S. J. Kumar1, Z. D. Warriner1, Y. W. Chang1, M. A. Plymale1, D. L. Davenport1, A. Wade1, R. W. Edmunds1, J. S. Roth1 1University Of Kentucky,General Surgery,Lexington, KY, USA
Introduction: We describe five years’ experience of totally extraperitoneal approach (TEP) with component separation for complex ventral hernia repair (VHR). Complex ventral and incisional hernia management with abdominal wall reconstruction (AWR) has typically involved obligatory peritoneal entry for adhesiolysis, with subsequent risk of enterotomy. We have previously demonstrated that totally extraperitoneal (TEP) approach to AWR is feasible and results in shorter operative times with similar complication rates. Our objective is to review continued experience with TEP hernia repair at our institution, specifically addressing technique, decision-making, and outcomes.
Methods: A retrospective review of TEP cases performed over five years. TEP involves hernia sac identification and preservation. Hernia sac is dissected circumferentially until edges of intact anterior fascia identified. Posterior component separation performed as required for fascial closure. Hernia sac is then imbricated within the preperitoneal space or posterior rectus sheath in the midline. Mesh is placed as retromuscular sublay and linea alba restored ventral to mesh.
Results: Between January 2012 and December 2016, we used this technique for 166 cases. Four cases required intraperitoneal entry to explant densely adhered mesh. 86.1% of cases had ≤ 1 prior repair and 89.2% ASA wound class 1. Median defect size 135cm2 and mostly Rives-Stoppa or transversus abdominis release performed for component separation. Median operative time was 175 minutes, blood loss 100ml, and incidence of enterotomy was 0%. Median length of stay (4 days) and time to return of bowel function (4 days) were favorable. Overall wound complication rate was 27.1%, specifically 9% required seroma drainage and 3% (five patients) required re-operation for various wound or mesh complications. As of April 2018, 4 (four) patients returned back to our institution for SBO, all of which resolved with conservative management.
Conclusions: Totally extraperitoneal hernia repair can be performed safely, with a low risk of enterotomy and post operative small bowel obstruction in selected patients. The TEP approach allows for hernia repair with avoidance of both peritoneal entry and adhesiolysis. Future studies are required to validate these results.