The document discusses the eTEP-RS technique for ventral hernia repair. It begins by defining the different planes of the abdominal wall where mesh can be placed, including the retro-rectus plane used in eTEP-RS. The technique creates a retro-rectus space for reinforcement without the need for mesh fixation. It has advantages of reducing pain and preventing bowel-mesh contact compared to other laparoscopic techniques. However, eTEP-RS also has challenges like a long learning curve and risk of seroma due to the large space created. Overall, the document concludes the technique is a safe alternative to open repair when performed by experienced surgeons, but requires further analysis to determine its benefits compared to other approaches.

1. e TEP – RS
Abdominal wall Hernias
Dr.T.Varun Raju
Lap.Course Director - TVR Laparoscopy Center
H.O.D General & Laparoscopic Surgery
St.Theresa’s Hospital ,Hyderabad

2. Greetings

3. Ventral hernia repair
• The literature mentions
nomenclature which is used
with significant variability and
often incorrectly
• The recto-rectus plane is
often referred to as the ‘inlay’
, ‘sublay’ or ‘underlay’ plane.
• The pre-peritoneal layer is
often also referred to by all
three terms; ‘inlay’ , ‘sublay’
and ‘underlay’
• The intra-abdominal plane is
often referred to as ‘sublay’
or ‘underlay’.
Retro-rectus
plane
Intra-abdominal
plane
Pre-peritoneal
plane
INLAY
SUB-LAY
UNDER-LAY

4. Defining the planes of the anterior
abdominal wall
• Mesh is laid on top of the external oblique over the defect-
Subcutaneous/onlay/overlay
• Mesh is the same size as the hernia defect and the edges are sutured the
hernia neck - Inlay/interposition (always bridging)
• Posterior to the rectus muscles and anterior to the posterior rectus sheath
Retro-rectus – Sublay
• Anterior to the peritoneum and posterior the rectus sheath - Pre-
peritonealUnderlay (TAPP)
• Mesh is inserted into the Abdominal compartment and laid on the
anterior abdominal wall deep to the peritoneum. Often bridging especially
in laparoscopic surgery - Intra-abdominal/intra-peritoneal onlay mesh
(IPOM)

5. Mesh levels

6. Operative technique
Peri umbilical region

7. Patient’s position

8. Ports position

9. Retro recus space creation

10. Midline cross over

11. Opposite PRS opening

12. Hernial sac dissection

13. Hernial defect closure

14. ARS / Midline defect closure

15. P.P Mesh placement

16. Epigastric region

17. Limitations

18. Introduction
• Ventral hernia repair is one of the most common
surgical procedures in general surgery
• The incidence of incisional ventral hernia reaches
28% after ventral surgeries. The optimal treatment
for incisional abdominal wall hernias is still under
debate.
• The main goal of safe and successful surgery is
durable repair with low morbidity and recurrence
rates

19. Open surgery
• In general, open repair is correlated with a slow
recovery course and a higher risk of wound infection.
• The success of TAPP (transabdominal preperitoneal)
and TEP (totally extraperitoneal) repair for groin
hernias was undisputable, so the extraperitoneal
plane began to be noticed in minimally invasive
repair for incisional hernias
• Although laparoscopic surgery for abdominal wall
hernia has gained recognition in the twenty-first
century, there is still a dispute about the ideal
approach.
• Nowadays, so many diverse alternatives for the
management of these hernias are available from
different open to other minimally invasive
techniques

20. Standardized technique
• The diversity of methods makes the decision-making
process more demanding in incisional hernia.
• Surgeons still look for the optimal or standardized
technique that adequately minimizes complications and
improves results.
• Current evidence shows that the laparoscopic approach
has the advantage of a shorter hospital stay after repair,
an early return to work, and reduced surgical wound
complications compared to the open approach
• The latest developments in abdominal wall
reconstruction have offered surgeons a wide range of
methods to repair various ventral hernias.
• Closure of parietal defects simplifies mesh integration
and restores the structure of the abdominal wall, which
has a significant implication for its function

21. Retro muscular plane
• The e-TEP-RS approach,
according to Pascal’s law,
provides a plane for
reinforcement of the
abdominal wall
• Researchers show results
with recurrence rates not
exceeding 3%, but the
heterogeneity of these groups
should be acknowledged
LOW
RECURRENCE

22. No fixation
• The benefits of eTEP-RS are derived from the
creation of the extraperitoneal retromuscular
plane, excluding the need for a barrier mesh or its
fixation
• Furthermore, and most importantly, it prevents
direct contact between the bowel and a mesh
• In retromuscular position, mesh is sandwiched
between rectus muscles and posterior rectus
sheath, and thus can be positioned without
additional fixation
• In other types of ventral hernia repair, multiple
sutures or tacks have been shown to contribute to
pain in the immediate postoperative period, and to
chronic postoperative pain due to nerve
entrapments

23. IPOM
• According to Penchev et al.
retrospective comparative study
between eTEP-RS and IPOM, a
reduced pain score has been
reported in eTEP-RS patients
• As the mesh is placed in the
retrorectus plane and no fixation
technique is used, these aspects
might be the most valuable
feature of the eTEP approach
allowing for a low pain intensity.

24. Seroma
• The lower cost of flat non-barrier mesh
compared to intraperitoneal mesh may help
reduce costs compared to IPOM, but in the
early phase of the learning curve these
advantages might be offset by a prolonged
duration of the procedure
• As a vast space develops in a retrorectus
plane, there is a higher risk of occurrence of
seroma.
• To prevent this complication, it is routinely
used a vacuum suction drain below the mesh
for a period of 2–3 days with an abdominal
binder.
SEROMA
PREVENTION

25. Suture line rupture
• During surgery, the ability to judge
tension during closure of the peritoneum
and PRS layer is imperative for surgeons.
• Overlooked defects or rupture of the
posterior layer can possibly cause internal
hernias and an increased risk of
incarceration and strangulation of the
bowel. e-TEP-RS repair ventral hernias
surgery is associated with few essential
complications related to the method,
such as rupture or dehiscence of the
posterior layer or damage to the linea
alba while crossing, unintentional injury
to the neurovascular bundle or disruption
of the linea semilunaris while performing
lateral dissection.
COMPLICATIONS

26. Low pressure
• Good understanding of an
appropriate endoscopic anatomy
and meticulous dissection in the
retromuscular plane prevent
these events
• The pressure of carbon dioxide
insufflation can be decreased
before closure of the ventral
defect for convenience and to
avoid excessive fascial tension. Up
to 6–8 mmHg pressure is tolerable
and provides sufficient space for
endo-suturing in most cases
SUTURING
SKILLS

27. Need of a TAR
• The crucial advantage of e-TEP-
RS, especially in large incisional
hernia, is that if closure of the
defect is not achievable, then
release of the transversus
abdominis as a form of a posterior
component separation technique
can be performed as the
dissection space stays the same
• Another potential solution could
be the application of a barrier
mesh or greater omentum that
can be sutured into the defect
ADVANTAGES

28. Dicficulties
• The learning curve for
laparoscopic eTEP-RS repair
seems long, requiring advanced
technical skills from the surgeon
• Therefore, the limitations of e-
TEP-RS according to published
evidence are prolonged surgery
time, steep learning curve,
requirement for superior
laparoscopic skills, and
troublesome crossover to the
contralateral side in large defects
with previous incision
PROLONGED
SURGERY

29. Roboic surgery
• Usually, patients with incisional hernias
are offered open repair due to the
frequent need for adhesiolysis, increasing
the risk of unintentional enterotomy
• With the gain of experience and
adaptation to e-TEP-RS repair, more
complicated cases with larger hernias and
recurrent defects were qualified for
surgery.
• Robotic eTEP-RS may have added
advantages compared to laparoscopy,
especially when suturing the midline in
larger hernias and when performing
transversus abdominis release.
LARGE
HERNIAS

30. A demanding procedure
• The eTEP-RS is a demanding procedure that requires a
comprehensive knowledge of the anatomy of the
preperitoneal and retromuscular plane and where
superior laparoscopic skills are crucial to successfully
perform these maneuvers
• Furthermore, there are several approaches and
procedural aspects to consider when performing ventral
hernia repair with eTEP-RS
• Due to the inconvenience of this technique and its
recent use, some articles proved a prolonged operative
time for the eTEP-RS approach compared to other
laparoendoscopic repair techniques
• However, once the learning curve is overcome, a
reduction in operative times and unfavorable outcomes
is noticed
SEVERAL
APPROACHES

31. Injuries
• Despite the difficulty of this procedure, eTEP-RS seems to
be safe in terms of perioperative adverse events
• The number of intraoperative complications and the
conversion rate in the meta-analysis presented by
Köckerling et al. was 2.0% and 1.0%, respectively.
• These results appear to be comparable with laparoscopic
IPOM and seem to improve those derived from sublay
open ventral repair
• However, the surgeon must be cautious, since there is
still a risk of visceral injury due to a possible thermal
injury below the posterior layer, especially around the
hernia defect and also during the crossover maneuver,
particularly in patients who have had previous abdominal
surgery
CROSS OVER

32. Conclusions
• The eTEP-RS technique is a safe alternative to open ventral hernia repair in
selected cases and allows for the placement of a large piece of mesh
according to current recommendations.
• The eTEP-RS can be performed effectively by surgeons familiar with
laparoscopic techniques for groin and ventral hernia repairs with
satisfactory results and low rates of complication, including recurrence.
• Excellent knowledge of the detailed anatomy of the abdominal wall is
essential for safe and effective hernia repair.
• Compliance with certain rules of the laparoscopic eTEP-RS surgery
facilitates improved ergonomics for this procedure .
• As a new approach to hernia repair, e-TEP-RS requires further analyses to
determine its benefits over the approaches most frequently used.

33. Thank you all