2. A hernia is an abnormal protrusion of a viscus or a part of it, through the wall of the cavity containing it. Ventral
hernias occur at sites of weakness within the musculoaponeuroticantero-lateral abdominal wall. Ventral hernias may
be primary, or incisional, occurring at prior surgical site[1]
There are a number of open & laparoscopic treatment options of ventral hernias. Most would involve the placement
of a prosthetic mesh to prevent recurrence. The various planes of prosthesis placement are:
Onlay – The mesh lies superficial to the anterior sheath or external oblique aponeurosis with an overlap
Inlay – The mesh is trimmed to the size of the sheath defect and is sutured to the edges
Sublay – The mesh is placed deep to the defect, either retro-rectus or inter-muscular, but always superficial to the
peritoneum
Underlay – The mesh is placed intra-peritoneally
3. • Of all the planes of mesh placement, it is Sublay which appears most ideal.
• However, placement of this wide mesh was traditionally performed by an open route, producing significant post-
operative morbidity. The use of laparoscopy to perform a retrorectus placement was met with technical difficulty due to
inability of widely placed trans-abdominal ports to suture the anterior sheath defect & posterior sheath in a vertical
axis. The enhanced view total extra-peritoneal (eTEP) approach was first described by Jorge Daes of Columbia in 2012
for the repair of inguinal hernias[2].
• eTEP was based on the fact that the retro-rectus space is continuous with the pre-peritoneal space below the arcuate
line of Douglas[3,4]
• Through our study, we hope to describe the technique of endoscopic eTEP Rives-Stoppa repair for ventral hernia
repair, identify a subset of patients who have most to gain from the surgery, document the challenges & any possible
complications faced
4. • Through our study, we hope to describe the technique of endoscopic eTEP Rives-Stoppa repair for ventral hernia
repair, identify a subset of patients who have most to gain from the surgery, document the challenges & any
possible complications faced.
5. MATERIAL AND METHODS
All patients presenting during the study period and fitting the inclusion criteria were included in the study and
underwent e-TEP RS with or without transversusabdominisrelease(TAR). A total of 40 patients were included in
the study. A 30day , 3months, 6 months , 1 year follow was maintained with patients being evaluated on the
basis of symptomatology and radiological imaging .
INCLUSION CRITERIA
1. Patients diagnosed to have ventral hernia whether primary or incisonal or with previous hernia repairs .
2. Irrespective of sex
3. Patients aged between 18 years and 70 years.
4. Patients in whom post-operative follow up is feasible
6. On examination, site of hernia, reducibility and size of hernia were noted. Site of hernia was recorded as per the
European Hernia Society (EHS) classification.[5]
Location Classification
Midline Sub-xiphoid M1
Epigastric M2
Umbilical M3
Infra-umbilical M4
Suprapubic M5
Lateral Sub-costal L1
Flank L2
Iliac L3
Lumbar L4
Recurrence Yes No
Width (cm)
W1< 4 W2= 4-10 W3> 10
EHS CLASSIFICATION
Peri-operative parameters included were the American Society of Anaesthesiologists (ASA) score, operative time,
estimated blood loss, fascial closure, mesh used, number of meshes, intra-operative complications and use of surgical
drains.
7. All patients underwent a pre-operative CT scan and size of hernia, location as per EHS classification and number of
defects was recorded. Hernial contents were assessed, Tanaka’s index analysed to assess for loss of domain (hernia
with volume ratio > 25%).
Patients were followed up 1, 3 and 12 months after the surgery as per the feasibility.
Significance is assessed at 5% level of significance.The collected data was collected, coded, entered into Microsoft
excel work sheet and exported to SPSS. Data was analyzed using SPSS version 21.
8. RESULTS AND OBSERVATIONS
Results
All patients who reported to department of general surgery with ventral hernia’s and who fulfilled the inclusion criteria
during the study period. A total of 41 subjects were taken for this study.
CHART 1: Column chart showing the age distribution
0
2
4
6
8
10
12
14
16
18
25-34 years 35-44 years 45-54 years >55 years
Frequency
Frequency
10. EHS classification Frequency Percentage
M1 (Subxyphoidal) 02 4.8%
M2`(Epigastrica) 14 34.1
M3 (Umbilical) 28 68.2%
M4 (Infraumbilical) 15 36.5%
M5 (Suprapubic) 06 14.6%
L1 (Subcostal) 02 4.8%
L2 (Flank) 0 -
L3 (Iliac) 04 9.7%
L4 (Lumbar) 0 -
Distribution of defects among the subjects as per EHS classification
0
5
10
15
20
25
30
Frequency
Frequency
11. Doughnut chart showing the etiology
Frequency
Primary
Incisional
26
14
1
Frequency
eTEP RS
eTEP Unilateral TAR
eTEP Bilateral TAR
Pie chart showing the operational procedure done
12. Discussion
A total of 41 patients suffering with ventral hernia were studied for their demographic and clinical profile. The
following observations were noted.
0
10
20
30
40
50
60
70
present nicolas et al belyansky deshpande baig
Mean age comparison between various studies
14. 0
50
100
150
200
250
PRESENT Baig SJ Penchev D Jorge D J Schwarz BELYANSKY
MEAN OPERATIVE TIME IN MINUTES
MEAN OPERATIVE TIME IN MINUTES
CHART 21 Mean operative time in various studies
16. 1
0 0 0 0
1
0 0
1 1 1 1
5
1
3
0
4
0
1 1 1
2
6
1
10
1 1 1 1
0
2
4
6
8
10
12
READMISSION
RECURRENCE
SEROMA
SSI
Complications rate in various studies
In this study, the first follow up was done after 30 days. Except for one subject all the other subjects had a routine checkup.
One subject had an emergency checkup. It was noted that one subject had readmission, reoperation and recurrence. The
complication noted was seroma. No other complication like hematoma, cellulitis and UTI’s were noted. Recurrence was
noted in only one subject and the quality of life improvement was noted in all the 41 subjects after the second follow up.
17. CONCLUSION
All 41 subjects’ hernia repairs were successful with just one subject recurrence and needing re-operation. The
overall hospital stay was reduced; pain was also minimal with minimal use of analgesics. This procedure was cost
benefiting and mainly the subject’s quality of life was improved.
Therefore this study proves e TEP (expanded totally extra peritioneal hernia repair ) to be a cost effective ventral
hernia repair with great patient satisfaction and improved results in the follow up in terms of recurrence , infection ,
and problems needing readmission .
In this study audit which was done in tertiary care teaching hospital , was compared with global standard studies ,
similar results were obtained , except for operative time , and hospital stay , which can be improved by increasing
the case load and improving operative skills.
18. 1. Deerenberg EB, Timmermans L, Hogerzeil DP et al (2015) A systematic review of the surgical treatment of
large incisional hernia. Hernia 19:89–101. doi:10.1007/s10029-014-1321-x
2. Fink C, Baumann P, Wente MN et al (2014) Incisional hernia rate 3 years after midline laparotomy. BJS
101:51–54. doi:10.1002/ bjs.9364
3.stoppa RE. The treatment of complicated groin and incisional hernias. World J Surg. 1989;13(5):545-554.
doi:10.1007/BF01658869.
4.Daes J. The enhanced view–totally extraperitoneal technique for repair of inguinal hernia.
doi:10.1007/s00464-011-1993-6.
19. 5.Muysoms FE, Miserez M, Berrevoet F, et al. Classification of primary and incisional abdominal wall hernias.
Hernia. 2009;13(4):407-414. doi:10.1007/s10029-009-0518-x
![A hernia is an abnormal protrusion of a viscus or a part of it, through the wall of the cavity containing it. Ventral
hernias occur at sites of weakness within the musculoaponeuroticantero-lateral abdominal wall. Ventral hernias may
be primary, or incisional, occurring at prior surgical site[1]
There are a number of open & laparoscopic treatment options of ventral hernias. Most would involve the placement
of a prosthetic mesh to prevent recurrence. The various planes of prosthesis placement are:
Onlay – The mesh lies superficial to the anterior sheath or external oblique aponeurosis with an overlap
Inlay – The mesh is trimmed to the size of the sheath defect and is sutured to the edges
Sublay – The mesh is placed deep to the defect, either retro-rectus or inter-muscular, but always superficial to the
peritoneum
Underlay – The mesh is placed intra-peritoneally](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)