eTEP approach

Who would have thought that the mundane TEP would blossom into an entirely new approach to AWR?


e-TEP Overview

Belyansky has progressed on the extended TEP (e-TEP) approach popularised by Jorge Daes for groin and lower abdominal hernias and used it to develop an endoscopic approach to PCST/TAR. The group of e-TEP pioneers includes Belyansky, Novitsky, Daes, Radu and Ramana, and their index series of endoscopic retromuscular cases is under publication currently.


A Spacemaker or PDB balloon (Medtronic) is used to develop a space in the left upper retro-rectus area. The balloon is inserted by a simple cutdown and muscle split till the posterior rectus sheath (PRS) is reached. Under endoscopic vision, the retrorectus space is developed. Once this is done, additional 5 mm ports are placed medial to the semilunar line. At least one contralateral port is usually needed, though more may be used, if bilateral TAR is indicated. An important part of the procedure is to cross over to the other side by dividing the linea alba. This is done in the upper retro-rectus space. The entire falciform ligament is mobilized down along with the PRS. The dissection extends caudally till the hernia sac is safely and sharply entered. Adhesiolysis is completed, and the lower extraperitoneal space is fully exposed like in the open PCST.

The PRS is incised laterally and the Transversus Abdominis is exposed. The TAR is accomplished along the full length of the flank. Space creation is as in the open procedure.

Rectus sheath closure (both the anterior as well as the posterior) is made far easier with the barbed sutures available in the market (V-Loc or Stratafix). Mesh fixation is easy with 30 ml of fibrin glue which, however, becomes an expensive fix. It is possible that minimal fixation may also work, though there are concerns of early post-operative mesh displacement. There is currently no evidence to recommend one over the other.
The mesh covers the 12 mm and other ports.

Patients typically go home the day after the surgery. The surgery takes time, but the patient has much less pain and has higher QOL scores as compared to open PCST procedures.
Costa and Abdalla do a lap midline reconstruction using staplers. Under laparoscopic vision, a retro-rectus tunnel is formed with a blunt laparoscopic instrument on either side of the defect all the way from 4 cm below the umbilicus to the costal margin and an endoscopic stapler fired, incorporating the posterior sheath, sac and anterior sheath, leading to a full, stapled midline line alba.

This is still in its nascent stage and cannot be said to be anything other than an interesting, innovative and experimental approach to AWR.


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