monthly focus

surgical intervention video

Small bowel occlusion (SBO) following repair of hernia and diastasis through a laparoscopic enhanced-view totally extraperitoneal  (eTEP) approach is a rare condition, with an incidence of 3%. It typically occurs due to excessive tension in the closure of the posterior sheath during the immediate postoperative period.

Bibliography:

1\. Gadea Mateo, R., Martí Cuñat, E., & Pou Santonja, G. (2021). Obstrucción intestinal tras hernioplastia totalmente extraperitoneal por hernia inguinal bilateral: una infrecuente complicación en el posoperatorio inmediato \[Intestinal obstruction after totally extraperitoneal bilateral inguinal hernia repair: an infrequent complication in the early postoperative period. Sociedad hispanoamericana de hernia. Https://hernia.grupo aran.com

2\. Shpitz B, Lansberg L, Bugayev N, Tiomkin V, Klein E. Should peritoneal tears be routinely closed during laparoscopic total extraperitoneal repair of inguinal hernias? a reappraisal. Surg Endosc Other Interv Tech. 2004;18(12):1771-3. DOI: 10.1007/s00464-004- 9001-z

Tear of the posterior sheath after enhanced-view totally extraperitoneal (eTEP) approach: laparoscopic resolution and recommendations 

Déchirure de la gaine postérieure après approche extrapéritonéale totale à vue améliorée (eTEP) : résolution laparoscopique et recommandations 

Spigelian hernias occur through the Spigelian fascia, which consists of the aponeurotic layer located between the rectus muscle medially and the lateral semilunar line laterally. The absence of the posterior fascia of the rectus muscle may contribute to the inherent weakness of this area. It is more common in women and typically affects middle-aged to elderly patients. Spigelian hernias should be repaired due to the risk of incarceration associated with their narrow neck. Surgical repair can be performed using laparoscopic techniques, offering advantages such as a faster recovery and a lower rate of complications as compared to conventional surgery.

Bibliography:

1\. Rupit Serrano, M. de J., Jaime Limón, Á. R., Palacio Vélez, F. (2017). Obstrucción intestinal secundaria a hernia de Spiegel estrangulada con contenido de íleon terminal, apéndice cecal, ciego y colon ascendente. Reporte de un caso \[Strangulated spigelian hernia with contents of the terminal ileum, cecal appendix, cecum and ascending colon. Report of a case]. Cirujano General, 39(3). ISSN 1405-0099.

2\. Faber Machado, Carlos Calle, Federico Lopez. Hernia de Spiegel como causa de obstrucción intestinal de íleon en una paciente anticoagulada por fibrilación auricular, abordaje laparoscópico. Reporte de caso Revista de Hernias y Heridas, 10.20960/rhh.184. Sociedad hispanoamericana de hernia.

Laparoscopic resolution of an incarcerated Spigelian hernia and simultaneous multiple inguinal wall defects

Prise en charge laparoscopique d'une hernie de Spiegel étranglée et de la présence simultanée de multiples défects de la paroi inguinale

Prise en charge laparoscopique d'une hernie de Spiegel

Spiegel’s hernias (SpH) are an uncommon type of primary ventral hernias (PVHs), representing 0.1 to 2% of all ventral hernias (1). Patients with SpH may either be asymptomatic or present with a tumor in the lower middle abdomen, lateral to the rectus muscle, at the level of the so-called “SpH belt”, an area located between the anterior rectus maximus muscle medially and the semilunar line laterally, and between the umbilicus and the interspinous plane (2). Low SpHs are rare and must be differentiated from direct inguinal or supravesical hernias (3). They are located caudally to the inferior epigastric artery within Hesselbach’s triangle, close to the inguinal region. A finding of 8% of low SpHs has been reported in a series of inguinal hernia repairs (4).

This video has the following learning objectives: to recognize low Spiegel’s hernias (SpHs) as a differential diagnosis of inguinal hernia, to interpret CT-scan findings for the recognition of low SpHs, and to expose the main gestures used in the laparoscopic surgical approach to low SpHs.

Bibliography:

1\. Francesco A Polistina, Greta Garbo, Paolo Trevisan, Mauro Frego. Twelve years of experience treating Spigelian hernia. Surgery 2015 Mar;157(3):547-50. doi: 10.1016/j.surg.2014.09.027. Epub 2015 Feb 3. PMID: 25656692 DOI: 10.1016/j.surg.2014.09.027

2\. L Spangen. Spigelian hernia. World J Surg 1989 Sep-Oct;13(5):573-80. doi: 10.1007/BF01658873. PMID: 2683401 DOI: 10.1007/BF01658873

3\. Hannu Paajanen, Seppo Ojala, Antti Virkkunen. Incidence of occult inguinal and Spigelian hernias during laparoscopy of other reasons. Surgery 2006 Jul;140(1):9-12; discussion 12-3. doi: 10.1016/j.surg.2006.01.005. PMID: 16857436 DOI: 10.1016/j.surg.2006.01.005

4\. S Klimopoulos, C Kounoudes, A Validakis, G Galanis. Low spigelian hernias: experience of 26 consecutive cases in 24 patients. Eur J Surg 2001 Aug;167(8):631-3. doi: 10.1080/110241501753171272. PMID: 11716453 DOI: 10.1080/110241501753171272

Low Spiegel's hernia, laparoscopic resolution

Clinical case presentation:

This is the case of an obese 66-year-old female patient, chronic smoker, with a BMI of 34.7. Her medical history included diabetes mellitus type 2. In 2022, she was diagnosed with a large and reducible M3W2 primary ventral hernia associated with diastasis recti, 36mm at epigastric and 68mm at supraumbilical level, respectively. She presented at the emergency department with a 24-hour history of an umbilical painful and irreducible lump associated with nausea.

Diagnostic work-up:

Her serum chemistries showed 14.400 leukocytes /L, 65% of prothrombin time, and 190.85mg/dL of C-reactive protein. Abdominal X-ray did not show any abnormalities. Abdominal ultrasound showed a large umbilical sac, which contained the greater omentum with signs of suffering. There was no anesthetic contraindication for an emergent endoscopic surgery.

Treatment strategy:

An umbilical hernioplasty and diastasis recti correction were performed using the eTEP Rives-Stoppa (RS) technique. A 2/0 absorbable barbed suture was used to close the defect and correct the diastasis recti. A macroporous polypropylene mesh was implanted without fixation, which entirely covered the dissected area and not just the hernia area. No drains were used.

Patient outcomes:

The patient had an uneventful hospital stay and was discharged 36 hours after surgery. An umbilical subcutaneous seroma, M3-type IV, according to the Morales-Conde classification, developed at the second postoperative week and required puncture and aspiration in order to be resolved successfully. There was no evidence of recurrence neither clinically nor radiologically at 18 months of follow-up.

Conclusion:

There is a lack of scientific evidence about the use of the eTEP RS technique in the emergent treatment of complicated ventral hernia. The eTEP RS approach to this type of hernia is a promising abdominal wall reconstruction procedure. The procedure is reproducible and safe, with short hospital stay and low morbidity in the short and middle term.

Bibliography:

1\. Sholapur S, Shaikh A, C G A, Tandur A, Padekar HD, Bhandarwar A, Jagdale S. Intraperitoneal Onlay Mesh (IPOM Plus) Repair Versus Extended-View Totally Extraperitoneal Rives-Stoppa (eTEP-RS) Repair in Primary Ventral Hernias: Experience With 50 Cases in a Tertiary Care Hospital. Cureus. 2024 Apr 5;16(4): e57678. doi: 10.7759/cureus.57678. PMID: 38590981; PMCID: PMC10999782.

2 Shlomi Rayman, Eliyahou Gorgov, Dan Assaf, Idan Carmeli, Nadav Nevo, Jacob Rachmuth, Youri Mnouskin. Quality of life, post-operative complications, and hernia recurrence following enhanced-view Totally Extra-Peritoneal (eTEP) Rives-Stoppa for incisional and primary ventral hernia repair. Updates Surg 2023 Oct;75(7):1971-1978. doi: 10.1007/s13304-023-01572-x. Epub 2023 Jun 28. PMID: 37378814 DOI: 10.1007/s13304-023-01572-x

3\. B Ramana, E Arora, I Belyansky. Signs and landmarks in eTEP Rives-Stoppa repair of ventral hernias. Hernia 2021 Apr;25(2):545-550. doi: 10.1007/s10029-020-02216-4. Epub 2020 May 18. PMID: 32424727 DOI: 10.1007/s10029-020-02216-4

4\. Jacopo Andreuccetti, Alberto Sartori, Enrico Lauro, Lorenzo Crepaz, Silvia Sanna, Giusto Pignata, Umberto Bracale, Alberto Di Leo. Extended totally extraperitoneal Rives-Stoppa (eTEP-RS) technique for ventral hernia: initial experience of The Wall Hernia Group and a surgical technique update. Updates Surg 2021 Oct;73(5):1955-1961. doi: 10.1007/s13304-021-01067-7. Epub 2021 Apr 30. PMID: 33929701 DOI: 10.1007/s13304-021-01067-7

eTEP Rives Stoppa (eTEP RS) technique for a large incarcerated primary ventral hernia in an obese patient: expanding the indications for this approach to the emergency setting

Technique eTEP Rives Stoppa (eTEP RS) pour hernie ventrale primaire incarcérée de grande taille chez une patiente obèse : élargissement des indications de cette approche au contexte de l'urgence

In this live interactive surgery, Prof. Didier Mutter, MD, PhD, FACS, FRSM, Dr. Mihaela Ignat, MD, PhD, and Dr. Pietro Riva, MD demonstrate the laparoscopic management of a ventral hernia. This video presents the case of a patient with a left subcostal hernia secondary to a colectomy complicated by a previous anastomotic fistula. Imaging studies confirmed the presence of a double hernia sac on the left subcostal scar, with small bowel loop and omental encapsulation. Laparoscopic surgery was performed, with the placement of four ports creating a triangulation opposite the incisional hernia area. The author successively presents the different operating stages in the repair of an incisional hernia via a transabdominal approach, namely adhesiolysis, dissection and release of encapsulated hernia components, release of the retromuscular aspect of the anterior abdominal wall muscles over 5cm around the hernia edges, closure of the hernial orifice with a V-Loc™ running suture, repairing the abdominal wall. A dual parietal mesh was then inserted, with transparietal suturing with four cardinal stitches and additional fixation using double crown absorbable clips (double-crown mesh fixation technique). Postoperative outcomes were uneventful, and the patient was discharged home after 48 hours. The patient presented a strong abdominal wall at the 6-month follow-up.

Live interactive surgery: laparoscopic management of a ventral hernia

Cure de hernie inguinale par voie d'abord laparoscopique : technique TAPP

This educational video presents the case of a laparoscopic groin hernia repair using the transabdominal preperitoneal (TAPP) approach in a 60-year-old man with a symptomatic right inguinal hernia.

The patient experienced increasing discomfort and pain in the groin area, exacerbated by physical activity.

After clinical evaluation, a laparoscopic TAPP procedure was indicated.

During surgery, a direct right inguinal hernia was identified, and the hernia sac was reduced back into the abdominal cavity. A mesh prosthesis was then placed to reinforce the defect. The TAPP approach allows for a bilateral exploration and minimally invasive repair with visual control, offering an effective solution for the management of inguinal hernias in active individuals. The patient had an uneventful recovery, and no signs of recurrence were observed during postoperative follow-up.

Bibliography:

1\. Houcine Maghrebi, Amin Makni, Amin Sebai, Faouzi Chebbi, Wael Rebai, Amin Daghfous, Rachid Ksantini, Mohamed Jouini, Montassar Kacem, Zoubeir Ben Safta. Outcomes of laparoscopic surgery for groin hernia repair: our experience in Tunisia \[Résultats de la chirurgie laparoscopique pour la hernie de l’aine: l’expérience Tunisienne]. Pan African Medical Journal. January 2018; 29(43). DOI: 10.11604/pamj.2018.29.43.14013. License CC BY 2.0.

2\. J Leroy, M Bailey, D Mutter, J Marescaux. Key steps of laparoscopic TAPP inguinal hernia repair. WebSurg. Epublication WebSurg.com, May 2015;15(05). URL: [https://websurg.com/doi/vd01en4474](https://websurg.com/doi/vd01en4474)

Laparoscopic groin hernia repair: TAPP procedure

In this live interactive surgery, Dr. Bernard Dallemagne, MD demonstrates the laparoscopic management of a left inguinal hernia using the totally extraperitoneal (TEP) approach. This video shows a totally extraperitoneal (TEP) approach to a left inguinal hernia. The procedure began with a preaponeurotic incision and the creation of a dissection space using an atraumatic port and camera. A 30-degree scope was used. As soon as sufficient space was created, two additional ports were positioned, one port on the midline two fingerbreadths above the pubis, the second port also on the midline, halfway between the scope and the lowermost port, hence allowing for the progressive release of the retroperitoneal space. It was necessary to identify the epigastric artery to make sure that it was located underneath the scope. It was then possible to progressively free the hernial orifice, and to parietalize components of the spermatic cord. After complete dissection, a 15 by 13cm mesh was inserted, completely covering the dissection spaces. The benefit of the TEP approach was that no mesh fixation was required. As could be seen, exsufflation helped to perfectly fix the mesh to the posterior part of the anterior abdominal wall.

The patient was discharged home on the same day. Postoperative outcomes were uneventful, and the patient could resume physical activities after one month.

Live interactive surgery: laparoscopic TEP approach for left inguinal hernia 

In this live interactive surgery, Professor Didier Mutter, MD, PhD, FACS, FRSM demonstrates the laparoscopic management of a bilateral inguinal hernia using the transabdominal preperitoneal (TAPP) approach. This video presents the case of an overweight patient with a bilateral inguinal hernia (direct hernia on the left side, mixed, direct, and indirect on the right side). The author explains the principles of the TAPP approach to a bilateral inguinal hernia, outlines the bilateral exploration and dissection of this bilateral hernia pathology. A left approach was performed, with parietalization of the spermatic cord components, and complete lowering of the peritoneum, followed by a right approach. The two meshes, right-sided and left-sided, are placed superimposed at the level of the pubis, providing complete coverage of the anterior abdominal wall. The peritoneal defect was closed in an original fashion, using clips. The surgery was performed on an outpatient basis, and postoperative outcomes were uneventful.

Live interactive surgery: laparoscopic management of a bilateral inguinal hernia: TAPP approach 

Cure vidéolaparoscopique d'une hernie d'éventration à l'aide d'une prothèse rétromusculaire (technique eRives)

The authors present their technique of videolaparoscopic repair of incisional hernia with a retromuscular mesh, an endoscopic approach to perform the conventional Rives operation. Although this technique is frequently called “eTEP”, the authors prefer to call it “eRives”, since it follows the principles of the open Rives technique, and it is not preperitoneal, strictly speaking. The principles stated by Rives and Stoppa more than 50 years ago are still valid, namely midline reconstruction and implantation of a mesh in the retrorectus space are the pillars of a successful repair of a midline hernia. This video demonstrates a stepwise approach to an eRives operation for a M23W2R2 incisional hernia in a 63-year-old physically active man.

Bibliography:

1\. Belyansky I, Daes J, Radu VG, Balasubramanian R, Reza Zahiri H, Weltz AS, Sibia US, Park A, Novitsky Y. A novel approach using the enhanced-view totally extraperitoneal (eTEP) technique for laparoscopic retromuscular hernia repair. Surg Endosc 2018 Mar;32(3):1525-1532. doi: 10.1007/s00464-017-5840-2. Epub 2017 Sep 15.PMID: 28916960. [https://doi.org/10.1007/s00464-017-5840-2](https://doi.org/10.1007/s00464-017-5840-2)

2\. Salido Fernandez S, Fraile Vilarrasa M, Osorio Silla I, Georgiev Hristov T, Bernar de Oriol J, González-Ayora S, Pardo García R, Guadalajara Labajo H. Extended Totally Extraperitoneal (eTEP) Approach for Ventral Hernia Repair: Initial Results. Cir Esp (Engl Ed) 2020 May;98(5):260-266. doi: 10.1016/j.ciresp.2020.01.006. Epub 2020 Mar 12.PMID: 32172955. [https://doi.org/10.1016/j.cireng.2020.04.013](https://doi.org/10.1016/j.cireng.2020.04.013)

3\. Andre Luiz Gioia Morrell, Alexander Morrell, Alexander Charles Morrell-Junior, Jose Mauricio DE Freitas Mendes, Allan Gioia Morrell. Standardization and ten essential steps in the lateral robotic extended totally extraperitoneal (eTEP) repair of ventral hernias. Rev Col Bras Cir 2020 Oct 7:47:e20202622. doi: 10.1590/0100-6991e-20202622. eCollection 2020. PMID: 33053065 DOI: 10.1590/0100-6991e-20202622. [https://doi.org/10.1590/0100-6991e-20202622](https://doi.org/10.1590/0100-6991e-20202622)

Videolaparoscopic repair of incisional hernia with retromuscular mesh (eRives)

Cure de hernie inguinale (technique TAPP) pour hernie fémorale étranglée avec entérectomie et anastomose primaire

Acute inguinal hernias are common surgical emergencies conventionally managed through open surgery. Although several authors advocated for the laparoscopic approach in recent years, controversy persists among surgeons. The benefits of the laparoscopic technique extend beyond the elective context. Apart from detecting hidden and visible hernias and covering the entire myopectineal orifice (MPO), it also makes precise diagnosis possible, lessens the necessity for laparotomy, and lowers the incidence of wound infections. In this approach, intestinal viability is evaluated once the hernia has been identified and the strangulated content has been reduced. Save from cases of gangrenous perforation necessitating immediate intervention, hernia repair ensues. The subsequent reassessment of the strangulated bowel allows for revascularization, often obviating the need for bowel resection and unnecessary laparotomy. In this educational video, the authors present a case study of a 61-year-old woman with a strangulated femoral hernia. A laparoscopic transabdominal preperitoneal (TAPP) repair was performed, requiring segmental bowel enterectomy due to non-reversible ischemia. 

Bibliography:

1. Claus C, Furtado M, Malcher F, Cavazzola LT, Felix E. Ten golden rules for a safe MIS inguinal hernia repair using a new anatomical concept as a guide. Surg Endosc. 2020 Apr;34(4):1458-1464. doi: 10.1007/s00464-020-07449-z. Epub 2020 Feb 19. PMID: 32076858

2. Yang, G. (2017). Laparoscopy in emergency hernia repair. Annals Of Laparoscopic And Endoscopic Surgery, 2(6). doi:10.21037/ales.2017.05.05

Inguinal TAPP repair for strangulated femoral hernia with enterectomy and primary anastomosis

In this live interactive surgery, Professor Didier Mutter, MD, PhD, FACS, FRSM demonstrates the laparoscopic management of a left inguinal hernia using a transabdominal preperitoneal approach (TAPP). This video shows the case of a 35-year-old male patient with a BMI of 26 presenting with a Nyhus IIIB indirect left inguinal hernia. A three-trocar transabdominal preperitoneal (TAPP) approach was performed. Exploration allowed to precisely identify the anatomical landmarks, namely gonadal vessels and deferent duct; the epigastric artery defining the indirect inguinal hernia, and the umbilical artery representing the most internal landmark of the dissection. Surgery was performed in a conventional manner, with the following operative steps: peritoneal opening, peritoneal lowering, approach to the space of Bogros medially, hernia sac parietalization, and release of the deferent duct and vascular pedicle. The triangle of Doom and the triangle of pain were identified. The procedure ended with the positioning of a 13 by 12 by 8cm recut mesh entirely covering the freed hernial orifices. Reperitonization was then performed to completely cover the hernial mesh.

Live interactive surgery: laparoscopic TAPP approach for left inguinal hernia 

Cure de hernies incisionnelles W3 avec toxine botulique par approche extrapéritonéale totale étendue ventrale (eTEP)

One treatment option in the management of large abdominal wall defects is the use of botulinum toxin (BT) which produces a functional blockade that reaches its maximum effect between 4 and 6 weeks after administration. This causes the lateral abdominal muscles to elongate, allowing for a tension-free abdominal reconstruction. The repair of large defects represents a great challenge for abdominal wall surgeons, and the minimally invasive approach offers new opportunities.

Bibliography:

1\. Adriana Hernández López, Estefanía J. Villalobos Rubalcava. Botulinum toxin type A infiltration in the preoperative preparation of hernias with 10-15 cm defects. Rev Hispanoam Hernia 2016;4(2) 43-49. [https://doi.org/10.1016/j.rehah.2016.02.003](https://doi.org/10.1016/j.rehah.2016.02.003)

2\. Diego A Hipolito Canario, Ari J Isaacson, Jessica A Martissa, Jessica K Stewart. Ultrasound-Guided Chemical Component Separation with Botulinum Toxin A prior to Surgical Hernia Repair. J Vasc Interv Radiol 2021 Feb;32(2):256-261. doi: 10.1016/j.jvir.2020.09.013. Epub 2020 Dec 7. PMID: 33303339 DOI: 10.1016/j.jvir.2020.09.013

Focus on abdominal wall hernia repair (AWHR)