Extended Total Extraperitoneal Rives-Stoppa Repair: A New Effective Frontier for Ventral Hernia Repair

INTRODUCTION

In 2012, Jorge Daes pioneered the Extended Totally Extraperitoneal (eTEP) technique, revolutionizing the management of challenging inguinal hernias^[1]. This groundbreaking approach was designed to expand the operative space beyond what the traditional TEP method offers, enabling effective treatment of larger and more complex groin hernias. Building on this foundation, Igor Belyansky adapted the eTEP method for ventral hernias, strategically utilizing the retromuscular space for mesh placement in alignment with the principles of Rives and Stoppa (RS). This innovative evolution, now known as the Extended Totally Extraperitoneal Rives-Stoppa (eTEP-RS) repair, has broadened the horizons of hernia surgery^[2].

CASE REPORT

A 46-year-old male presented to the surgical outpatient department (OPD) with reducible swelling in the umbilical area, noticed since 6 months. He was a banker with a desk job. He had no addictions or co-morbidities. He had no urinary or bowel-related complaints. The swelling had gradually increased in size, and of late, he had started experiencing some pain over it. On examination, he had an expansile cough impulse over the umbilical area along with a soft, reducible, well-defined swelling about 5 cm ´ 4 cm in size. Thus, on OPD consultation, a diagnosis of an uncomplicated umbilical hernia was made, and he was advised to undergo a surgical repair for the same. After due pre-operative investigational workup and confirmation of fitness for general anesthesia, he was planned for an extended view total extraperitoneal repair (eTEP).

The surgery was performed with the patient in a supine position with both upper limbs tucked by his side. The surgeon stood on the patient’s left side while the camera surgeon stood on the right side. A blunt entry was first acquired in the left retrorectal space using a blunt 10 mm trocar, about two finger widths below the costal margin. Then, through this the 0° telescope attached to the camera was inserted for confirmation of space. After this, a blunt telescopic dissection was performed to develop the left retrorectal space, caudad, towards the arcuate line, and beyond into the extraperitoneal space of the pelvis [Figure 1a]. Thereafter, the telescope was switched over from 0° to 30°, and two trocars (10 and 5 mm) were inserted under direct vision. The 10 mm trocar was inserted along the semilunar line, one fistful width caudad to the 1^st trocar, taking due precaution to avoid injury to the nearby neurovascular bundle. The 5 mm trocar was inserted in the left extraperitoneal space. The medial end of the left posterior rectus sheath (PRS) was then incised using monopolar cutting current on a hook, near the linea alba (LA); thereby exposing the falciform ligament (FL) and the LA [Figures 1b-d]. This incision was then vertically extended cephalad and caudad, taking due precaution to not injure the LA. The sac was identified during the caudad dissection and was reduced in toto, thereby exposing the defect. Once the incision on the left PRS was complete, the median umbilical ligament below and the FL above were identified. The ‘crossover’ maneuver was then performed between the LA and the FL, taking due precaution not to breach the LA and at the same time avoid an opening in the FL, thereby risking reduction/loss of space. This involved careful dissection to move over to the right side to identify the right PRS. Once identified, the right PRS was incised, thereby exposing the right rectus abdominis muscle [Figure 2a]. This incision on the right PRS was again extended just like the left side in both directions, to open and interconnect the entire bilateral retrorectal space (also called the RS space) [Figures 2b and c]. An additional 10 mm trocar was then inserted on the right side, mirroring the left upper trocar. The camera was then shifted to the right trocar, and the upper two left-sided trocars were used to suture-close the umbilical defect, using barbed suture (No. 1 V-Loc^®) [Figures 2d, 3a and b]. The buttonhole peritoneal defect at the site of the hernia was then suture closed with the same suture [Figure 3c]. Then, a 15 cm ´ 15 cm Prolene soft mesh was rolled, inserted inside, and spread out to cover the defect uniformly in all directions [Figure 3d]. No suture or tack fixation of the mesh was performed. Hemostasis was confirmed, and the space was desufflated under vision. The patient had a smooth postoperative recovery and was discharged from the hospital on postoperative day (POD) 1, with advice to avoid exercise, contact sports, lifting heavy weights, and straining for 6 weeks. On his POD 10 OPD visit, all his wounds had healed well. At the time of writing this paper, a telephonic enquiry was made with him. He continues to be asymptomatic 6 months after his surgery.

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Figure 1:

(a) Initial development of left retrorectal space (white asterisk) between rectus muscle (blue asterisk) and posterior rectus sheath (black asterisk), (b) Incision on left PRS (blue arrow), (c and d) Incision on left PRS (blue arrows) exposing the falciform ligament (red asterisks).

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Figure 2:

(a) Incision(blue arrow) on right PRS exposing the right rectus muscle (white asterisk) after the crossover from left to right just below the linea alba (black asterisk), also seen is transversalis fascia(red asterisk), (b) Development of right retrorectal space (blue arrow), (c) Caudad extension of dissection exposing the defect (blue arrow), linea alba (red asterisk) & both rectus muscles (black asterisks), (d) Initiation of suture closure of defect(blue arrow).

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Figure 3:

(a) Umbilical herniorrhaphy in progress, (b) End result (blue arrow), (c) Suture closure of peritoneal button hole defect (blue arrow), (d) Prolene soft mesh uniformly spread under the sutured hernial defect.

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DISCUSSION

The journey began in 1993 when Leblanc and Booth introduced laparoscopic ventral hernia repair (LVHR), a technique that involved placing an intra-peritoneal onlay mesh (IPOM) as a barrier, yielding successful outcomes^[3]. However, the long-term complications associated with intra-peritoneal mesh placement became apparent over time. Direct contact between the mesh and abdominal viscera led to issues such as adhesive obstruction, enterocutaneous fistula formation, and mesh erosion in some patients.

To address these challenges, Prasad et al. proposed the Transabdominal Pre-Peritoneal (TAPP) approach^[4]. This innovative technique involved creating delicate peritoneal flaps to facilitate the placement of the mesh within the pre-peritoneal space, utilizing a transabdominal route to minimize the complications linked to intra-peritoneal mesh placement.

It is widely accepted that placing mesh in the retromuscular space offers several advantages, including enhanced vascularization on both sides, reduced recurrence rates, minimal fixation-related complications, decreased pain, and a lower risk of bowel adhesions. Additionally, it proves to be cost-effective as it eliminates the need for expensive composite mesh with an anti-adhesion barrier^[5].

Although the IPOM plus technique is relatively straightforward and requires less intraoperative time, it is associated with notable drawbacks. These include increased postoperative pain, prolonged hospital stays, higher incidences of wound seromas, and elevated risks of postoperative paralytic ileus. Conversely, the eTEP-RS technique, while technically more demanding and time-intensive, demonstrated distinct advantages. These include reduced postoperative pain, shorter hospital stays, faster recovery, and a lower likelihood of seromas and paralytic ileus. However, studies have shown no statistically significant differences between the two techniques concerning surgical site infections (SSIs), surgical site occurrences (SSOs), and recurrence rates. Overall, eTEP-RS has emerged as a more favorable approach for managing primary ventral hernias compared to IPOM plus^[6].

For cases involving large ventral hernias with defects too extensive for primary closure, the posterior component separation technique (PCST) using Transversus Abdominis Release (TAR), as described by Dr. Novitsky, is preferred. When combined with the eTEP technique, this approach, termed eTEP TAR, leverages the same dissection plane, making it a highly effective solution for such challenging cases^[7]. The timeline of modern-day developments in ‘keyhole’ surgical repairs of ventral hernias has been summarized [Table 1].

CONCLUSION

As seen in this report, eTEP-RS is a feasible novel approach to the laparoscopic repair of ventral herniae. Also, as seen here, it has distinct advantages over IPOM & IPOM+ operations. Though it has a steep learning curve, advanced laparoscopic operative skills complemented by an advanced setup facilitate the smooth conduct of this operation.