Repair of Ventral Hernias by Totally Extraperitoneal Approach (VTEP): Technique and Short-Term Results
NGO P | COSSA JP
Seance of wednesday 30 october 2019 (Communications libres)
DOI number : 10.26299/zdgr-ew60/emem.2018.2.015
Abstract
Background: Patch repair of ventral hernias is recommended to reduce the recurrence rate. The laparoscopic repair provides better cosmetic result and lower risk of sepsis than open approach. Despite the fact that in open surgery the preferred location for the patch is in the retro-rectus space, the most commonly used method of laparoscopic repair is IPOM
(IntraPeritoneal Onlay Mesh). In this technique the patch is fixed by staples or tacks, which can induce intense postoperative pain or chronic pain. Moreover, though the patch usually is a composite prosthesis equipped with an antiadhesive barrier, intestinal adhesions can occur, especially to the border of the patch or to the staples and provoke severe complications.
In order to comply with the principles of open surgery, we have developed the repair of ventral hernias by totally extraperitoneal approach (VTEP). The patch being separated from the intestine by the posterior sheath and the peritoneum, the risk of adhesion is avoided, and since the patch is sandwiched between the rectus muscles and the posterior sheath, no fixation is required.
Technique: Three trocars are placed in the retro-rectus space. Depending on the hernia type and the patient’s morphology, the trocars can be placed in the upper (subcostal) abdomen
(descending procedure), or in the lower (suprapubic) abdomen (ascending procedure), or on
the lateral border of the rectus muscle (lateral procedure). Dissection is carried out in the retro-rectus space. The characteristic step of the technique consists of crossing the midline to create large communication between both retro-rectus spaces, while preserving the proper linea alba. Retro-rectus dissection is extended, the hernia is dissected and reduced.
The peritoneum can be opened intentionally or incidentally. In this case it is closed by suture. The patch is deployed on the floor formed by the posterior sheath and peritoneum, without fixation.
Results: On a continuous series of 99 patients, 89 were operated in day-case setting and 10 in
overnight stay. The sizes of the hernia orifice and of the patch were 7 (1-28) cm 2 and 222 (50-345) cm 2 respectively. The mean duration of operation was 60 (30-105) mn. There were 5 conversions to IPOM and 3 complications, including 1 seroma, 1 urine retention and 1 intestinal obstruction, due to bowel incarceration in a gap of the peritoneum suture. The mean value of postoperative pain assessed by VAS, was 2 (0-7). The times to resume daily activity and work were 2 (1-15) days and 10 (1-30) days respectively.
(IntraPeritoneal Onlay Mesh). In this technique the patch is fixed by staples or tacks, which can induce intense postoperative pain or chronic pain. Moreover, though the patch usually is a composite prosthesis equipped with an antiadhesive barrier, intestinal adhesions can occur, especially to the border of the patch or to the staples and provoke severe complications.
In order to comply with the principles of open surgery, we have developed the repair of ventral hernias by totally extraperitoneal approach (VTEP). The patch being separated from the intestine by the posterior sheath and the peritoneum, the risk of adhesion is avoided, and since the patch is sandwiched between the rectus muscles and the posterior sheath, no fixation is required.
Technique: Three trocars are placed in the retro-rectus space. Depending on the hernia type and the patient’s morphology, the trocars can be placed in the upper (subcostal) abdomen
(descending procedure), or in the lower (suprapubic) abdomen (ascending procedure), or on
the lateral border of the rectus muscle (lateral procedure). Dissection is carried out in the retro-rectus space. The characteristic step of the technique consists of crossing the midline to create large communication between both retro-rectus spaces, while preserving the proper linea alba. Retro-rectus dissection is extended, the hernia is dissected and reduced.
The peritoneum can be opened intentionally or incidentally. In this case it is closed by suture. The patch is deployed on the floor formed by the posterior sheath and peritoneum, without fixation.
Results: On a continuous series of 99 patients, 89 were operated in day-case setting and 10 in
overnight stay. The sizes of the hernia orifice and of the patch were 7 (1-28) cm 2 and 222 (50-345) cm 2 respectively. The mean duration of operation was 60 (30-105) mn. There were 5 conversions to IPOM and 3 complications, including 1 seroma, 1 urine retention and 1 intestinal obstruction, due to bowel incarceration in a gap of the peritoneum suture. The mean value of postoperative pain assessed by VAS, was 2 (0-7). The times to resume daily activity and work were 2 (1-15) days and 10 (1-30) days respectively.