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Totally endoscopic sublay (TES) repair for midline ventral hernia: surgical technique and preliminary results

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The Rives–Stoppa procedure is used for ventral hernia repair but requires a large midline incision. This report describes a new, totally endoscopic approach to the retromuscular plane, corresponding to a reversed totally extraperitoneal procedure, to perform sublay repair of primary and secondary ventral hernias. This totally endoscopic sublay (TES) repair is described in detail, and its safety and efficacy were evaluated.


In this prospective study, we assessed 26 consecutive primary and secondary epigastric midline ventral hernias that were repaired between July 2017 and July 2018 using the TES procedure. A large mesh was placed in the retrorectus position using this minimally invasive approach. Indications for this procedure include umbilical, epigastric, incisional hernias, and rectus diastasis.


All TES procedures were successfully performed without conversion to an open operation. The mean operative time was 106.6 ± 29.1 min (range 75–205), with average mesh area of 318.8 cm2 for an average defect area of 26.5 cm2. Postoperative pain was mild, and the mean visual analog scale (VAS) under physical stress (e.g., climbing stairs) was 2.4 at the third postoperative day. The average postoperative hospital stay was 2.8 ± 0.8 days (range 2–5). Two patients developed postoperative seroma, with no final adverse effect. No recurrence nor readmissions within 30 days was observed during a mean follow-up of 9.2 ± 4.4 months.


Initial experiences with this technique show that the TES procedure is safe and reliable, requires no specific instruments, and is highly reproducible. There is no need for an expensive anti-adhesion mesh or fixation device, making it cost-effective.

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The authors acknowledge Dr. Miao J, Dr. Li Y, and Dr. Cai C from Guangdong, Dr. Zhang C from Zhejiang, Dr. Wu W, and Dr. Yu J from Shanghai, Dr. Xiong G from Hunan, and Dr. Chen Y and Dr. Zhao W from Gansu for their valuable contributions to this paper.


Beijing Municipal Administration of Hospitals’ Youth Programme (QML20170307).

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Correspondence to Reinhard Bittner.

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Drs. Binggen Li, Changfu Qin, and Reinhard Bittner have no conflicts of interest or financial ties to disclose.

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The early results of this study were presented at the 2018 International Hernia Congress (AHS Annual Meeting), March 12–15, 2018, Miami, FL.

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Li, B., Qin, C. & Bittner, R. Totally endoscopic sublay (TES) repair for midline ventral hernia: surgical technique and preliminary results. Surg Endosc 34, 1543–1550 (2020).

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