What is the recommended approach for repairing ventral hernias using preperitoneal Totally Extraperitoneal (TEP) repair?

Preperitoneal TEP Approach for Ventral Hernia Repair

Laparoscopic repair of ventral hernias using the totally extraperitoneal (TEP) approach is recommended for stable patients without signs of strangulation or peritonitis, as it preserves the anatomical and physiological structure of the abdominal wall while reducing postoperative complications. 1

Indications and Patient Selection

• Ideal candidates for preperitoneal TEP repair:

  • Small to medium-sized primary ventral hernias (defect size <4 cm) 2
  • Stable patients without signs of strangulation or peritonitis 1
  • Patients with concomitant diastasis recti 2

• Contraindications:

  • Hemodynamic instability (open approach preferred) 1
  • Signs of bowel ischemia or perforation (immediate laparotomy indicated) 1
  • Suspected need for bowel resection (open preperitoneal approach preferred) 3

Technical Approach to Preperitoneal TEP Repair

Access and Space Creation

1. Initial access:

   • Suprasymphysic approach: Create initial access in the suprasymphysic area and develop the preperitoneal space upward 4
   • Subxiphoid approach: Enter preperitoneal space directly below the xiphoid and develop downward (top-down approach) 2

2. Space development:

   • Carefully develop the plane between the peritoneum and posterior rectus sheath 4, 2
   • Preserve the linea alba while dividing median aponeurotic structures 5
   • Create a unified retromuscular space for mesh placement 6

Hernia Management

1. Hernia sac reduction:

   • Identify and carefully reduce the hernia sac and its contents 4, 2
   • Take care to avoid peritoneal tears; if they occur, close with sutures 5

2. Defect closure:

   • Primary closure of the hernia defect with sutures is recommended 4, 2
   • For defects >3 cm that cannot be closed primarily, mesh reinforcement is essential 1

3. Mesh placement:

   • Place a large mesh in the preperitoneal position with adequate overlap (minimum 3 cm beyond defect margins) 1, 4
   • Fixation is typically not required, avoiding potential pain from tacks or staples 5
   • Mesh size should be significantly larger than the defect (mean mesh:defect ratio reported as 7:1) 5

Advantages of Preperitoneal TEP Approach

• Avoids intraperitoneal mesh placement, reducing risk of adhesions and bowel complications 4, 5
• Eliminates need for expensive anti-adhesion-coated meshes and fixation devices 4
• Preserves anatomical and physiological structure of the abdominal wall 4
• Associated with mild postoperative pain (mean VAS 1.8-2.45) 5, 2
• Allows early return to daily activities (mean 4 days) and work (mean 11.5 days) 5

Potential Complications and Management

• Peritoneal tears: Occur in approximately 38% of cases; close with sutures 5
• Seroma: Reported in 1-5% of cases; most resolve spontaneously 5, 6
• Conversion: Conversion to IPOM may be necessary in 4-5% of cases 5
• Recurrence: Low recurrence rates (0-3%) with adequate follow-up 4, 5, 6
• Ileus: May occur in up to 12% of cases; typically resolves with conservative management 7, 6

Technical Considerations for Complex Cases

• For larger defects or when primary closure is not possible, consider adding transversus abdominis release (TAR) 6
• For combined ventral and inguinal hernias, the e-TEP approach can address both simultaneously 6
• In obese patients or those with previous scars, the e-TEP approach may be particularly advantageous 7

Postoperative Care

• Early mobilization is crucial to prevent complications 1
• Monitor for common complications including seroma, hematoma, and wound infection 1
• Progressive core strengthening focusing on transverse abdominis muscle is recommended during recovery 1

The preperitoneal TEP approach for ventral hernia repair represents an evolution in minimally invasive techniques that combines the benefits of laparoscopy while avoiding the drawbacks of intraperitoneal mesh placement. While technically demanding, it offers excellent outcomes when performed by surgeons skilled in advanced laparoscopic techniques.