Overview
Definition:
The eTEP (enhanced Totally Extraperitoneal) Transabdominal Preperitoneal (TAR) approach is a laparoscopic technique for complex ventral hernia repair
It involves dissecting within the preperitoneal space between the transversalis fascia and the peritoneum, allowing for large mesh placement without direct contact with abdominal contents
This method is particularly beneficial for recurrent, large, or contaminated ventral hernias.
Epidemiology:
Ventral hernias are common, with incisional hernias occurring in up to 11-20% of patients after abdominal surgery
Complex ventral hernias, defined by large defects (>10 cm), multiple recurrences, or contamination, pose significant reconstructive challenges, impacting a substantial number of surgical patients annually.
Clinical Significance:
Complex ventral hernias lead to significant morbidity, including chronic pain, impaired mobility, bowel obstruction, and incarceration
eTEP TAR offers a less invasive yet robust solution, enabling tension-free mesh fixation in the preperitoneal space, which is associated with lower recurrence rates and faster patient recovery compared to open repairs or older laparoscopic techniques.
Indications
Primary Indications:
Large (>10 cm) ventral hernias
Recurrent ventral hernias, especially after multiple prior repairs
Incisional hernias
Paraumbilical hernias
Potential for mesh contamination in previously infected sites
Patients requiring simultaneous intra-abdominal procedures.
Contraindications:
Absolute contraindications are rare but include uncontrolled sepsis, unreconstructable bowel, or inability to tolerate pneumoperitoneum
Relative contraindications include severe coagulopathy, extensive adhesions making preperitoneal dissection difficult, or patient refusal of laparoscopic approach.
Selection Criteria:
Patient factors: BMI, comorbidities, previous surgeries
Hernia factors: defect size, recurrence history, presence of stoma or enterocutaneous fistula, fascial integrity
Surgeon experience with laparoscopic abdominal wall reconstruction.
Preoperative Preparation
Patient Assessment:
Thorough history and physical examination focusing on previous surgeries, hernia symptoms, and risk factors for wound complications
Detailed nutritional assessment and optimization, especially in malnourished patients
Smoking cessation counseling and management of comorbidities like diabetes and obesity.
Imaging:
Computed tomography (CT) scan of the abdomen and pelvis is crucial
It helps delineate the hernia defect size and location, assess the integrity of the transversalis fascia, identify any intra-abdominal adhesions, and evaluate the extent of mesh overlap required
Dynamic CT or ultrasound may be considered in select cases.
Consent And Counseling:
Comprehensive discussion with the patient regarding the benefits, risks, and alternatives to eTEP TAR
This includes explaining the minimally invasive nature, potential complications like bleeding, infection, seroma, mesh migration, nerve injury, and the possibility of conversion to open surgery
Informed consent for mesh implantation and its implications.
Procedure Steps
Port Placement:
Typically involves 3-4 ports: an umbilical camera port and two or three working ports placed laterally to the rectus sheath in the anterior abdominal wall
Initial pneumoperitoneum is established to create space.
Peritoneal Dissection:
A small incision is made in the peritoneum in the midline infraumbilically or supraumbilically
Dissection proceeds laterally in the preperitoneal space, detaching the peritoneum from the posterior rectus sheath and muscles
This creates a large working envelope.
Hernial Sac Mobilization:
The hernial sac and its contents are carefully mobilized away from the surrounding tissues within the preperitoneal space
Adhesions to the peritoneum are meticulously divided
In cases of incarcerated contents, gentle reduction is performed after adequate dissection.
Mesh Placement:
A large, dual-mesh prosthesis (e.g., composite mesh with a visceral barrier) is introduced into the preperitoneal space
The mesh should overlap the hernia defect by at least 5 cm in all directions
Fixation is achieved using tacks, sutures, or fibrin glue, ensuring good apposition to the transversalis fascia.
Peritoneal Closure:
Crucially, the peritoneal defect is completely closed laparoscopically
This prevents direct contact of the bowel with the mesh, reducing the risk of enterocutaneous fistula formation and mesh infection.
Postoperative Care
Pain Management:
Multimodal analgesia is essential, including intravenous or oral opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and potentially regional blocks
Early mobilization is encouraged.
Drainage And Monitoring:
Surgical drains are typically not placed in the preperitoneal space
Patients are monitored for signs of infection, bleeding, seroma formation, and signs of bowel obstruction
Vital signs and urine output are closely observed.
Activity Restrictions:
Patients are advised to avoid strenuous activities, heavy lifting (>10 kg), and significant abdominal exertion for 4-6 weeks
Gradual return to normal activities is guided by pain and functional recovery
Wound care instructions are provided.
Discharge Criteria:
Pain controlled with oral medication, tolerating oral intake, absence of fever or significant wound complications, and ability to ambulate independently
Typically discharged within 24-48 hours post-operatively.
Complications
Early Complications:
Seroma formation (most common), bleeding, infection (wound or mesh), hematoma, urinary retention, ileus, port-site herniation
Less common: bowel injury, injury to vascular or neural structures.
Late Complications:
Chronic pain, mesh infection (delayed), mesh migration or shrinkage, recurrence, incisional hernia at port sites, enterocutaneous fistula (rare with adequate peritoneal closure), chronic seroma.
Prevention Strategies:
Meticulous dissection to avoid injury
Complete peritoneal closure is paramount
Adequate mesh overlap and secure fixation
Prophylactic antibiotics
Careful patient selection and optimization
Early recognition and management of seroma and infection
Appropriate wound closure techniques.
Prognosis
Factors Affecting Prognosis:
Hernia complexity, surgeon experience, mesh type and fixation, adherence to postoperative instructions, and patient comorbidities significantly influence outcomes
Accurate peritoneal closure is critical in preventing mesh-related complications.
Outcomes:
eTEP TAR is associated with low recurrence rates (typically <5%) for complex hernias, reduced postoperative pain, and shorter hospital stays compared to open repairs
Patient satisfaction is generally high due to faster recovery and better cosmesis.
Follow Up:
Routine follow-up is recommended at 1, 6, and 12 months post-operatively
This involves clinical examination to assess for recurrence or complications and patient-reported outcomes
Long-term surveillance may be advised for very large or high-risk hernias.
Key Points
Exam Focus:
Understand the anatomical planes for eTEP TAR, the importance of complete peritoneal closure, mesh selection criteria for complex hernias, and common complications
Differentiate eTEP from other laparoscopic ventral hernia repairs (e.g., IPOM).
Clinical Pearls:
Achieving adequate preperitoneal space is key to successful mesh placement
Don't rush the peritoneal dissection
be thorough
Always aim for a tension-free mesh and secure fixation
Peritoneal closure is non-negotiable for safety.
Common Mistakes:
Incomplete peritoneal closure leading to mesh-bowel contact
Inadequate mesh overlap
Over-reliance on tacks for fixation without adequate coverage
Poor patient selection for laparoscopic approach
Underestimating the importance of postoperative pain control and activity restriction.