Endoscopic Mini/Less Open Sublay (EMILOS) Technique: A Variation of the MILOS Operation in the Therapeutic Spectrum of Primary and Secondary Ventral Hernias
The optimal operative treatment of primary and secondary hernias of the abdominal wall is still debatable. Traditional open techniques are burdened with a high rate of infection , whereas the laparoscopic intraperitoneal onlay mesh (IPOM) repair carries an increased risk for intraoperative lesions to the bowel, adhesions, and bowel obstructions [2–4]. Despite great progress in mesh technology and development of expensive meshes promising less formation of adhesions between the mesh and the intestine, the potential risk of an intraperitoneal foreign body has not yet been solved . Furthermore, the IPOM technique typically requires expensive fixation devices and, more important, fixation with tacks or sutures causes severe acute and chronic pain. In order to avoid these disadvantages of current open and laparoscopic techniques, the MILOS (mini/less open sublay) concept was developed by W. Reinpold (► Chap. 33). The aim of this novel technique is to keep the mesh out of the abdominal cavity. Following the MILOS concept, the surgeon is able to place a large mesh into the retromuscular plane through a small skin incision (2–6 cm = mini open; 6–12 cm = less open). The MILOS operation is an open procedure, using endoscopic dissection instruments and a novel specifically designed light tube which facilitates exposure, visualization, and retraction (Endotorch, Wolf TM). Despite this new innovative device, the technique which is extensively described in ► Chap. 33 may be technically challenging especially not at least because the assisting surgeon’s view is limited. Therefore, in order to increase utilization of the “MILOS concept,” we developed the endoscopic mini/less open sublay (EMILOS) operation which is essentially a reversed total extraperitoneal(TEP) procedure . This variation of the original MILOS operation is a true hybrid technique which consists of two parts, the first steps (step 1–4) are identical to the MILOS operation, then immediately after opening of the rectus sheath, the operation continues with endoscopic dissection “reversed TEP” of the total retromuscular space.
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