monthly focus

surgical intervention video

Usually, medium-sized umbilical hernias are treated with an open approach since it is the most used technique. However, in situations of increased risk of surgical wound complications, such as immunosuppression, corticosteroid therapy, obesity or diabetes, as well as other associated hernia defects or diastasis of the rectus and in large hernias (>4cm), the use of the minimally invasive approach is indicated (1, 2). 

This video demonstrates a stepwise TARUP (transabdominal retromuscular umbilical prosthetic hernia repair) technique for hernia repair with mesh placement, with the use of the da Vinci Xi™ surgical robotic system, which offers a certain number of benefits.



References:

1. Henriksen NA, Montgomery A, Kaufmann R, Berrevoet F, East B, Fischer J, et al. Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society. British Journal of Surgery 2020; 107:171–90.

2. Rodrigues V, López-Cano M. Técnica TARUP. Ventajas de la cirugía mínimamente invasiva de la pared abdominal asistida por robot. Cirugía Española 2021; 99:302–5.



Robotic transabdominal retromuscular umbilical prosthetic hernia repair (TARUP)

Cure d'éventration ombilicale par technique robot-assistée de type r-TARUP avec renforcement prothétique 

Abdominal wall surgery is in constant evolution. Complications related to surgical wounds and postoperative pain have been the subject of various analyses for many years, leading to the emergence of new techniques to address them. Laparoscopic hernia surgery emerged with the aim of improving postoperative pain and reducing wound complications (1). When the IPOM technique was initially described, it was observed that pain indeed decreases, but the high seroma rate may complicate the postoperative period (2). It appeared that closing the hernia defect provided clear benefits (3), and the LIRA (laparoscopic intracorporeal rectus aponeuroplasty) technique allowed for a tension-free closure of the defect and appropriate mesh integration, with positive results to date (3). It is a reproducible technique that allows progression to more complex techniques such as extended totally extraperitoneal repair (eTEP). The authors present the case of a male patient with a recurrent M2W2 hernia, in whom a LIRA technique was performed. In this video, key steps were demonstrated to facilitate the learning of the technique. The main objective of this video is to help novice surgeons to understand this technique. 

Bibliography:

1. Zhang Y, Zhou H, Chai Y, Cao C, Jin K, Hu Z (2014) Laparoscopic versus open incisional and ventral hernia repair: a systematic review and meta-analysis. World J Surg 38(9):2233–2240. https://doi.org/10.1007/s00268-014-2578-z

2. Van Hoef S, Tollens T (2019) Primary non-complicated midline ventral hernia: is laparoscopic IPOM still a reasonable approach? Hernia 23(5):915–925. https://doi.org/10.1007/s10029-019-02031-6

3. Suwa K, Okamoto T, Yanaga K (2016) Closure versus non-closure of fascial defects in laparoscopic ventral and incisional hernia repairs: a review of the literature. Surg Today 46(7):764–773. https://doi.org/10.1007/s00595-015- 1219-y

4. Gómez-Menchero J, Balla A, García Moreno JL, Gila Bohorquez A, Bellido-Luque JA, Morales-Conde S. Laparoscopic intracorporeal rectus aponeuroplasty (LIRA) technique versus intraperitoneal onlay mesh (IPOM plus) for ventral hernia repair: a comparative analysis. Hernia. 2023 Aug 17. doi: 10.1007/s10029-023- 02858-0. Epub ahead of print. PMID: 37592164

LIRA (laparoscopic intracorporeal rectus aponeuroplasty) technique for recurrent epigastric hernia

Technique LIRA par voie d'abord laparoscopique pour hernies épigastriques récurrentes

In recent years, diastasis recti has become a condition that has sparked interest among general surgeons. Minimally invasive treatment has become a safe and effective alternative for resolving diastasis recti. Various techniques have been described between 2012 and 2020. Endoscopic repair through rectus muscle re-approximation and placement of a supra-aponeurotic mesh is the most widely used technique. 



References:



Hernández-Granados P, Henriksen NA, Berrevoet F, Cuccurullo D, López-Cano M, Nienhuijs S, Ross D, Montgomery A. European Hernia Society guidelines on management of rectus diastasis. Br J Surg. 2021 Oct 23;108(10):1189-1191. doi: 10.1093/bjs/znab128. PMID: 34595502.



Claus CM, Malcher F, Totti Cavazzola L, Furtado M, Morrell A, Azevedo M, Meirelles L, Santos H y Garcia R. Subcutaneous onlay laparoscopic approach (SCOLA) for ventral hernia and rectus abdominis diastasis repair: technical description and initial results. ABCD Arq Bras Cir Dig 2018;31(4):e1399.



Juárez Muas D. Preaponeurotic Endoscopic repair (REPA) of diastasis recti associated or not to midline hernias. Surg Endosc. 2018. https://doi.org/10.1007/s00464-018-6450-3.



Reinpold W, Köckerling F, Bittner R, Conze J, Fortelny R, Koch A, Kukleta J, Kuthe A, Lorenz R, Stechemesser B. Classification of Rectus Diastasis-A Proposal by the German Hernia Society (DHG) and the International Endohernia Society (IEHS). Front Surg. 2019 Jan 28;6:1. doi: 10.3389/fsurg.2019.00001. PMID: 30746364; PMCID: PMC6360174.



Malcher F, Lima DL, Lima RNCL, Cavazzola LT, Claus C, Dong CT, Sreeramoju P. Endoscopic onlay repair for ventral hernia and rectus abdominis diastasis repair: Why so many different names for the same procedure? A qualitative systematic review. Surg Endosc. 2021 Oct;35(10):5414-5421. doi: 10.1007/s00464-021-08560-5. Epub 2021 May 24. PMID: 34031740.

Systematization of technical steps in the endoscopic treatment of diastasis recti

Systématisation des étapes opératoires dans le traitement endoscopique du diastasis recti

Since its first description in 2017, the enhanced-view totally extraperitoneal (eTEP) approach for laparoscopic retromuscular hernia repair has gained popularity as it combines the advantages of a retromuscular mesh placement according to the Rives-Stoppa technique, with the benefits of minimally invasive hernia surgery (1). This approach is technically challenging with a long learning curve. However, it seemingly offers several advantages as compared to the laparoscopic intraperitoneal onlay mesh placement technique (IPOM) (2).

This video presents the case of a 57-year-old female patient presenting with multiple midline incarcerated postoperative hernias after an emergency midline laparotomy. The multiple ‘Swiss cheese’ hernia defects started from the epigastrium, spanning all the way to the hypogastrium for a total length of 22cm and a maximum width of 4.5cm (M2-3-4, W2, according to the EHS classification). The patient had a BMI of 26 and was a heavy smoker with a 30 pack per year smoking history.

Three ports were placed laterally in the left side for the left retrorectus space dissection with the addition of two more ports for the dissection of the right retrorectus space and for the suturing of the abdominal wall. A 30 by 15cm macroporous polyvinylidene fluoride (PVDF) mesh was placed behind the rectus abdominis muscle and fixed with cyanoacrylate glue (3). No drain was used.

The patient was discharged on the first postoperative day (POD 1) and resumed work on POD 3. Four months after surgery, she had excellent cosmetic and functional results.

In spite of its technical challenges, the eTEP approach should be considered for patients with complex abdominal wall hernias.



Bibliographic references: 

1. A novel approach using the enhanced-view totally extraperitoneal (eTEP) technique for laparoscopic retromuscular hernia repair. Igor Belyansky, Jorge Daes, Victor Gheorghe Radu, Ramana Balasubramanian, H Reza Zahiri, Adam S Weltz, Udai S Sibia, Adrian Park, Yuri Novitsky. Surg Endosc 2018;32(3):1525-32. doi: 10.1007/s00464-017-5840-2. Epub 2017 Sep 15. https://pubmed.ncbi.nlm.nih.gov/28916960/ 

2. Comparison of outcomes of the extended-view totally extraperitoneal rives-stoppa (eTEP-RS) and the intraperitoneal onlay mesh with defect closure (IPOM-plus) for W1-W2 midline incisional hernia repair-a single-center experience. Halil Afşin Taşdelen. Surg Endosc 2023;37(4):3260-71. doi: 10.1007/s00464-023-09922-x. Epub 2023 Feb 10. https://pubmed.ncbi.nlm.nih.gov/36764936/ 

3. Degradation resistance of PVDF mesh in vivo in comparison to PP mesh. Hongshi Wang, Bernd Klosterhalfen, Andreas Müllen, Thomas Otto, Axel Dievernich, Stefan Jockenhövel. J Mech Behav Biomed Mater 2021;119:104490. doi: 10.1016/j.jmbbm.2021.104490. Epub 2021 Mar 23. https://pubmed.ncbi.nlm.nih.gov/33780848/ 

eTEP Rives-Stoppa repair for M2-3-4, W2 postoperative ventral hernia

Technique eTEP selon Rives-Stoppa pour hernie ventrale postopératoire M2-3-4W2

Technique eTEP pour cure rétromusculaire de hernie ventrale (ombilicale et épigastrique) récidivante et hernie inguinale droite

In this educational video, the authors demonstrate the laparoscopic repair of recurrent umbilical and epigastric hernias with an extended totally extraperitoneal (eTEP) retromuscular technique. The authors perform this approach using 6 trocars: one 12mm balloon trocar, one 11mm trocar, and four 5mm trocars. Anatomical landmarks were marked with a skin marking pen on the patient’s abdomen. The authors performed the open insertion of a 12mm disposable trocar using a cylindrical balloon for the initial dissection performed from the retromuscular space to the left rectus abdominis muscle. The procedure was pursued while the authors dissected the pelvic preperitoneal space and performed a crossover dissection from the left to the right retromuscular space through the preperitoneal space. An incision to the medial edge of the left posterior rectus aponeurosis was subsequently performed. The upper crossover to the right was performed before the incision of the medial edge of the right posterior rectus aponeurosis and the dissection of the right retromuscular space with the reduction of the hernia sac. The right-sided dissection was advanced to the right preperitoneal space and ended with the dissection of the right inguinal hernia. Peritoneal tears were sutured and the rectus abdominis diastasis repaired with a continuous barbed suture, including the closure of the ventral hernia defect with plication of the hernia sac. A medium-weight polypropylene mesh of 25 by 15cm was placed in the retrorectus space, which was drained with a suction drain. 



References:

Morrell ALG, Morrell A, Morrell-Junior AC, Mendes JMF, Morrell AG. Standardization and ten essential steps in the lateral robotic extended totally extraperitoneal (eTEP) repair of ventral hernias. Rev Col Bras Cir. 2020 Oct 7;47:e20202622. English, Portuguese. doi: 10.1590/0100-6991e-20202622. PMID: 33053065.

Ramana B, Arora E, Belyansky I. Signs and landmarks in eTEP Rives-Stoppa repair of ventral hernias. Hernia. 2021 Apr;25(2):545-550. doi: 10.1007/s10029-020-02216-4. Epub 2020 May 18. PMID: 32424727.

Mitura K, Rzewuska A, Skolimowska-Rzewuska M, Romańczuk M, Kisielewski K, Wyrzykowska D. Laparoscopic enhanced-view totally extraperitoneal Rives-Stoppa repair (eTEP-RS) for ventral and incisional hernias - early operative outcomes and technical remarks on a novel retromuscular approach. Wideochir Inne Tech Maloinwazyjne. 2020 Dec;15(4):533-545. doi: 10.5114/wiitm.2020.99371. Epub 2020 Sep 25. PMID: 33294067; PMCID: PMC7687670.

Belyansky I, Daes J, Radu VG, Balasubramanian R, Reza Zahiri H, Weltz AS, Sibia US, Park A, Novitsky Y. A novel approach using the enhanced-view totally extraperitoneal (eTEP) technique for laparoscopic retromuscular hernia repair. Surg Endosc. 2018 Mar;32(3):1525-1532. doi: 10.1007/s00464-017-5840-2. Epub 2017 Sep 15. PMID: 28916960.

Enhanced-view totally extraperitoneal (eTEP) retromuscular repair for ventral (umbilical and epigastric) recurrent hernia and right inguinal hernia

The critical view of the myopectineal orifice (MPO) is defined as the appropriate exposure of the anatomical area that must be obtained before placing the mesh during laparoscopic and robotic inguinal hernia repair. This concept is a consolidation of recommendations shown to reduce hernia recurrence and postoperative complications and standardizes the teaching and evaluation of minimally invasive inguinal hernia repair.

This video presents the case of a right-sided indirect inguinal hernia. The authors demonstrate here the steps to achieve the critical view of the MPO in an extended totally extraperitoneal (eTEP) inguinal hernia repair, followed by mesh placement.

Bibliography:

1. Daes J, Felix E. Critical view of the myopectineal orifice. Annals of surgery. 2017 Jul 1;266(1):e1-2.
2. Claus C, Furtado M, Malcher F, Cavazzola LT, Felix E. Ten golden rules for a safe MIS inguinal hernia repair using a new anatomical concept as a guide. Surgical endoscopy. 2020 Apr;34:1458-64.
3. Felix E, Lourié D, Daes J. Understanding the Critical View of the Myopectineal Orifice (MPO) for Safe Minimally Invasive Surgical Inguinal Hernia Repair. In Newer Concepts and Procedures in Hernia Surgery-An Atlas 2023 Jan 1 (pp. 3-10). Singapore: Springer Nature Singapore.

Extended totally extraperitoneal (eTEP) repair of right-sided inguinal hernia demonstrating the critical view (CV) of the myopectineal orifice (MPO)

Cure de hernie inguinale droite totalement extrapéritonéale étendue (eTEP) avec identification formelle de l'orifice musculo-pectinéal

Abstract:

The transabdominal preperitoneal (TAPP) technique in ventral hernia repair allows for the placement of a much larger mesh than in the anterior surgical approach. It is also closer to current recommendations, especially for patients with additional risk factors, such as obesity without diastasis recti. The TAPP technique allows for mesh introduction into the preperitoneal space, which prevents direct contact between the mesh and the intestines. The mini ventral TAPP approach is feasible and safe.



Bibliographic references:

1. I.F. Megas, et al. A propensity‐score matched analysis of ventral‐TAPP vs. laparoscopic IPOM for small and mid‐sized ventral hernias. Comparison of perioperative data, surgical outcome and cost‐effectiveness. https://doi.org/10.1007/s10029-022-02586-x 

2. Muysoms, F.E., et al., Classication of primary and incisional abdominal wall hernias. https://doi.org/10.1007/s10029-009-0518-x 

3. Skolimowska-Rzewuska M., Romańczuk M., Mitura B., Wyrzykowska D., Mitura K. Laparoscopic transabdominal preperitoneal repair (umbilical TAPP) versus open ventral patch repair for medium size umbilical hernias in overweight and obese patients. https://doi.org/10.5114/wiitm.2021.110415 

4. Gillies M., Anthony L., Al-Roubaie A., Rockliff A., Phong J. Trends in Incisional and Ventral Hernia Repair: A Population Analysis From 2001 to 2021. https://doi.org/10.7759/cureus.35744 

5. Daes Jorge. Evolución de la reparación laparoscópica de las hernias ventrales y del sitio de la incisión. https://10.1016/j.rehah.2016.05.001 





Mini ventral transabdominal preperitoneal (TAPP) repair for small size ventral hernia (M2W1) in an overweight patient

Mini cure de hernie ventrale de petite taille (M2W1) par voie d'abord transabdominale prépéritonéale (technique TAPP) chez une patiente en surpoids

Prise en charge laparoscopique d'une récidive de hernie inguinale droite après cure laparoscopique par voie d'abord transabdominoprépéritonéale (TAPP) 

The video presents the clinical case of a 49-year-old male patient who had undergone a laparoscopic TAPP repair for a right inguinal hernia one year earlier. He presented with an internal recurrence of his right inguinal hernia and with a voluminous left inguinal hernia. On clinical exam and imaging, a 2 to 3cm direct hernia protrusion, Nyhus type IIIa, was found. It was decided to perform a laparoscopic repair for the left inguinal hernia and to explore the right inguinal hernia. Based on anatomical aspects, a laparoscopic redo was performed.

It is usually recommended to treat inguinal hernia recurrence after a laparoscopic transabdominal preperitoneal approach (TAPP) using an anterior approach to work on a non-operated site. In this video, it was decided to manage the patient’s contralateral hernia laparoscopically, and to simultaneously explore the hernia recurrence.

Focus on abdominal wall hernia repair (AWHR)