Enhanced view Totally Extraperitoneal (eTEP) Rives-Stoppa Repair

The Enhanced-view Totally Extraperitoneal (eTEP) Rives-Stoppa Repair is an advanced surgical technique used primarily for the repair of ventral and incisional hernias. This approach combines the principles of the Rives-Stoppa procedure with the benefits of a minimally invasive, laparoscopic technique.

Key Features of eTEP Rives-Stoppa Repair

• Minimally Invasive Approach: The eTEP technique is performed laparoscopically, which allows for a minimally invasive procedure. This approach involves creating a large extraperitoneal space to work within, without entering the abdominal cavity, which reduces the risk of complications such as intestinal injury, postoperative ileus, and adhesions.
• Mesh Placement: In the eTEP Rives-Stoppa repair, a mesh is placed in the retromuscular space, behind the rectus abdominis muscles. This placement is intended to allow for maximum mesh integration and strengthening of the abdominal wall, reducing the likelihood of hernia recurrence. keeping the mesh outside the abdominal cavity reduces the chances if infection and adhesions. Polypropylene mesh is commonly used due to its balance of strength and flexibility.
• Enhanced Surgical View: The technique provides an enhanced view of the retromuscular space, which improves the ergonomics of the surgery and allows for precise dissection and repair of the hernia. This enhanced visualization is particularly beneficial in the identification and management of complex hernias.
• Component Separation: For large or complex hernias, the procedure may include a posterior component separation technique, such as Transversus Abdominis Release (TAR), to facilitate tension-free closure of the defect. This separation is crucial for addressing extensive hernia defects that cannot be closed primarily without undue tension.
• Advantages: The eTEP Rives-Stoppa repair offers several advantages, including reduced postoperative pain, fewer adhesions, and a quicker recovery compared to traditional open hernia repair methods. It also allows for the use of a less expensive mesh, as a composite mesh with an anti-adhesion barrier is not required. Additionally, the extraperitoneal nature of this approach significantly lowers the risk of complications associated with intraperitoneal mesh placement, such as mesh-related adhesions and erosion into the bowel.

Overall, the eTEP Rives-Stoppa repair is a sophisticated technique that requires a thorough understanding of abdominal wall anatomy and advanced laparoscopic skills. It is considered a safe and effective alternative to open hernia repair, with promising outcomes in terms of patient recovery and hernia recurrence rates.

The eTEP Rives-Stoppa Hernia Repair Technique Procedure Steps

The Enhanced-view Totally Extraperitoneal (eTEP) Rives-Stoppa Repair is a sophisticated surgical procedure for ventral hernia repair. Here are the general steps involved in the procedure:

• Patient Preparation: The patient is positioned and prepped for surgery. The procedure is performed under general anesthesia. Proper positioning is crucial to ensure optimal access to the retromuscular space.
• Creation of Surgical Space: The eTEP technique involves creating a large extraperitoneal space. This is achieved by opening the retro-rectus spaces and connecting them with the preperitoneal spaces of Retzius and Bogros. The creation of this space is fundamental to the success of the procedure, as it provides the necessary room for safe mesh placement and hernia defect repair.
• Dissection: Careful dissection is performed to expose the retromuscular space. This step requires expert knowledge of the anatomy and precise handling of laparoscopic or robotic instruments to avoid injury to surrounding tissues. Meticulous dissection ensures the integrity of vital structures and the optimal placement of the mesh.
• Closure of Hernia Defect: The hernia defect is closed using sutures to restore the linea alba, which is the central tendon of the abdomen. This closure is critical for reestablishing the functional integrity of the abdominal wall.
• Mesh Placement: A polypropylene mesh is placed in the retromuscular space. The mesh is typically macroporous and medium-weight, providing support and augmentation to the abdominal wall. The retromuscular space is measured and the mesh is cut to the measured size and fits the entire dissected space creating wide mesh overlap and reinforcement of the abdominal wall.
• Mesh Fixation: Initially, mesh fixation may involve the use of glue or tackers, but with experience, surgeons often rely on the overlap of the mesh to prevent recurrence, minimizing the need for fixation. This technique reduces the risk of chronic pain associated with mesh fixation devices.
• Component Separation: In cases of large or complex hernias, a posterior component separation technique, such as Transversus Abdominis Release (TAR), which involves incising the transverse abdominal muscle, may be performed to facilitate tension-free closure of the defect. This step is crucial for achieving durable repair in challenging cases.
• Closure: The posterior layer, such as the posterior rectus sheaths or peritoneum, is closed using resorbable barbed sutures. This layer provides an additional barrier between the mesh and the abdominal contents, further reducing the risk of postoperative complications.
• Postoperative Care: Patients are typically ambulated on the first postoperative day and discharged within a few days, depending on their recovery. Early ambulation is encouraged to reduce the risk of deep vein thrombosis (DVT) and to promote faster recovery.

This procedure requires a thorough understanding of abdominal wall anatomy and advanced laparoscopic skills. It offers the benefits of a minimally invasive approach with reduced postoperative pain and quicker recovery compared to traditional open repair methods.

Benefits of the eTEP Rives-Stoppa Hernia Repair Technique

The Enhanced-view Totally Extraperitoneal (eTEP) Rives-Stoppa Repair offers several advantages, particularly in the context of ventral and inguinal hernia surgery:

• Reduced Risk of Complications: The eTEP approach may minimize the risk of intestinal injury and reduces the frequency of postoperative ileus. It also results in fewer intraperitoneal adhesions and associated complications compared to intraperitoneal approaches. The extraperitoneal placement of the mesh avoids direct contact with the bowel, thus reducing the risk of mesh-related complications.
• Minimally Invasive: As a laparoscopic or robotic technique, eTEP approach is less invasive than traditional open surgery, leading to quicker recovery times and less postoperative pain. It provides an enhanced view of the surgical field, facilitating precise dissection and repair. The minimally invasive nature also reduces scarring and the overall physical trauma of surgery.
• Effective Mesh Placement: The procedure allows for the placement of a large piece of mesh in the retromuscular space, which provides extensive prosthetic reinforcement of the visceral sac. This placement reduces complications associated with mesh exposure to intra-abdominal contents and improves mesh integration. The use of a medium-weight, macroporous mesh enhances tissue ingrowth and long-term durability of the repair.
• Cost-Effectiveness: The use of a conventional mesh without the need for an anti-adhesion barrier reduces costs while still providing effective reinforcement. This cost-effectiveness makes the procedure more accessible to a broader patient population.
• Versatility: The eTEP approach is suitable for various types of hernias, including ventral, inguinal, and lumbar hernias.This versatility allows the eTEP technique to be applied in a wide range of clinical scenarios, offering a tailored approach to each patient’s needs.

Overall, the eTEP Rives-Stoppa Repair is a safe and effective technique with significant advantages over traditional open hernia repair methods, offering improved patient outcomes and reduced recurrence rates.

How does the eTEP Rives-Stoppa Hernia Repair Technique improve postoperative outcomes?

The Enhanced-view Totally Extraperitoneal (eTEP) technique improves postoperative outcomes in several ways:

• Reduced Postoperative Pain: The eTEP technique is associated with significantly less postoperative pain compared to other methods such as the intraperitoneal onlay mesh (IPOM) technique. This reduction in pain is particularly notable in the immediate postoperative period and contributes to better patient comfort and quicker recovery. The minimal use of fixation devices also reduces chronic pain risks.
• Lower Complication Rates: Studies have shown that the eTEP approach results in very low rates of surgical site infections, seromas, and major complications. For example, a meta-analysis reported a <1% rate of surgical site infections and a 1% rate of major complications. The extraperitoneal dissection and mesh placement contribute to these low complication rates.
• Improved Functional Recovery: Patients undergoing the eTEP procedure experience less restriction in normal activities shortly after surgery. This is attributed to the minimally invasive nature of the procedure and the avoidance of traumatic mesh fixation methods. Patients often return to normal activities and work sooner compared to traditional open surgery.
• Shorter Hospital Stay: The eTEP technique often results in a shorter hospital stay which is beneficial for both patient recovery and healthcare resource utilization. In most cases patient are discharged home the same day. This shorter stay is a direct result of reduced pain, lower complication rates, and quicker recovery.
• Low Recurrence Rates: The technique has demonstrated low recurrence rates, with studies reporting a recurrence rate of <5% after a median follow-up period of several months. This low recurrence is achieved through meticulous dissection, proper mesh placement, and secure closure of the hernia defect.
• Enhanced Quality of Life: Patients report improvements in quality of life post-surgery, including better aesthetics and reduced pain, which are important factors for overall satisfaction with the surgical outcome. The improved quality of life is also linked to the minimal scarring and effective repair achieved with eTEP.

Overall, the eTEP technique offers significant advantages in terms of reduced pain, lower complication rates, and improved recovery, making it a favorable option for ventral hernia repair.

What types of hernias can be treated with the eTEP Rives-Stoppa Repair?

The Enhanced-view Totally Extraperitoneal (eTEP) Rives-Stoppa Repair is primarily used to treat various types of hernias, particularly ventral and inguinal hernias. Here are the specific types of hernias that can be addressed using this technique:

• Ventral Hernias: This includes both primary ventral hernias and incisional hernias, which occur at the site of a previous surgical incision. The eTEP approach is effective for these hernias due to its minimally invasive nature and ability to place a mesh in the retromuscular space. It is particularly beneficial in cases where the abdominal wall has been weakened by previous surgeries.
• Inguinal Hernias: The eTEP technique was initially devised to address difficult inguinal hernias, including those that extend into the groin, by creating a larger extraperitoneal space, which allows for effective mesh placement without entering the abdominal cavity. This approach reduces the risk of complications commonly associated with intraperitoneal repairs of inguinal hernias.
• Complex Hernias: The technique can be adapted for complex hernias, including those with multiple defect sites or those involving previous surgical interventions. In such cases, additional procedures like Transversus Abdominis Release (TAR) may be used in conjunction with eTEP to achieve optimal repair. This adaptability makes the eTEP technique a valuable tool in the surgeon’s armamentarium for complex hernia repairs.
• Recurrent Hernias: The eTEP method is also suitable for recurrent hernias, where previous repair attempts have failed. The technique’s ability to provide a robust and tension-free repair makes it a viable option for these challenging cases. Recurrent hernias can be particularly difficult to treat, and the eTEP technique offers a reliable solution with a low recurrence rate.

Overall, the eTEP Rives-Stoppa Repair is a versatile technique that can be applied to a wide range of hernia types, offering the benefits of minimally invasive surgery with effective outcomes.

What types of hernias can eTEP Rives-Stoppa Repair not treat?

The eTEP Rives-Stoppa Repair is not suitable for certain types of hernias and conditions. The following situations are generally considered contraindications for using the eTEP approach:

• Loss of Domain: This condition involves a significant portion of the abdominal contents being outside the abdominal cavity, making it difficult to achieve a successful repair with the eTEP technique. In such cases, alternative approaches, such as open surgery or staged repair, may be necessary.
• Poor Condition of Overlying Skin: If the skin over the hernia site is in poor condition, it may not be suitable for the minimally invasive eTEP approach. This limitation is due to the risk of wound complications and the need for extensive soft tissue coverage.
• Infection or Scar Tissue: The presence of infection or significant scar tissue, such as a pubo-xiphoid scar, can complicate the eTEP procedure, making it less effective or safe. Infected or scarred tissues increase the risk of postoperative complications and may necessitate an alternative surgical approach.
• Recurrent Hernia After Rives-Stoppa or TAR: Patients who have experienced a recurrence after a previous Rives-Stoppa or Transversus Abdominis Release (TAR) repair may not be ideal candidates for another eTEP procedure. These patients may require a different approach, such as open surgery, to effectively manage their condition.

These contraindications highlight the importance of careful patient selection to ensure the safety and effectiveness of the eTEP Rives-Stoppa Repair.

Dr. Iskandar’s Thoughts on the Technique

This techniques checks a lot of the boxes when it comes to achieving the goals of a good hernia repair:

• it can be performed minimally invasive which leads to less pain and less infections
• it leads to restoration of the anatomy which leads to improvement of the core function
• placement of mesh in the retromuscular space is advantageous by leading to better mesh integration, and less mesh related complications.
• it does require advanced expertise and skills to perform safely

Conclusion

In conclusion, the Enhanced-view Totally Extraperitoneal (eTEP) Rives-Stoppa Repair represents a significant advancement in hernia surgery, offering a minimally invasive yet highly effective approach for the treatment of ventral, inguinal, and complex hernias. By combining the principles of the Rives-Stoppa technique with enhanced laparoscopic capabilities, eTEP provides surgeons with a versatile tool that reduces postoperative pain, minimizes complications, and promotes faster recovery. While not suitable for every type of hernia, the eTEP Rives-Stoppa Repair has proven to be a reliable and cost-effective option for many patients, delivering excellent outcomes with a low recurrence rate. As surgical expertise in this technique continues to grow, the eTEP approach is likely to become an increasingly preferred method for hernia repair, offering patients improved quality of life and long-term results.