Original Article

Extended totally extraperitoneal repair (eTEP) for ventral

hernias: Short‑term results from a single centre
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Sarfaraz Jalil Baig, Pallawi Priya

Department of Minimal Access Surgery and Surgical Gastroenterology, Belle Vue Clinic, Kolkata, West Bengal, India
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Abstract Introduction: There has been a surge of innovative procedures in the field of abdominal wall hernias. Works
of pioneers such as Dr. Yuri Novitsky, Dr. Jorge Daes and Dr. Igor Belyansky have started a new era in the field
of hernia surgery. Conventional and popular surgeries for ventral hernias are open onlay mesh hernioplasty,
open retromuscular mesh hernioplasty (Rives‑Stoppa procedure) and laparoscopic intraperitoneal mesh
hernioplasty. Evidence seems to suggest that retromuscular mesh hernioplasty has advantages over other
procedures regarding recurrence and surgical site occurrences. An alternative strategy has been developed
for this setting where a mesh is placed in retromuscular space by minimal access technique of the extended
Totally Extraperitoneal approach (eTEP).
Methods: We have retrospectively analysed the data of 21 patients who underwent an eTEP procedure
with a minimum follow‑up of 2 months. Their data were analysed for operative details, intra‑operative and
post‑operative complications.
Results: For a total of 21 patients, we have recorded a total of two surgical site occurrences (1 seroma and 1
linea alba dehiscence) and one recurrence. One patient had chronic pain. There was no surgical site infection.
Conclusion: Judging from our short‑term results, we suggest that the eTEP technique can be adapted in
centres with advanced laparoscopic skills with the careful patient selection.

Keywords: eTEP TAR, eTEP‑RS, extended totally extraperitoneal repair e‑TEP, extended totally extraperitoneal
Rives‑Stoppa repair, Rives‑Stoppa, Sublay mesh hernioplasty, totally extraperitoneal repair, transversus
abdominis release, ventral hernia

Address for correspondence: Dr. Sarfaraz Jalil Baig, Department of Minimal Access Surgery and Surgical Gastroenterology, Belle Vue Clinic, Kolkata,
West Bengal, India.
E‑mail: docsarfarazbaig2@gmail.com
Received: 26.02.2018, Accepted: 23.04.2018

INTRODUCTION Some surgeons have extended the indication to ventral hernias

with the purpose to place the mesh in the retromuscular
Extended totally extraperitoneal repair (eTEP) is a novel space, as suggested by Rives and Stoppa (RS).[2] This has
technique that was first introduced by Jorge Daes in 2012 been called Extended Totally Extraperitoneal RS repair
to address difficult inguinal hernias.[1] The principle is to (eTEP RS). When the defect is too wide to be closed without
create a larger space than what is done in TEP to tackle tension, a component separation procedure is added.
large groin hernias. Generally, the posterior component separation technique

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DOI: How to cite this article: Baig SJ, Priya P. Extended totally extraperitoneal
10.4103/jmas.JMAS_29_18 repair (eTEP) for ventral hernias: Short-term results from a single centre. J
Min Access Surg 2019;15:198-203.

198 © 2018 Journal of Minimal Access Surgery | Published by Wolters Kluwer - Medknow
 Baig and Priya: eTEP for ventral hernia

(PCST) in the form of Transversus abdominis release (TAR) camera is shifted to the right upper port (D) for further
as described by Dr. Novitsky et al.[3] is preferred with the dissection and suturing the defect.
eTEP technique since the plane of dissection is the same.
This is called eTEP TAR. It is believed that mesh placement For epigastric and subxiphoid hernias, we initially create
in retromuscular space translates into vascularisation of one of the retro‑rectus spaces like in lower hernias;
the mesh from both sides, less recurrence, fewer issues of thereafter, lower ports at the infra‑umbilical region are
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fixation, less pain and fewer chances of bowel adhesions made as shown in Figure 1b. Two monitors are needed,
in addition to being economical due to the deployment one at the foot end for initial space creation, and another
of a cheaper mesh as composite mesh with anti‑adhesion at the head end that is used for the rest of the surgery.
barrier is not needed.[4] However, the technique has a steep
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Entering the retro‑rectus space

learning curve. In this article, we present how we perform
We start with a 15‑mm incision below the left costal
this procedure and the short‑term results of our experience.
margin at the left mid‑clavicular line. Retro‑rectus space is
METHODS created with a PDB spacer balloon (Medtronic). A 10‑mm
telescope is inserted into this space that is further dissected
Case selection with an energy source. The dissection proceeds caudally
The case selection depends primarily on the width of the until the pubic bone is completely visualised. The lateral
defect although a host of other factors such as obesity, limit of the dissection is carefully maintained keeping
location, previous mesh and surgery, skin scars, sinus tracts medial to the linea semilunaris to prevent any inadvertent
and redundancy also play a role in decision‑making. injury to the neurovascular bundle [Figure 2a].

Currently, we use intra‑peritoneal onlay mesh hernioplasty Crossing the midline

with the closure of fascial defect (IPOM plus) for patients Two more 5‑mm ports are made in the retro‑rectus space
with defect size 4 cm and less. medial to the linea semilunaris at the midclavicular line at a
distance of 5 cm from each other (B and C). The telescope
We select all hernias that have a defect >4 cm for eTEP is shifted to the lower port (C) to visualise the cranial end
in our practice. of the space and the left posterior rectus sheath is incised
at its medial margin with a diathermy hook or scissors.
Defects that cannot be closed without tension necessitate a The yellow pad of fat is seen that represents the falciform
TAR. We have been able to manage eTEP TAR for hernia ligament [Figure 2c]. This is dissected down from the roof
defects as wide as 12 cm. We have employed open surgery to cross the midline and visualise the right posterior rectus
for hernias larger than 12 cm. sheath. Here, we have modified the technique for our ease.
We create the right retro‑rectus space at the beginning of
Exclusion criteria surgery and inflate it with carbon dioxide that helps in
• Defect width >12 cm identifying and placing the incision on the right posterior
• Poor skin condition rectus sheath. We also use a needle to guide us in incising
• Sinus tract posterior rectus sheath. The camera is shifted to the right
• Previous retro‑rectus mesh placement. upper port (D) for further dissection. The left upper
ports (A and B) are then used as working ports.
Technique
We follow the same technique as described by Dr. Belyansky For epigastric and subxiphoid hernias
et al.[2] with a few modifications. Initial entry is from a left paraumbilical port. In these cases,
we cross the midline from below. This is technically easier
Positioning of patient and ports since the extraperitoneal space blends into the retro‑rectus
The patient is placed supine with arms tucked by the side spaces cranially.
and extended at the hips to enable instrumentation without
hindrance from the pelvis and thighs. Entering the peritoneal cavity
The dissection is continued caudally until we reach
The port positions are shown in Figure 1. For umbilical, umbilicus. The peritoneum is opened with an energy source
infra‑umbilical and suprapubic hernias, [Figure 1a] the TV at a safe distance from hernia sac to enter the peritoneal
monitor is placed at the foot end. We place the camera cavity [Figure 2b]. The contents are inspected and dissected
initially in the upper left port (A) until the midline is crossed down carefully with sharp dissection and judicious use of
and both retro‑rectus spaces are dissected. Thereafter, the energy source, especially in the presence of a bowel.
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a b a
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Figure 1: Port positions. (a) for umbilical and infraumbilical hernia;

(b) for supraumbilical hernia

b c
Figure 2: (a) Creation of retro‑rectus space. Note the neurovascular
bundles ‑ black arrow, Linea Semilunaris ‑ yellow arrow, posterior rectus
sheath ‑ blue arrow (b) intraperitoneal dissection and taking down
hernia contents (c) crossing the midline. Note the falciform pad of fat

a b
Figure 3: (a) Closure of linea alba. Rectus abdominis are marked with
white arrows (b) closure of posterior rectus sheath

Closure of the linea alba

The defect is closed at a lower insufflation pressure with a
45‑mm taper cut 1 polypropylene or a 1‑0 or 2‑0 barbed non‑
absorbable sutures [Figure 3a]. The posterior rectus sheath is
closed with absorbable barbed suture or 2‑0 PDS [Figure 3b].

Transversus abdominis release

If a TAR is required in the event of inability to
approximate the defect edges or posterior rectus sheath,
an incision is made on the posterior rectus sheath in upper
Figure 4: Transversus abdominis release. TA fibres are marked with
abdomen where the TA fibres are fleshy, medial to the black arrow
linea semilunaris, preserving the neurovascular bundles.
The TA fibres are identified and divided with a hook We prefer to fix the mesh with the fibrin glue or no fixation
diathermy [Figure 4]. Plane is developed between the TA at all.
fibres and transversalis fascia using the principle described
by Belyansky et al.[2] and Novitsky et al.[3] in their original The gas insufflation is then stopped and space is deflated
papers. The procedure is unilateral or bilateral depending under vision taking care that the mesh is flat. If there
on the amount of release required. is any folding of mesh noted during deflation, carbon
dioxide is introduced again and the mesh is deployed
Placement and fixation of the mesh properly.
The mesh size depends on the defect size and the space
created. Generally, a 20 cm × 25 cm is used for eTEP Atypical sited hernias
RS [Figure 5] where the mesh is placed flat from one linea We have performed four cases of atypically sited hernias
semilunaris to another and from epigastrium to pubis, but with the eTEP technique (2 lumbar, 1 subcostal and 1
there is significant inter‑individual variation. For eTEP Pfannensteil). We have employed TAR on the ipsilateral
TAR, we use 30 cm × 30 cm mesh to cover from one side and RS on the opposite side for subcostal and lateral
axillary line to another. Our personal preference is to use pfannensteil hernias. For lumbar hernias, ipsilateral TAR
a medium weight macroporous polypropylene mesh. was sufficient for adequate overlap of the mesh.
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 Baig and Priya: eTEP for ventral hernia

Table 1: Patient characteristics (n=21)

Patient characteristics n (%)
Age (years)
Mean 54.67
Median 54
SD 13.05
BMI (kg/m2)
Mean 28.57
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Median 29
SD 4.14
Gender
Males 6 (28)
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Females 15 (72)
Smoker 0
Diabetic 3 (14)
Hypertensive 4 (19)
CAD 1 (4.7)
CVA 1 (4.7)
Figure 5: Mesh placement. Pubic bone is marked with an arrow Recurrent hernia 5 (23.8)
SD: Standard deviation, BMI: Body mass index, CAD: Coronary artery
disease, CVA: Cerebrovascular accident
Post‑operative care
We allow clear liquids 6–8 h after surgery and oral feeds of the patients are discharged on POD 2 or 3 with a mean
the morning after. Drains are usually not given. Analgesics time from surgery to discharge being 2.67 days and range
are used in the first 5 days routinely. Patients are usually being 2–5 days. We have used a flat suction drain in only
discharged within 48–72 h of the procedure. one patient which was taken out at 48 h after surgery. In
this patient, after dissection and mesh placement, the raw
RESULTS surface looked ‘oozy’. Placing the drain was a subjective
decision [Table 2].
We have done a total of 21 cases of eTEP until December
2017. Outcomes
One patient developed a suture dehiscence in POD
Patient characteristics 1 that could be palpated clinically. There had been a
The mean age was 54.67 years. 6 were male and 15 were technical difficulty in suturing the anterior abdominal
female. Mean BMI was 28.57 kg/m2. Three patients were wall in this case due to ergonomic reasons. We had to
diabetic, four were hypertensives and one had CAD, and re‑operate with a limited laparotomy to close the defect.
one had a history of CVA. Out of 21, 3 patients had a The patient did well thereafter. One patient who had
primary hernia, and 18 had an incisional hernia. 5 had a undergone an eTEP TAR developed a seroma that
recurrent hernia [Table 1]. could be observed after 10 days of surgery. Since it was
painful and was causing extreme discomfort, we decided
Periopertive characteristics
to drain it. It needed single aspiration and a tight corset
9 were eTEP RS and 12 were eTEP TAR. The mean
for a month to which it responded satisfactorily. There
operating time was 176.48 min and ranged from 138 to
was one recurrence at 3 months follow up. There were
310 min. We have seen that with increasing expertise, our
no SSI. One patient had significant pain at 1 month
operative time has gone down. Mean defect width was
follow up [Table 3].
6.65 cm and defect area was 45.33 cm2. The mean mesh
size was 535 cm2. We tend to use 30 cm × 30 cm mesh DISCUSSION
for eTEP TAR and 20 cm × 25 cm mesh for eTEP RS,
however, it varies depending on the patient’s build and With increasing evidence suggesting better results in the
defect size. Initially, our preferred method of fixation was outcome (recurrence and SSO) with the retro‑rectus mesh
a single tacker to the pubic bone with or without glue, for ventral hernias, many surgeons have tried to use this
slowly we have moved to using no fixation at all. In one space with minimal access.
patient with an epigastric hernia, we have used a single
trans fascial suture in the subxiphoid region for fixation. The eTEP technique was initially devised to tackle large
All the patients are ambulated on post‑operative day (POD) groin hernias by Dr. Jorge Daes. The eTEP procedure
1 except one patient who had an anterior dehiscence and involves opening of retro‑rectus spaces along with the
needed to undergo a secondary suturing on POD 1. Most preperitoneal spaces of Retzius and Bogros at the groin
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 Baig and Priya: eTEP for ventral hernia

Table 2: Perioperative details retro‑rectus space bilaterally and connecting them, with
Intraoperative parameters Values minimal access method, to duplicate the open RS repair.
eTEP‑RS (n) 9 For larger defects, the same plane can be utilised to perform
eTEP‑TAR (n) 12
Operative time (min)
PCST (TAR), as described by Dr. Yuri Novitsky, to enable
Mean 176.48 tension‑free closure of hernia gap and achieving a greater
Median 178 mesh overlap.
SD 40.95
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Defect width (cm)

Mean 6.65 Currently, we have used the technique for hernias with a
Median 6 width of 4–12 cm. It is difficult for us to suture defects
SD 1.95
wider than this. We prefer to use IPOM‑plus for smaller
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Defect area (cm2)

Mean 45.33 defects because of its ease and less operative time.
Median 40
SD 22.38 Our technique is the same as the innovator except for one
Mesh size (cm2)
Mean 535 difference. We create both retro‑rectus spaces initially by
Median 500 open technique and inflate it. This helps us in identifying
SD 193.35
Fixation
and entering the opposite space more easily.
None 7
Single tacker to the pubic bone 9 We have used TAR for closing large defects, allowing
Single tacker to the pubic bone + glue 3 closure of posterior rectus sheath and non‑midline hernias.
Glue alone 1
Single transfascial suture 1 We have noticed wide inter individual variability of distance
Drain (%) between the two linea semilunaris. Sometimes (n = 3), we
Yes 1 (4.7) had to do limited right TAR for tension‑free closure of
No 20 (95.3)
Time to ambulation posterior rectus sheath.
Mean 1.05
Median 1 In our series, there was 1 recurrence in the short to medium
SD 0.22
POD 1 pain score (VAS) term follow‑up. This recurrence was probably due to
Mean 3.48 misjudgement of mesh size required. After finding that,
Median 3 the mesh size inserted was too large for the space in a case
SD 0.87
Time to discharge after surgery (days) of eTEP right TAR, we cut the mesh intracorporeally.
Mean 2.67 It may have led to a mesh size that was actually smaller
Median 3
SD 0.79
than needed.
TAR: Transversus abdominis release, SD: Standard deviation,
POD: Post‑operative day, VAS: Visual analog scale, eTEP‑RS: Extended The complications‑linea alba dehiscence and recurrence‑
Totally Extraperitoneal Repair- Rives Stoppa reflect our learning curve that can be avoided in future with
Table 3: Post‑operative complications experience and practice.
Complications n (%)
Surgical site occurrence
Although we did not have a controlled trial comparing the
Seroma 1 (4.7) pain scores between our IPOM and eTEP patients, we
Hematoma 0 found that the latter had lower requirement of analgesics.
Linea alba dehiscence 1 (4.7)
Surgical site infection 0 This may be due to the fact that no/minimal fixation was
Systemic complications 0 used in these cases.
Mortality 0
Recurrence 1 (4.7)
30‑day readmission 0
The steep learning curve and the longer operative time are
Pain 1 (4.7) the main drawbacks of the procedure. The suturing of the
linea alba is both technically demanding and a critical step
to prevent dislodgement of the mesh.
level. This has led surgeons to explore the possibility of
using the retro‑rectus space for ventral hernia repair. CONCLUSION

eTEP technique for ventral hernias was developed by With all its limitations, eTEP is an attractive option for
Dr. Belyansky et al.[2] and the author was fortunate to have selected cases because of improved outcome. There is a
observed with the innovator at his centre. It is a novel need to perform RCT between eTEP and IPOM/IPOM
and ingenious technique that involves developing the plus in these settings to have an evidence‑based answer.
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 Baig and Priya: eTEP for ventral hernia

Financial support and sponsorship 2. Belyansky I, Daes J, Radu VG, Balasubramanian R, Reza Zahiri H,
Weltz AS, et al. A novel approach using the enhanced‑view totally
Nil. extraperitoneal (eTEP) technique for laparoscopic retromuscular hernia
repair. Surg Endosc 2018;32:1525‑32.
Conflicts of interest 3. Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ. Transversus
There are no conflicts of interest. abdominis muscle release: A novel approach to posterior component
separation during complex abdominal wall reconstruction. Am J Surg
2012;204:709‑16.
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REFERENCES 4. Binnebösel M, Klink CD, Otto J, Conze J, Jansen PL, Anurov M, et al.
Impact of mesh positioning on foreign body reaction and collagenous
1. Daes J. The enhanced view‑totally extraperitoneal technique for repair ingrowth in a rabbit model of open incisional hernia repair. Hernia
of inguinal hernia. Surg Endosc 2012;26:1187‑9. 2010;14:71‑7.
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