Extended Totally Extraperitoneal (eTEP) Hernia Repair Technique

The Extended Totally Extraperitoneal (eTEP) hernia surgery repair technique is a novel and advanced approach for the treatment of ventral and inguinal hernias. eTEP is a minimally invasive approach that can be performed laparoscopically or with robotic assistance, rather than being an open surgery technique. This technique was first introduced by Jorge Daes in 2012 and has since been adapted and refined by other surgeons for various types of hernias, including ventral hernias. The eTEP technique is characterized by its minimally invasive approach, which involves creating a large surgical workspace in the extraperitoneal space without entering the abdominal cavity. This is achieved through a series of surgical maneuvers and strategies aimed at enhancing the extraperitoneal work area and allowing for the placement of a larger surgical mesh to repair the hernia defect.

The eTEP Hernia Repair Technique Procedure Steps

The procedural steps for an eTEP (Extended Totally Extraperitoneal) hernia repair can vary depending on the type of hernia being treated (inguinal, ventral, or lumbar). However, the general steps for the eTEP approach are as follows:

1. Accessing the Extraperitoneal Space: The first step involves entering the extraperitoneal space, which is the space outside of the peritoneal cavity where the organs are located. This is typically done through a small incision and various methods are used.
2. Creating a Surgical Workspace: Once access is gained, the surgeon creates a large surgical workspace in the extraperitoneal space or retrmoscular space by dissecting and separating the tissues to expose the area where the hernia is located.
3. Hernia Sac Reduction: The hernia sac and its contents are then reduced, meaning they are pushed back into the proper anatomical position.
4. Defect closure: the hernia defect is closed, and the abdominal wall is tightened by placating the rectus muscle.
5. Mesh Placement: A mesh is placed in the retromuscular space to reinforce the area and prevent the hernia from recurring. The mesh is usually cut to the size of the space and therefore requires little to no fixation which can reduce post-operative pain.
6. Wound closure: After the mesh is positioned correctly, the surgical workspace is deflated, and the incisions are closed.
7. Postoperative Care: The patient is typically allowed to consume clear liquids a few hours after surgery and may be discharged within 48–72 hours, depending on their recovery.

 Key Features of eTEP Hernia Surgery

• Minimally Invasive: The eTEP technique is minimally invasive, providing lower overall complication rates, decreased wound complications, and shorter hospital stays compared to traditional open hernia repair methods.
• Mesh Placement: It allows for the placement of mesh in the retromuscular space, which is believed to offer better outcomes in terms of recurrence. Typically a larger mesh is placed in that space that covers and strengthens the majority of the abdominal wall. the retromuscular space is well vascularized leading to better mesh integration and less infections. Also mesh placement in this space requires little to no mesh fixation resulting in less pain. Lastly, placement of mesh outside the abdominal cavity leads to less chances of adhesions to intestine and scarring.
• Component Separation: For defects too wide to be closed without tension, a component separation procedure, specifically the posterior rectus sheath release is performed identical to a Rives-Stoppa repair. In cases of larger defects, a Transversus Abdominis Release (TAR) can be performed for further release. This enables tension-free closure of the hernia gap and achieves greater mesh overlap.
• Versatility: The eTEP approach can be adapted for various types of hernias, including ventral, inguinal, and lumbar hernias, making it a versatile technique for hernia repair.

 Advantages of eTEP Technique for Hernia Repair

• Reduced Risk of Complications: The extraperitoneal approach reduces the risk of intestinal injury, lessens the need for visceral retraction, and minimizes the frequency of postoperative ileus and intraperitoneal adhesions.
• Enhanced Recovery: Early discharge and enhanced recovery are possible due to diminished pain and a greater likelihood of early mobilization and unrestricted movement.
• Economic Benefits: The use of mesh in the eTEP technique is not only effective in reducing recurrence rates but is also cost-effective. the mesh used in the retromuscular space does not require a special coating and is typically costs less.

What are the success rates of eTEP hernia repair?

Here are the key findings from a recent study, explained in laypersons’ terms:

The study involved surgeons who did eTEP hernia surgery on 150 patients over three years.

Out of the 150 patients:

• 73 (48.7%) had incisional hernias (hernias that happen at an old surgery scar)
• 48 (32%) had primary hernias (hernias that happen for the first time)
• 29 (19.3%) had recurrent hernias (hernias that came back after being fixed before)

Most of the patients were females (74%). Primary hernias happened equally in males and females, but incisional and recurrent hernias were more common in females.

For smaller hernias, doctors used a method called eTEP RS (Rives-Stoppa). For larger hernias, they used eTEP TAR which also relaxes some muscles to help close the hernia.

The eTEP RS repair took about 2 hours to do, while eTEP TAR took about 3.5 hours.

After the surgery:

• Only 5.8% of patients had fluid collect under the skin (seroma)
• Only 3.3% felt some bulging or discomfort in the upper belly
• No patients got infections or had the hernia come back during the surgery study.

This study shows the eTEP method worked well to repair different kinds of hernias, even complicated ones, with few problems afterward. The study reports it is a good option, especially for hernias on the sides of the belly. Surgeons need a lot of special training to do it well.

Dr. Mazen Iskandar is thoroughly trained and experienced in eTEP surgery. You can view a video of Dr. Iskandar performing a complex eTEP procedure (Note: contains images of surgery).

What types of hernias can be repaired with the eTEP technique? 

The eTEP (Extended Totally Extraperitoneal) technique can be used to repair various types of hernias, including:

• Ventral Hernias: The eTEP technique was initially devised to tackle large groin hernias but has been extended to include ventral hernias, where the mesh is placed in the retromuscular space.
• Incisional Hernias: It is also used for incisional hernias, which can occur as a complication of laparotomies.
• Recurrent Hernias: The eTEP approach is suitable for recurrent hernias, offering a minimally invasive option for patients who have had previous hernia repairs.
• Atypical Sited Hernias: The technique has been successfully used for atypically sited hernias such as lumbar, subcostal, and Pfannensteil hernias.
• Lateral Hernias: eTEP is particularly useful for managing unusual lateral hernias such as subcostal (L1) and iliac (L3) hernias, which are close to fixed bony structures and require adequate mesh overlap.

What kind of hernias cannot be treated with eTEP? 

There are certain situations where the eTEP technique might not be the best choice or could be contraindicated:

• Strangulated Hernias: While there is a case report showing the feasibility of the eTEP technique in an emergency setting for a strangulated incisional hernia, the general use of eTEP in the emergency repair of strangulated hernias, especially when bowel resection is required due to necrosis, might be limited. This is because the presence of bowel necrosis or infection is a contraindication for the use of this technique in such emergency situations.
• Hernias with Bowel Necrosis or Infection: The eTEP technique might not be suitable for hernias where there is significant bowel necrosis or infection, as the presence of these conditions could complicate the minimally invasive approach and might necessitate a more direct and open surgical intervention to address the issue adequately.
• Hernias Requiring Immediate Bowel Resection: In cases where immediate bowel resection is necessary due to the condition of the herniated tissue, the eTEP approach may not be the most appropriate choice. The need for immediate and direct access to the bowel for resection might favor a more traditional open approach.
• Patients with Extensive Previous Abdominal Surgeries: Although not explicitly mentioned as a contraindication, patients with extensive scarring and adhesions from previous abdominal surgeries might present a higher risk of complications due to the difficulty in creating the extraperitoneal space without causing injury to the bowel or other structures.

Final Thoughts

The eTEP hernia surgery repair technique represents a significant advancement in the field of hernia repair. Its minimally invasive nature, combined with the strategic placement of mesh and the potential for component separation, offers a comprehensive solution for hernia repair that is associated with improved patient outcomes, including reduced complication rates, faster recovery times, and lower recurrence rates. Surgeons seeking to adopt this technique should have detailed knowledge of the anatomy of the extraperitoneal space and undergo formal training, ideally including practice on fresh cadavers under mentorship, to ensure the safety and effectiveness of the procedure.