eTEP Rives-Stoppa: Key Technical Tips and Tricks
The eTEP Rives-Stoppa technique combines the advantages of retromuscular mesh placement with minimally invasive surgery, requiring meticulous attention to anatomical planes, systematic dissection, and selective use of transversus abdominis release (TAR) for larger defects. 1, 2
Patient Selection and Preoperative Planning
- Target centrally located ventral and incisional hernias with defect areas typically ranging from 6-300 cm², though most successful cases fall within 60 cm² median defect size 1
- Reserve this approach for patients who can tolerate extraperitoneal dissection and have anatomy suitable for retrorectus space development 2
- Plan for potential TAR in approximately 30% of cases (19 of 63 cases in one series) when primary fascial closure cannot be achieved with retrorectus dissection alone 1
Critical Technical Steps
Port Placement and Access
- Create initial access lateral to the rectus sheath to enter the extraperitoneal space, avoiding peritoneal violation 1, 2
- Extend the TEP approach cranially into the rectus sheath, using the same principles as inguinal hernia TEP repair 1
- Position ports to allow bilateral retrorectus dissection with adequate working space for crossover to the contralateral side 2
Dissection Strategy
- Maintain strict extraperitoneal dissection throughout the procedure to minimize contamination risk and preserve the peritoneal barrier 1, 2
- Develop the retrorectus space systematically, crossing the midline to access the contralateral retrorectus space for bilateral dissection 1
- Identify and preserve the neurovascular bundles during lateral dissection to prevent denervation of the abdominal wall musculature 3
Hernia Reduction and Defect Management
- Reduce the hernia contents completely before attempting fascial closure 1
- Restore the linea alba with primary fascial closure whenever possible to cover the mesh and reduce infection risk 3
- Perform TAR selectively when primary closure cannot be achieved - this was necessary in 30% of cases in the initial series 1
Mesh Placement
- Place polypropylene mesh in the retromuscular position with adequate overlap of at least 5 cm beyond the defect edges 1
- Use mesh sizes averaging 380 cm² to ensure sufficient coverage, even for smaller defects 4
- Secure mesh fixation to prevent migration while avoiding excessive fixation that may cause chronic pain 1
Operative Efficiency and Learning Curve
- Expect operative times around 198 minutes initially, with significant improvement after 29 cases (from 86.4 to 63.8 minutes) 2, 5
- Anticipate the steepest learning curve through the first 51 cases, with adverse outcomes peaking in the middle phase (cases 30-51) before declining 5
- Target skin-to-skin times of approximately 72 minutes once proficiency is achieved 5
Common Pitfalls and How to Avoid Them
Peritoneal Violation
- Maintain constant awareness of the peritoneal layer during dissection - any violation converts the procedure to a transabdominal approach 1, 2
- Use carbon dioxide insufflation to allow rapid absorption if inadvertent peritoneal entry occurs 2
Inadequate Fascial Closure
- Do not force primary closure if excessive tension exists - proceed to TAR rather than accepting incomplete closure 1, 3
- Avoid creating large skin flaps by using laparoscopic component separation when needed, which minimizes devascularization 3
Seroma Formation
- Expect subcutaneous seromas in approximately 5% of cases (2 of 37 patients in one series), which may require interventional drainage 2
- Minimize dead space through meticulous dissection and adequate mesh overlap 4
Postoperative Management
- Discharge most patients within 1 day (median 0.7-1 day hospitalization) for uncomplicated cases 1, 2
- Plan follow-up at 2,6, and 12 months to monitor for recurrence and chronic pain 1
- Manage postoperative ileus expectantly if it occurs, as most cases resolve without intervention 2