What are the differences between extended Totally Extraperitoneal (TEP) and enhanced TEP repair techniques for a patient with an incisional hernia and a history of abdominal surgery?

Extended TEP vs Enhanced TEP: Technical Distinctions and Clinical Applications

Extended TEP (eTEP) and Enhanced TEP (e-TEP) represent distinct technical modifications of the traditional totally extraperitoneal approach, with eTEP specifically designed for ventral and incisional hernia repair through expanded preperitoneal dissection, while e-TEP (enhanced-view TEP) refers to a modified inguinal hernia technique that creates greater working space within the traditional TEP plane.

Technical Definitions and Anatomical Approach

Extended TEP (eTEP)

• eTEP accesses the space between the rectus abdominis muscle and posterior rectus sheath, connecting this space with the fatty preperitoneal space at the midline and the contralateral retrorectal space, creating a large cavity for ventral hernia repair 1
• The technique allows identification and dissection of the hernia sac in the created cavity, with optional posterior component release using transversus abdominis release (TAR) when needed 1
• eTEP enables placement of large prosthetic mesh (average 473.5 cm² to 634.4 cm²) in the retromuscular space, distinct from the abdominal cavity, overcoming disadvantages of intraperitoneal onlay mesh (IPOM) repairs 2, 3
• The approach provides flexible port setup optimal for laparoscopic closure of defects with wide mesh coverage and minimal transfascial fixation 3

Enhanced-View TEP (e-TEP)

• e-TEP is a modification of classical TEP for inguinal hernia repair that overcomes the limited dissection space of traditional TEP by creating an enhanced working area within the preperitoneal plane 4
• The technique maintains the fundamental TEP principle of not penetrating the peritoneal cavity, thus avoiding potential intraperitoneal complications 4
• e-TEP allows for regional or local anesthesia plus sedation and provides an incomparable view of the inguinal region where hernias originate 4

Clinical Applications and Indications

Extended TEP (eTEP) - For Ventral/Incisional Hernias

• eTEP is indicated for midline primary and incisional hernias, including large complex ventral abdominal hernias with mean defect areas of 21-132 cm² 2, 5, 3
• The technique can address supraumbilical defects (50%), infraumbilical defects (25%), and lateral hernias (25%) 1
• eTEP-RS (Rives-Stoppa) with TAR is required in approximately 40-45% of cases for adequate fascial release and defect closure 2, 5
• Patients with or without diastasis of rectus abdominis muscle (DRAM) can be treated with this approach 2

Enhanced-View TEP (e-TEP) - For Inguinal Hernias

• e-TEP is particularly valuable for difficult inguinal hernia cases including inguinoscrotal hernias, incarcerated hernias, and patients with previous radical prostatectomy 4
• The technique can be combined with eTEP-RS for simultaneous repair of ventral and inguinal hernias (reported in 14% of eTEP cases) 2

Operative Outcomes and Technical Considerations

Extended TEP (eTEP) Performance Metrics

• Mean operative time ranges from 126-219 minutes, with mean blood loss of 40.5-52.6 mL 2, 1, 3
• Median postoperative pain scores are 3 on visual analogue scale on first postoperative day, with significant improvements in Carolina's Comfort Scale scores showing 68% reduction in pain and 87% reduction in movement limitations at 6 months 1, 3
• Median length of stay is 1-3.9 days, significantly shorter than traditional open approaches 1, 5
• Major complications occur in 10.5-20.7% of cases, primarily consisting of seroma formation and prolonged ileus 2, 5
• Recurrence rates are extremely low (1.3-5%) at mean follow-up of 10-16 months 1, 5, 3

Enhanced-View TEP (e-TEP) Performance Metrics

• Average operating time is 38 minutes for inguinal hernias, though this may be longer in complex cases 4
• The peritoneum is often accidentally opened during e-TEP, but air leaking into the peritoneal cavity does not interfere with surgery completion 4
• Minor complications include small seromas and umbilical wound issues, with no conversions reported despite difficult case selection 4

Critical Technical Distinctions for Patient Selection

When to Choose Extended TEP (eTEP)

• For patients with incisional hernias and history of abdominal surgery, eTEP-RS is the appropriate choice, as it provides retromuscular mesh placement in an anatomical plane distinct from previous surgical fields 2, 3
• Defects requiring mesh overlap of at least 5 cm beyond defect edges (per American College of Surgeons recommendations) are well-suited for eTEP, given the large mesh sizes achievable (380-634 cm²) 6, 2, 3
• eTEP should be mastered in relatively smaller ventral hernias before attempting larger, complex ones, as the technique is technically challenging 2

When to Choose Enhanced-View TEP (e-TEP)

• For inguinal hernias requiring greater working space than traditional TEP provides, particularly in inguinoscrotal or recurrent cases 4
• When regional or local anesthesia is preferred over general anesthesia for inguinal hernia repair 4

Common Pitfalls and Technical Challenges

Extended TEP (eTEP) Pitfalls

• Inadequate mesh overlap can lead to recurrence, as demonstrated by one reported supra-umbilical recurrence following bilateral TAR over the superior edge of mesh 2
• Conversion to intraperitoneal mesh placement or open retromuscular repair may be necessary in 2.5% of cases when anatomical planes cannot be adequately developed 3
• Seroma formation is the most common complication, occurring in up to 20% of cases, though most are asymptomatic 2, 5

Enhanced-View TEP (e-TEP) Pitfalls

• Peritoneal opening is common but manageable, and surgeons should not abort the procedure when this occurs 4
• The learning curve requires experience with traditional TEP before attempting e-TEP modifications 4

Contraindications Based on Clinical Context

For Incisional Hernia Patients with Previous Abdominal Surgery

• eTEP-RS is contraindicated when bowel strangulation is suspected or confirmed, or when bowel resection is anticipated, per American College of Surgeons and World Society of Emergency Surgery guidelines 6, 7
• Hemodynamic instability, gross enteric spillage, or peritonitis are absolute contraindications to minimally invasive eTEP approach 6
• Inability to tolerate general anesthesia contraindicates eTEP, as the technique requires pneumoperitoneum and prolonged operative times 6