Precostal top-down extended totally extraperitoneal ventral hernia plasty (eTEP): simplification of a complex technical approach.

PURPOSE: Retromuscular mesh augmentation is generally considered to be the ideal technique for repairing ventral hernias and can be performed laparoscopically by 'enhanced view totally extraperitoneal plasty' (eTEP)-a technically complex procedure that requires a high level of surgical expertise. We aimed to develop a simplified technical modification. METHODS: Thirty-one patients with ventral hernias were operated with a modified precostal, top-down eTEP approach, and prospectively recorded in our hernia registry. We describe this novel standardized precostal access and the bilateral development of both retromuscular compartments with a cylindrical dilating balloon port. Demographic-, hernia-specific-, and perioperative data were analyzed retrospectively. RESULTS: Twenty-two primary and 9 incisional hernias with an average defect size of 34.5 cm2 were repaired. An average implant of 420 cm2 always completely covered diastasis recti and/or scars from previous midline laparotomies. Average procedure time was 128 min. One conversion was required due to peritoneal injury. Postoperatively there was one local infection and one patient suffered an interparietal herniation. There were no recurrences during the average 8-month follow-up period. CONCLUSION: With technical modification of precostal access and pneumatic balloon dilation of both retro-rectus compartments, the complex procedure can be simplified through time saving and straightforward unidirectional 'top-down' dissection. The better overview facilitates the crossover for connecting both retro-rectus spaces. In addition, the cranial access allows the anterior- and posterior layers to be closed up to the xiphoid.

Critical evaluation of an innovative mesh for bilateral transabdominal preperitoneal (TAPP) repair of inguinal hernias.

PURPOSE: Transabdominal preperitoneal hernia mesh plasty (TAPP) offers significant benefits to patients undergoing bilateral inguinal hernia repair. We evaluated a novel pre-shaped, large-pored, titanium-coated, lightweight polypropylene mesh for bilateral placement as an alternative to two separate meshes. METHODS: Thirty-six patients underwent elective surgical repair of bilateral inguinal hernias with the new mesh at three departments of surgery in Linz and Graz, Austria, between May 1, 2015 and June 30, 2017. RESULTS: All operations were completed without intraoperative complications or conversion to open procedures. The mean operation time was 74 min. There were no postoperative procedure-related complications with the exception of one hematoseroma of the spermatic cord. Two symptomatic medial recurrences (2/36 patients = 5.6%, 2/72 hernia repairs = 2.8%, respectively) after supravesical and medial hernia repair with the bilateral mesh were seen at structured follow-up examinations 6 and 12 months postoperatively. CONCLUSION: Treatment of bilateral inguinal hernias with the newly designed bilateral mesh for TAPP theoretically brings benefits in terms of resistance to forces acting on the mesh. The larger area may decrease the risk for mesh bulging and recurrence, and one large mesh might provide more stable support than two separate meshes overlapping at the midline. The results of our study do not confirm these theoretical benefits regarding a high recurrence rate (2.8%) after treatment of medial hernia defects. We recommend re-designing the mesh with only a small central slit, which would provide a broader mesh bridge with sufficient overlap for all types of inguinal and femoral hernias, including medial and supravesical defects. After the mesh has been re-designed, a new study should evaluate its real benefits before it is marketed.