Totally extraperitoneal approach for open complex abdominal wall reconstruction

Abstract

Background

Ventral hernia repair is typically performed via a transabdominal approach and the peritoneal cavity is opened and explored. Totally extraperitoneal ventral hernia repair (TEVHR) facilitates dissection of the hernia sac without entering the peritoneal cavity. This study evaluates our experience of TEVHR, addressing technique, decision-making, and outcomes.

Methods

This is an IRB-approved retrospective review of open TEVHR performed between January 2012 and December 2016. Medical records were reviewed for patient demographics, operative details, postoperative outcomes, hospital readmissions, and reoperations.

Results

One hundred sixty-six patients underwent TEVHR (84 males, 82 females) with a mean BMI range of 30–39. Eighty-six percent of patients underwent repair for primary or first-time recurrent hernia, and 89% CDC wound class I. Median hernia defect size was 135 cm2. Hernia repair techniques included Rives-Stoppa (34%) or transversus abdominis release (57%). Median operative time was 175 min, median blood loss 100 mL, and median length of stay 4 days. There were no unplanned bowel resections or enterotomies. Four cases required intraperitoneal entry to explant prior mesh. Wound complication rate was 27%: 9% seroma drainage, 18% superficial surgical site infection (SSI), and 2% deep space SSI. Five patients (3%) required reoperation for wound or mesh complications. Over the study, four patients were hospitalized for postoperative small bowel obstruction and managed non-operatively. Of the 166 patients, 96%, 54%, and 44% were seen at 3-month, 6-month, and 12-month follow-ups, respectively. Recurrences were observed in 2% of patients at 12-month follow-up. One patient developed an enterocutaneous fistula 28 months postoperatively.

Conclusions

TEVHR is a safe alternative to traditional transabdominal approaches to ventral hernia repair. The extraperitoneal dissection facilitates hernia repair, avoiding peritoneal entry and adhesiolysis, resulting in decreased operative times. In our study, there was low risk for postoperative bowel obstruction and enterotomy. Future prospective studies with long-term follow-up are required to draw definitive conclusions.

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Correspondence to John Scott Roth.

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Disclosure

Dr. Roth discloses he has grant funding from Bard and Miromatrix; he is a consultant for Bard, Johnson & Johnson, and Allergan; and he owns stock in Miromatrix.Mr. Nisiewicz, Mr. Wade and Drs. Kumar, Warriner, Chang, Plymale, Davenport, and Edmunds have no conflicts of interest or financial ties to disclose.

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Kumar, S., Edmunds, R.W., Nisiewicz, M.J. et al. Totally extraperitoneal approach for open complex abdominal wall reconstruction. Surg Endosc 35, 159–164 (2021). https://doi.org/10.1007/s00464-020-07374-1

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Keywords

  • Hernia repair
  • Totally extraperitoneal approach
  • Transabdominal approach
  • Rives-Stoppa