices resulting in a low
probability of mesh migration.
Operative time
For a proper analysis of surgical time we filtered out the
four cases of conversion and analyze only the 56 procedures
finished by eTEP approach. We noticed that this procedure
is shorter for primary ventral hernias compared to incisional
ones by 55min (p = 0.005) and there is also a significant dif-
ference between eTEP and eTEP-TAR of 95min (p = 0.005)
in terms of surgery time (skin-to-skin). These differences
also apply for operative room time (total duration of OR
occupation).
Results
Postoperative length of stay was the same for most patients:
81.7% (49 patients) spent only one post-op night in the hos-
pital. The median postoperative stay was similar for all eTEP
patients, regardless of surgery time or underlying hernia
pathology (Table6).
This short hospital stay was mainly related to a low
level of pain. To analyze this, we assessed the pain control
methods and only eight out of the first 25 patients required
analgesia by epidural catheter. This type of analgesia was
“inherited” from the IPOM period when all patients with
incisional hernia received one. After a few months we com-
pletely abandoned it and used only intravenous analgesics
(NSAI) or opioids during hospital stay. If we rule out the
patients with epidural catheter and count the doses of pain
medications, it turns out that, on average, an eTEP patient
gets 2.7 doses of painkiller for every 24h of hospital stay.
Starting with the year 2017, we began to actively asses
the quality of life of our patients and 42 patients filled out
our questionnaire; the results are expressed in Fig.15.
There is a significant improvement of overall score
between preoperative, 2-week postoperative follow-up
(p = 0.03) and 3-month postoperative follow-up (p = 0.02)
(Table7).
Intraoperative incidents were: rupture of the semilunaris
line at the beginning of the procedure, while developing the
retro-rectus space caused by overinflation of the balloon (one
case), which needed a TAR to cover the damaged area and
a small bowel perforation during dissection which required
suturing (one case).
The conversion (four cases) was due to respiratory dif-
ficulties (two cases), intensive fibrosis in the retro-rectus
space (one case) and bowel adhesions to a previous mesh
in another case.
In-stay complications are represented by: one case of
suture disruption (mechanical failure) that needed an open
procedure to re-approximate the linea alba and one case of
umbilical hematoma in a patient that stayed 3days under
medical supervision in the hospital but without the need for
an active intervention.
One early readmission was due to a small bowel obstruc-
tion caused by a tear in the posterior layer that needed
laparoscopic suture. We concluded retrospectively that this
complication occurred because of too much tension in the
posterior layer. From that point on we have always focused
on reducing posterior layer tension. The other readmitted
case was a hemorrhagic gastritis caused by excessive NSAI
use.
Chronic pain (defined as pain persistence over 3months
postoperatively which impaired daily activities) was
10
15
2
6
eTEP-RS eTEP-TAR
0
2
4
6
8
10
12
14
16
Defect
width;
cm
Fig. 14 Defect width comparison between eTEPRS and eTEP-TAR
Table 6 Hernia (procedure) Frequency (n) Surgery time (min),
median (min–max)
OR time (min),
median (min–max)
Postop LOS (h),
median (min–
max)
Ventral (eTEP) 21 140 (85–225) 190 (140–270) 23.0 (17.0–69.7)
Incisional (eTEP) 17 195 (115–280) 240 (165–320) 23.8 (18.7–70.8)
Incisional (eTEP-TAR) 16 290 (100–510) 347 (140–575) 23.3 (18.6–102.5)

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recorded in two cases: one of them was the patient with a
semilunaris line tear during balloon inflation and the other
one a patient with a multisite hernia. At the 2-year follow-
up clinical control the patient with the semilunaris line tear
showed a complete recovery, with no functional impairments
or chronic pain.
There are no recorded recurrences in our cohort at the
mean follow-up of 15 months (min 7 and max 26) in 56 out
of 60 patients (4 patients were considered lost to follow-up).
Discussion
• A detailed knowledge of the anatomy is a must. During
the dissection it is important to recognize and avoid
injury to the neuro- and vascular-elements (inferior epi-
gastric pedicles, intercostal neurovascular bundles) and
fascial structures, such as the semilunar line. Preserva-
tion of neurovascular supply leads to maintenance of
native rectus function and thus a more robust and func-
tional repair [14]. Also, injury to the semilunaris line
causes an irreversible destabilization of the abdominal
wall.
• Restoration of the linea alba (the “central tendon of the
abdomen”) remains the goal of abdominal wall recon-
struction; it improves the isokinetic and isometric func-
tions of the abdominal wall and ultimately the quality
of life [18].
• Mesh placement outside of the abdominal cavity repre-
sents a huge advantage, on one hand, avoiding contact
between mesh and the viscera (with all of the associ-
ated late consecutive complications) and, on the other
hand, reducing the cost (quite high for dual meshes and
fixation devices).
• The results of our prospective study are superposable
with the early results of this procedure published in
Surgical Endoscopy in 2017 [8].
0
2
4
6
8
10
12
Pre_OperatorPost_Operator 2weeks_Followup3months_Followup
ALL 9.24 10.253.831.72
Rest_pain 0.48 2.55 0.78 0.44
Normal_acvity 2.24 5.45 1.83 0.72
Estecs 6.52 2.91.220.56
Fig. 15 Discomfort level measured by 0–10 numerical scale
Table 7 Complications Complication Number of cases Percentage Grade according to
Clavien–Dindo
Intraoperative incidents 2/60 3.33% n/a
Intraoperative complications 4/60 6.66% n/a
In-stay complications 2/60 3.33% Grade I, grade IIIb
30-day re-admissions 2/60 3.33% Grade II, grade IIIb
Seroma/hematoma 1/60 1.66% Grade I
Infection 0/60 0% n/a
Chronic pain 2/57 3.5% Grade I
Recurrence 0/56 0% n/a

Hernia
1 3
Conclusion
The eTEP approach is a feasible and safe option for ventral
hernia repair with a low postoperative rate of complications:
no recurrences and low risk of chronic pain.
Compliance with ethical standards
Conflict of interest The author(s) declare that they have no competing
interests.
Ethical approval The protocol was approved by the ethics committee
of the institutions.
Human and animal rights This article does not contain any studies
with human participants or animals performed by any of the authors.
Informed consent All the patients gave the informed consent for pro-
cedure and scientific data use as standard in our hospital.
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