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eTEP -RS Dr.TVR.pptx

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Varunraju9

E-TEP RS is a rapidly evolving laparoscopic procedure for ventral and incisional hernias.Please ask me questions if you have regarding this excellent procedure.

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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
Greetings
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
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)
Mesh levels
Operative technique
Peri umbilical region

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eTEP -RS Dr.TVR.pptx

  • 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
  • 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)
  • 9. Retro recus space creation
  • 14. ARS / Midline defect closure
  • 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.