What are the different laparoscopic approaches for ventral hernia repair?

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Last updated: November 12, 2026 • View editorial policy

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Laparoscopic Approaches to Ventral Hernia Repair

The primary laparoscopic approaches for ventral hernia repair are: (1) Intraperitoneal Onlay Mesh (IPOM), (2) Transabdominal Preperitoneal (TAPP), (3) Totally Extraperitoneal (TEP), and (4) Enhanced-view Totally Extraperitoneal (eTEP) with or without Transversus Abdominis Release (TAR).

Core Laparoscopic Techniques

1. Intraperitoneal Onlay Mesh (IPOM)

  • Traditional standard approach where mesh is placed intraperitoneally with direct visceral contact
  • Most widely available and technically simplest technique 1
  • Requires specialized composite mesh to minimize adhesions and mesh-related complications
  • Typically involves mesh fixation to the abdominal wall
  • Used in 62% of minimally invasive ventral hernia repairs historically, though declining in favor of extraperitoneal approaches 1

2. Transabdominal Preperitoneal (TAPP)

  • Involves creating a peritoneal flap to access the preperitoneal space
  • Mesh placed in preperitoneal position, avoiding direct visceral contact
  • Allows use of standard (non-composite) mesh without fixation 2
  • Operative time longer than TEP (96.1 vs. 84.7 minutes) due to peritoneal flap creation 2
  • Increasingly utilized, particularly with robotic assistance (>85% robotic) 1
  • Recommended for incarcerated hernias without strangulation 3

3. Totally Extraperitoneal (TEP)

  • Completely extraperitoneal approach without entering peritoneal cavity
  • Enables broader mesh placement (242.9 cm² vs. 166.9 cm² in TAPP) 2
  • Particularly effective for correcting rectus diastasis (achieved in 61% of cases) 2
  • Shorter operative time compared to TAPP 2
  • Avoids peritoneal violation, reducing adhesion risk

4. Enhanced-view Totally Extraperitoneal (eTEP)

  • Advanced extraperitoneal technique with improved anatomical visualization
  • Can be combined with Rives-Stoppa (eTEP-RS) or Transversus Abdominis Release (eTEP-TAR) for larger defects
  • Significantly lower postoperative pain at 12h (VAS 3-4) and 24h (VAS 2) compared to IPOM (VAS 7.5 and 4 respectively) 4
  • Lower recurrence rates: 3.1% at 1 year and 6.2% at 2 years vs. IPOM (7.9% and 15.8%) 4
  • Major drawback: significantly longer operative time (360 vs. 240 minutes for IPOM) 4
  • TAR performed in 14% of retromuscular repairs even for small hernias 1

Additional Specialized Techniques

5. Transabdominal Partial Extraperitoneal (TAPE)

  • Hybrid approach combining transabdominal and extraperitoneal elements
  • Used selectively for lateral ventral hernias 5

6. Hernioscopy

  • Mixed laparoscopic-open technique
  • Specifically for assessing bowel viability after spontaneous reduction of strangulated hernias 3
  • Prevents unnecessary laparotomy in high-risk patients
  • Demonstrated decreased morbidity and mortality (zero major complications vs. 4 in non-laparoscopy group, including 2 deaths) 3

Clinical Decision Algorithm

For uncomplicated ventral hernias:

  • Small defects (<4 cm): TAPP, TEP, or IPOM acceptable 2
  • Medium-to-large defects: eTEP-RS or eTEP-TAR preferred for lower pain and recurrence 4
  • Presence of rectus diastasis: TEP enables ergonomic correction 2

For emergency/complicated hernias:

  • Incarcerated without strangulation: Laparoscopic TAPP or TEP feasible 3
  • Suspected strangulation or bowel resection needed: Open preperitoneal approach preferable (grade 2C recommendation) 3
  • Spontaneous reduction with uncertain viability: Diagnostic laparoscopy/hernioscopy recommended (grade 2B) 3

Important Caveats

Trend Analysis: Extraperitoneal approaches (TAPP, TEP, eTEP) have increased from 10% in 2013 to 53% in 2021 of all minimally invasive repairs, predominantly performed robotically 1

Complication Considerations:

  • Retromuscular repairs show higher 30-day reoperation rates (OR 3.54-5.29) and readmission rates compared to IPOM and preperitoneal approaches 1
  • IPOM carries risk of bowel injury from mesh-viscera contact 4
  • Seroma rates vary widely (0.8-81%) across all techniques 6

Technical Complexity: eTEP techniques require significant surgical expertise and result in substantially longer operative times, necessitating careful patient selection 4

References

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