What is the recommended approach for patients requiring hernia repair using Endoscopic Totally Extraperitoneal (E TEP) repair?

E-TEP (Extended Totally Extraperitoneal) Repair for Hernia

Primary Recommendation

E-TEP repair is a safe and effective minimally invasive approach for both inguinal and ventral hernias, offering advantages of reduced postoperative pain, shorter hospital stays, and avoidance of intraperitoneal mesh placement, though it requires adequate surgical expertise and proper patient selection. 1, 2

Indications for E-TEP Approach

Inguinal Hernias

• E-TEP is particularly advantageous for bilateral inguinal hernias (33% of cases), recurrent hernias (31% of cases), and patients with obesity or previous abdominal scars where traditional approaches may be more challenging 3
• The technique allows identification and repair of occult contralateral hernias, present in 11.2-50% of cases 4

Ventral and Incisional Hernias

• E-TEP is appropriate for ventral hernias with defect sizes ranging from 2-6 cm, with mean defect areas of approximately 51 cm² 1, 5
• The approach is suitable for supraumbilical, infraumbilical, and lateral hernias 2
• Larger or more complex defects may require transversus abdominis release (TAR), performed in approximately 29-35% of cases 1, 2

Technical Approach and Operative Details

Surgical Technique

• Access is gained between the rectus abdominis muscle and posterior rectus sheath, connecting this space with the fatty preperitoneal space at midline and contralateral retrorectal space 2
• The hernia sac is identified and dissected within the created cavity 2
• Posterior component release (TAR) can be performed when needed for larger defects 1, 2
• Closure of the posterior plane and linea alba is completed before mesh deployment along the entire dissected space 2

Operative Times

• Mean operative time for E-TEP ventral hernia repair ranges from 126-177 minutes, which decreases with surgeon experience 1, 2
• For inguinal hernias, unilateral TEP repairs average 63 minutes and bilateral repairs 78 minutes 3
• Operative times for TEP are significantly shorter than open mesh repair for both unilateral and bilateral inguinal hernias 3

Anesthesia Considerations

• General anesthesia is the standard approach for E-TEP repair 3
• For TEP inguinal hernia repair, epidural anesthesia is feasible in 68% of cases when a sensory level of T6 or above is achieved 6
• Key factors for successful epidural anesthesia include adequate catheter length, appropriate insertion site, and prevention of pneumoperitoneum-related shoulder pain 6
• Conversion to general anesthesia occurs in approximately 32% of epidural cases, primarily due to pneumoperitoneum and shoulder-tip pain 6

Clinical Outcomes

Pain and Recovery

• Median postoperative pain on day 1 is 3/10 on visual analog scale, significantly lower than IPOM Plus repair 2, 5
• Mean hospital stay is 1-2.2 days 1, 2
• Analgesic requirements are significantly reduced compared to intraperitoneal approaches 5

Complications

• Urinary retention occurs in 7.9% of TEP inguinal repairs but is more common than open repair (1.1%) 3
• Skin numbness is significantly less common with TEP (2.8%) compared to open repair (35.8%) 3
• Prolonged groin discomfort occurs in only 1.4% of TEP cases versus 5.3% in open repair 3
• For ventral hernias, paralytic ileus occurs in approximately 4%, surgical site infection in 3%, and recurrence in 1.8-4.3% at 6-month follow-up 1, 5

Mesh Considerations

• Mean mesh size for ventral hernia E-TEP repair is approximately 398 cm² 1
• The extraperitoneal placement avoids intraperitoneal mesh complications and adhesions 1
• For emergency or complicated hernias, synthetic mesh is recommended in clean fields without bowel compromise 7, 8

Critical Pitfalls to Avoid

• Inadequate sensory level (below T6) when using epidural anesthesia leads to 71% conversion rate to general anesthesia 6
• Pneumoperitoneum and shoulder-tip pain are the primary causes of conversion to general anesthesia (67% of conversions) 6
• Insufficient surgical experience can prolong operative times, though this improves significantly with practice 3, 1
• Inadequate mesh overlap should be avoided; for diaphragmatic and complex hernias, a minimum overlap of 1.5-2.5 cm is recommended 9

Patient Selection Criteria

Appropriate Candidates

• Patients with bilateral or recurrent inguinal hernias benefit most from the TEP approach 3
• Ventral hernia patients with BMI up to 29 kg/m² and defects 2-6 cm are suitable 1, 5
• Stable patients without signs of strangulation or bowel compromise are ideal for minimally invasive approaches 4, 7

Contraindications

• Unstable patients with suspected intestinal strangulation require immediate open abdominal approach 7, 8
• Patients with peritonitis or bowel perforation need open repair 8
• When bowel gangrene is suspected or intestinal resection is needed, general anesthesia and potentially open approach should be preferred 8