Endoscopic enhanced-view totally extraperitoneal retromuscular approach for ventral hernia repair

  • D. PenchevEmail author
  • G. Kotashev
  • V. Mutafchiyski



Primary or incisional ventral hernia repair is one of the most common surgical procedures, addressed to general surgeons. The enhanced view-totally extraperitoneal technique (eTEP) was first described by Deas for inguinal hernias, but lately it has been applied to ventral hernias by Belyansky et al. So far, results are promising and data about the procedure are rising.


Retrospective comparative analysis of 27 recruited eTEP procedures and 27 IPOM operations for the period between April 2017 and June 2018 at the department of Endoscopic surgery of Military Medical Academy, Sofia. Baseline characteristics, operative records and perioperative data are provided and compared for both groups.


Fifty-four patients were included. There were no differences between age, sex, BMI, primary or incisional hernias, co-morbidity, active smoking, EHS-classification and immunosuppression through the patients in different groups. Mean defect area—eTEP is 71 cm2 with no statistical difference, compared to IPOM—76 cm2. Operative time in eTEP is significantly longer with mean time of 186 min and 90 min in IPOM patients. Mean length of stay did not differ between the groups, with 2.9 days after eTEP and 3.4 after IPOM. Median pain score from the intraoperative (the day of surgery) to the seventh postoperative day is lower in the eTEP group. No surgical site infections and/or mesh infections were present. There was one readmission in the IPOM group with ASBO, and it was managed conservatively. There were no reinterventions and perioperative mortality in the sample.


We found out that the eTEP/eRS approach is feasible and safe. Our study shows comparable results of eTEP/eRS to the IPOM procedure with reduced video analogue scale pain score to the 7th postoperative day and increased operative time. The study contributes to the upcoming evidence in the field of new minimally invasive techniques for ventral hernia repair.


Ventral hernia eTEP Retromuscular Rives–Stoppa 


Compliance with ethical standards


Drs. Penchev, Kotashev and Mutafchiyski have no conflicts of interest or financial ties to disclose.


  1. 1.
    Poulose K, Shelton J, Phillips S, Moore D, Nealon W, Penson D, Beck W, Holzman M (2012) Epidemiology and cost of ventral hernia repair: making the case for hernia research. Hernia 16:179–183CrossRefGoogle Scholar
  2. 2.
    Breuing K, Butler C, Ferzoco S, Franz M, Hultman C, Kilbridge J, Rosen M, Silverman R, Vargo (2010) Incisional ventral hernias: Review of the literature and recommendations regarding the grading and technique of repair The Ventral Hernia. Surgery 148(3):544–558CrossRefGoogle Scholar
  3. 3.
    Holihan J, Nguyen D, Nguyen M, Mo J, Kao L, Liang M (2016) Mesh location in open ventral hernia repair: a systematic review and network meta-analysis. World J Surg 40(1):89–99CrossRefGoogle Scholar
  4. 4.
    Sajid M, Bokhari S, Mallick A, Cheek E, Baig M (2009) Laparoscopic versus open repair of incisional/ventral hernia: a meta-analysis. Am J Surg 197:64–72CrossRefGoogle Scholar
  5. 5.
    Poelman M, Apers J, Brand H, Cense H, Consten E, Deelder J, Dwars B, Geloven N, Lange E, Simmermacher R, Simons M, Sonneveld E, Schreurs H, Bonjer J (2013) The INCH-Trial: a multicenter randomized controlled trial comparing the efficacy of conventional open surgery and laparoscopic surgery for incisional hernia repair. BMC Surg 13(8):13–18Google Scholar
  6. 6.
    Itani K, Hur K, Kim L, Anthony T, Berger D, Reda D, Neumayer L (2010) Comparsion of laparoscopic and open repair with mesh for the treatment of ventral incisional hernia. Arch Surg 145(4):322–328CrossRefGoogle Scholar
  7. 7.
    Robinson T, Clarke J, Schoen J, Walsh M (2005) Major mesh-related complications following hernia repair Events reported to the Food and Drug Administration. Surg Endosc 19:1556–1560CrossRefGoogle Scholar
  8. 8.
    Colavita P, Tsirline MD, Belyansky V, Walters I, Lincourt A, Sing A, Heniford R B (2012) Prospective, long-term comparison of quality of life in laparoscopic versus open ventral hernia repair. Ann Surg 256(50):714–723CrossRefGoogle Scholar
  9. 9.
    Busnelli G, Nardi W, Featherston C, Pirichi D, Medina P (2018) Laparoscopic retromuscular incisional hernia repair. J Min Access Surg 0:0:0Google Scholar
  10. 10.
    Daes J (2012) The enhanced view-totally extraperitoneal technique for repair of inguinal hernia. Surg Endosc 26:1187–1189CrossRefGoogle Scholar
  11. 11.
    Warren J, Cobb W, Ewing J, Carbonell A (2017) Standard laparoscopic versus robotic retromuscular ventral hernia repair. Surg Endosc 31(1):324–332CrossRefGoogle Scholar
  12. 12.
    Vorst A, Kaoutzanis C, Carbonell A, Franz M (2015) Evolution and advances in laparoscopic ventral and incisional hernia repair. World J Gastrointest Surg 27(7):293–305CrossRefGoogle Scholar
  13. 13.
    Luque J, Luque A, Valdivia J, Gra´u J, Menchero J, Moreno J, Jurado J (2015) Totally endoscopic surgery on diastasis recti associated with midline hernias. The advantages of a minimally invasive approach. Prospective cohort study. Hernia 19(3):493–501CrossRefGoogle Scholar
  14. 14.
    Schwarz J, Reinpold W, Bittner R (2017) Endoscopic mini/less open sublay technique (EMILOS)-a new technique for ventral hernia repair. Langenbecks Arch Surg 402(1):173–180CrossRefGoogle Scholar
  15. 15.
    Orthopoulos G, Kudsi O (2017) Feasibility of robotic-assisted transabdominal preperitoneal ventral hernia repair. J Laparoendosc Adv Surg Tech 28(4):434–438 CrossRefGoogle Scholar
  16. 16.
    Iqbal C, Pham T, Joseph A, Mai J, Thompson G, Sarr M (2007) Long-term outcomes of 254 complex incisional hernia repairs using the modified Rives-Stoppa technique. World J Surg 31(12):2398–2404CrossRefGoogle Scholar
  17. 17.
    Forbes S, Eskicioglu C, McLeod R, Okrainec A (2009) Meta-analysis of randomized controlled trials comparing open and laparoscopic ventral and incisional hernia repair with mesh. Br J Surg 96(8):851–858CrossRefGoogle Scholar
  18. 18.
    Jenkins E, Yom V, Melman L, Brunt L, Eagon J, Frisella M,. Matthews B (2010) Prospective evaluation of adhesion characteristics to intraperitoneal mesh and adhesiolysis-related complications during laparoscopic re-exploration after prior ventral hernia repair. Surg Endosc 24:3002–3007CrossRefGoogle Scholar
  19. 19.
    Belyansky I, Daes J, Radu V, Balasubramanian R, Zahiri H, Weltz A, Sibia U, Park A (2018) A novel approach using the enhanced-view totally extraperitoneal (eTEP) technique for laparoscopic retromuscular hernia repair. Surg Endosc 32(3):1525–1532CrossRefGoogle Scholar
  20. 20.
    Eriksen J, Poornoroozy P, Jørgensen L, Jacobsen B, Friis-Andersen H, Rosenberg J (2009) Pain, quality of life and recovery after laparoscopic ventral hernia repair. Hernia 13(1):13–21CrossRefGoogle Scholar
  21. 21.
    Brill JB, Turner PL (2011) Long-term outcomes with transfascial sutures versus tacks in laparoscopic ventral hernia repair: a review. Am Surg 77(4):458–465Google Scholar
  22. 22.
    Nguyen S, Divino C, Buch K, Schnur FNP, Weber J, Katz KMD, Reiner L, Aldoroty M, Herron R D (2008) Postoperative pain after laparoscopic ventral hernia repair: a prospective comparison of sutures versus tacks. JSLS 12(2):113–116Google Scholar
  23. 23.
    Wassenaar E, Raymakers J, Rakic S (2007) Removal of transabdominal sutures for chronic pain after laparoscopic ventral and incisional hernia repair. Surg Laparosc Endosc Percutan Tech 17(6):514–516CrossRefGoogle Scholar
  24. 24.
    Booth J, Garvey P, Baumann D, Selber J, Nguyen A, Clemens M, Liu J, Butler C (2013) Primary fascial closure with mesh reinforcement is superior to bridged mesh repair for abdominal wall reconstruction. J Am Coll Surg 217:999–1009CrossRefGoogle Scholar
  25. 25.
    Carter S, Hicks S, Brahmbhatt R, Liang M (2014) Recurence and pseudorecurrence after laparoscopic ventral hernia repair: predictors and patient-focused outcomes. Am Surg 80:138–148Google Scholar
  26. 26.
    Hauters P, Desmet J, Gherardi D, Dewaele S, Poilvache H, Malvaux P (2017) Assessment of predictive factors for recurrence in laparoscopic ventral hernia repair using a bridging technique. Surg Endosc 31(9):3656–3663CrossRefGoogle Scholar
  27. 27.
    Mitura K, Skolimowska-Rzewuska M, Garnysz K (2017) Outcomes of bridging versus mesh augmentation in laparoscopic repair of small and medium midline ventral hernias. Surg Endosc 31(1):382–388CrossRefGoogle Scholar
  28. 28.
    Nguyen D, Chen D (2017) Laparoendoscopic stapled rives stoppa sublay technique for extraperitoneal ventral hernia repair. Eur Surg, 49(4): 175–179 CrossRefGoogle Scholar
  29. 29.
    Eker H, Hansson M, Buunen M, Janssen M, Pierik E, Hop C, Bonjer J, Jeekel J, Lange F (2013) Laparoscopic vs. open incisional hernia repair: a randomized clinical trial. JAMA Surg 148(3):259–263CrossRefGoogle Scholar
  30. 30.
    Torur D, Morten J, Sci M, Dorthe H, Berit M, Annemette J, Bente J (2018) Robotic surgery is less physically demanding then laparoscopic surgery: paired cross sectional study. Ann Surg, Google Scholar
  31. 31.
    Kaufmann R, Halm J, Eker H, Klitsie P, Nieuwenhuizen J, Geldere D, Simons M, Harst E, Riet M, Holt B, Kleinnrensink G, Jeekel J, Lange J (2018) Mesh versus suture repair of umbilical hernia in adults: a randomised, double-blind, controlled, multicentre trial. Lancet 391:860–869CrossRefGoogle Scholar
  32. 32.
    Earle D, Roth J, Saber A, Haggerty S, Bradley J, Fanelli R, Price R, Richardson W, Stefanidis D (2016) SAGES guidelines for laparoscopic ventral hernia repair. Surg Endosc 30(8):3163–3183CrossRefGoogle Scholar
  33. 33.
    Belyanski I, Reza Z, Sandord Z, Welz A, Park A (2018) Early operative outcomes of endoscopic (eTEP access) robotic-assisted retromuscular abdominal wall hernia repair. Hernia 22(5):837–847CrossRefGoogle Scholar
  34. 34.
    Reinpold W, Schroder M, Berger C, Nehls J, Schroder A, Hukauf M, Kockerling F, Bittner R (2018) Mini- or less-open sublay operation (MILOS): a new minimally invasive technique for the extraperitoneal mesh repair of incisional hernias. Ann Surg. Google Scholar
  35. 35.
    Martin Del Campo L, Weltz A, Belyanski I, Novitsky (2017) Comparative analysis of perioperative outcomes of robotic versus open transversus abdominis release. Surg Endosc 32(2):840–845CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Endoscopic SurgeryMilitary Medical Academy – SofiaSofiaBulgaria

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