Laparoscopic Extraperitoneal Repair with Upfront Coring out of Hernia Defect for Ventral Hernia

Abstract

Backgrounds and Objectives:

The enhanced-view totally extraperitoneal technique (eTEP) has gained popularity as a novel minimally invasive ventral hernia repair approach. However, this procedure becomes technically demanding once the view is no longer maintained, due to incidental pneumoperitoneum caused by peritoneal injury during the surgery. In an attempt to overcome this technical issue, we report laparoscopic extraperitoneal repair with upfront coring out of hernia defect (LERCO) where the intraperitoneal coring out of the hernia defect precedes the regular eTEP for the treatment of midline incisional ventral hernia.

Methods:

A total of nine patients with midline incisional ventral hernia were treated by LERCO. In the first step, 3 ports are inserted into the peritoneal cavity. The half circumference of the hernia defect is cored out and the extraperitoneal space is further dissected. Then, an additional 3 ports are inserted in the dissected extraperitoneal space. The remaining half circumference of the hernia defect is cored out and the dissection of the extraperitoneal space around the hernia defect is completed. Subsequently, the hernia defect as well as posterior sheath and peritoneum are reapproximated and the mesh is deployed in the extraperitoneal space.

Results:

In this series of patients, there was no open conversion during the surgery nor severe postoperative complications including hernia recurrence.

Conclusion:

LERCO secures the procedure under the optimal field of view during midline incisional ventral hernia repair. Although our results are promising, further accumulation of clinical experiences is warranted.

INTRODUCTION

Although the enhanced-view totally extraperitoneal technique (eTEP) has gained popularity as a novel minimally invasive approach for ventral hernia repair, its technical difficulty remains a topic of debate.^1–3 In eTEP, incidental pneumoperitoneum caused by peritoneal injury during the dissection of a rigid scar, especially in incisional ventral hernia repair, often impairs the view through gas leakage from the extraperitoneal space to peritoneal cavity. In this report, we demonstrate laparoscopic extraperitoneal repair with upfront coring out of hernia defect (LERCO), where the intraperitoneal coring out of the hernia defect precedes the regular eTEP, securing the procedure under the optimal field of view in midline incisional ventral hernia repair.

MATERIALS AND METHODS

The clinical outcomes of LERCO were obtained by retrospective review of nine patients with midline incisional ventral hernia with a width of the hernia defect less than 10 cm (either W1: <4 cm or W2: ≧4–10 cm)⁴ in our institution between May 2022 and September 2024. The patient characteristics included age at the surgery, gender, body mass index (BMI), prior surgery and zone of the hernia defect. Regarding the operative outcomes, width and length of the hernia defect, operation time, conversion to open procedure (+/−), transversus abdominis muscle release (TAR, +/−), mesh area, and postoperative complications were investigated. All the patients consequently provided written informed consent prior to the surgery. The patients were observed in our outpatient clinic after the discharge. This study was approved by the Ethics Committee of our hospital (No. 2025-02).

Surgical Technique

Patients are placed in supine position with both legs and arms closed under general anesthesia combined with epidural anesthesia or transversus abdominis plane block. The first 12-mm port is inserted in the peritoneal cavity (Figure 1) and the pneumoperitoneum is initiated and maintained at approximately 8 mmHg. The additional 2 5-mm ports are inserted under a 5-mm flexible scope and the adhesiolysis is performed where necessary. The hernia defect is identified (Figure 2A) and half of its circumference is cored out (Figure 2B). Subsequently, the extraperitoneal space including both preperitoneal and retromuscular space is accessed and dissected to an extent of at least 5 cm away from the hernia defect (upper curved arrow in Figure 1). In the next step, an additional 3 5-mm ports are inserted in the dissected extraperitoneal space (Figure 2C). The remaining half circumference of the hernia defect is further cored out (Figure 2D) and the dissection of the extraperitoneal space around the hernia defect is completed (lower curved arrow in Figure 1). Consequently, the hernia defect is separated into anterior and posterior sheath components along with the peritoneum and then reapproximated layer by layer using both absorbable barbed sutures (V-Loc, Covidien, Dublin, Ireland) for posterior sheath component along with the peritoneum (Figure 3A) and nonabsorbable barbed sutures for the anterior sheath component (Figure 3B). Both rectus abdominis muscles are spared and the linea alba is reconstructed. A self-fixating mesh (Parietex ProGrip, Covidien) with the adhesive plane toward the direction of peritoneal cavity is deployed in the dissected extraperitoneal space (Figures 3C and 4). Although the mesh is placed over the posterior sheath and peritoneum, it adheres rectus abdominis muscles after the release of pneumoperitoneum, reinforcing the abdominal wall.

Figure 1.

Port site. The red circle indicates the hernia defect. The number in the circles indicates the port width (mm) and sites. The curved arrows indicate the direction of the dissection in the extraperitoneal space by using 3 ports at the opposite side of the hernia defect.

Figure 2.

Representative images in the intraperitoneal approach. The hernia defect (A) is cored out and extraperitoneal space is dissected (B). (C) The arrow indicates one of the additional ports inserted in the dissected extraperitoneal space. (D) The remaining half circumference of the hernia defect is cored out. (A–C): view in the caudal-cranial direction. (D) View in the cranial-caudal direction.

Figure 3.

Representative images in the extraperitoneal approach. (A) The posterior sheath and peritoneum is closed with absorbable barbed sutures. (B) The anterior sheath component of the hernia defect is closed with non-absorbable barbed sutures. (C) The self-fixating mesh is deployed in the dissected extraperitoneal space. The view for all the figures is in the cranial-caudal direction.

Figure 4.

Cross-sectional scheme of mesh deployment. The mesh (blue line) is placed in the dissected extraperitoneal space over the posterior sheath (arrow) and peritoneum.

RESULTS

The patient characteristic and operative outcomes are shown in Table 1. The age at the surgery ranged from 54–87 years old. Prior surgery of the nine patients (5 males and 4 females) was either laparoscopic (n = 5) or open procedure (n = 4). In patient No.3, TEP for right primary inguinal hernia was simultaneously performed; therefore, the operation time for the entire procedure was included. In patient No. 2, hematoma (Clavien-Dindo classification: grade 1)⁵ was observed but ameliorated naturally in the postoperative course. There was no open conversion during the surgery. No severe postoperative complications, including hernia recurrence, were noted in the observational period ranging from 30–869 days after the surgery in our outpatient clinic.

Table 1.

Patient Characteristics and Operative Outcomes

Patient	Age	Gender	BMI	Prior Surg	Zone	Width (cm)	Length (cm)	Op Time (mins)	Conversion	TAR	Mesh Area (cm2)	Postop Comp
1	74	F	27.3	Lap	M3	7	7	295	-	+	500	-
2	86	F	22.1	Lap	M3	7	8	240	-	+	400	hematoma (C-D 1)
3	87	M	24.3	Open	M1-M2	4	4	270	-	-	225	-
4	82	F	53.9	Open	M3	4	7	193	-	-	300	-
5	64	F	24.3	Lap	M3	4	4	338	-	-	225	-
6	85	M	23.6	Lap	M3	4	4	151	-	-	330	-
7	58	M	25.7	Open	M2	3	3	122	-	-	400	-
8	54	M	24.2	Lap	M3	3	5	127	-	-	225	-
9	69	M	33.2	Open	M3	4	4	144	-	-	300	-

The localization of hernia was defined according to the classification of the European Hernia Society (EHS).⁴ BMI, body mass index; Prior Surg, prior surgery; Lap, Laparoscopy-assisted surgery; Op time, operation time; TAR, transversus abdominis muscle release; Postop comp, postoperative complications; C-D 1, Clavien-Dindo grade 1.

DISCUSSION

Recent growing evidence has demonstrated the feasibility of eTEP in treating small to medium-sized primary and incisional ventral hernias,⁶ facilitating early recovery, lowering postoperative pain,^3,7–9 and reducing the potential risk of fistula formation caused by intraperitoneal mesh contact with the intestines in laparoscopic intraperitoneal onlay mesh repair (IPOM). Prior to the introduction of eTEP in our institution, we defined the surgical indications of eTEP as primary and incisional ventral hernia with the width of the hernia defect less than 10 cm and without any operative scar extending around the abdomen, wound infection, hernia recurrence, and hernia strangulation. Nevertheless, there were several cases of conversion to open procedure mainly because of impaired view due to incidental pneumoperitoneum caused by peritoneal injury and subsequent gas leakage from the extraperitoneal space to peritoneal cavity during the dissection of a rigid scar, especially in incisional ventral hernia repair. In addition, the procedure for connecting the bilateral retromuscular space, referred to as crossover also requires the expertise to avoid peritoneal injury during the eTEP surgery for ventral hernia.

We showed that LERCO is the modified procedure of eTEP with upfront coring out of the hernia defect by intraperitoneal approach followed by regular eTEP, facilitating the maintenance of the optimal field of view during the surgery. The upfront intraperitoneal approach in LERCO shares similarities with laparoscopic transabdominal preperitoneal repair (TAPP) for ventral hernia (ie, ventral TAPP) whereby the entire procedure is achieved intraperitoneally.¹⁰ However, LERCO is novel in its transition of the approach from the peritoneal cavity to extraperitoneal space during the surgery. Furthermore, coring out of the hernia defect in the intraperitoneal approach allows for precise crossover under the optimal field of view as well as the minimization of the defect in the posterior sheath and peritoneum, simplifying the later reapproximation in the extraperitoneal approach. We performed LERCO in nine patients with midline incisional ventral hernia, with no fatal intraoperative or postoperative complications, thereby validating the safety of the technique.

The surgical indications of LERCO for the treatment of incisional ventral hernia remains limited. So far, the surgical indication of LERCO has been limited to patients with midline incisional ventral hernia because of the requirement of the port placement encircling the hernia defect. Our data for LERCO is also limited for the patients with small to medium-sized hernia defects with widths of less than 10 cm. Meanwhile, we performed LERCO on patients with operation scars extending around the abdomen due to prior open laparotomy, as they were considered at high risk for peritoneal injury during the surgery and, therefore, were contraindicated for eTEP in our institution. Our promising results suggest that LERCO extends the surgical indications for the treatment of midline incisional ventral hernia.

Compared to eTEP, LERCO offers the advantage of immediate identification of hernia content through its upfront intraperitoneal approach. Adhesiolysis in the peritoneal cavity could be limited near the hernia defect, as long as the closure of posterior sheath and peritoneum is achievable. The long operation time for LERCO in our study is similar to that in patients treated with eTEP for incisional ventral hernia,² implying the high demands of the technique. The notification of key steps in every section of the procedure along with full understanding of the anatomical structure of the abdominal wall is crucial for achieving success in the treatment of midline incisional ventral hernia.

CONCLUSION

LERCO for treating midline incisional ventral hernia is a promising procedure that helps avoid incidental pneumoperitoneum, which can impair the field of view during the surgery. Further accumulation of clinical evidence is warranted to establish treatment strategies and obtain long-term results of LERCO for the treatment of midline incisional ventral hernia.