Totally Endoscopic Incisional Hernia Repair (Etep) vs Ipom+ in Incisional Hernia Repair After Hepatobiliary Surgery. The Advantages of Minimally Invasive Extraperitoneal Mesh Placement Close to Bone Edges

Abstract Totally extraperitoneal endoscopic approach for the treatment of incisional hernia (eTEP) could be the gold standard technique in the future, due to it does not penetrate the abdominal cavity minimizing the possibility of intraperitoneal lesions, intestinal obstruction due to adhesions formation, and port site incisional hernias. This technique consists of a series of surgical maneuvers and strategies designed to enhance an extraperitoneal working space for the minimally invasive repair of midline and lateral hernias. Surgical approach in subcostal incisional hernias are challenging due to its proximity to costal margin. We present our experience in totally endoscopic retromuscular access with transversus abdominis release (eTEP-TAR) for incisional lateral subcostal hernias after HPB surgery, showing the advantages of this procedure in those type of lateral hernias. Methods From January 2019 to January 2023, patients with symptomatic right subcostal incisional hernia after were underwent to minimally invasive incisional hernia repair eTEP – TAR. The results were compared to those patients with the same hernias which were operated on using conventional laparoscopic hernia repair with defect closure (IPOM +) from 2012 to 2018 in a prospectively maintained database case/control study and retrospectively analyzed. Exclusion criteria: 12 cm width hernias, incarcerated hernias and skin deterioration. Variable measured: age – previous treatment – defect length and width – mesh – surgical time – intraoperative/postoperative complications – length of stay – pain (VAS for pain) at 1–7–30–90 days – activities restrictions at 1 and 6 postoperative months – recurrence rate results are expressed in mean +/- standard deviation. Results 25 patients were included in eTEP group and 22 in IPOM group. No significant differences were seen in preoperative measurements (age and previous treatments), type of Mean defect length 6,6 cm +/- 1,4 SD and width 6,3 cm +/- 1,5 cm in eTEP group (defect surface: 41,4 cm2 +/- 14,4) and 7,5 cm +/-1,2 with 5,9 cm +/- 1,4 (defect surface: 43,9 cm2+/- 10,5) respectively in IPOM group, without significant differences (p:0,3). Surgical time was longer in eTEP group with significant differences (106,3 min +/- 22,7 vs. 67,2 min +/- 15,5) with significant differences in favor of IPOM group. 5 intraoperative complications (2 superficial jejunal serosa injuries solved with suture, 1 epigastric vessel injury and 2 peritoneal holes with decreased working space in etep). Mean Length of stay was 33 hours +/- 13,8 and 61 hours +/- 12,2 in eTEP and IPOM groups respectively with significant improvement in favor of eTEP group (p 0,05). No differences on postoperative complications were identified. Regarding postoperative pain measured on the 1st, 7th, 30th and 90th day after surgery, eTEP group showed significantly less pain on 1st, 7th, 30th and 90th postoperative days than IPOM+ group (p 0,05). Activities restriction was significantly improved in eTEP group after 1 and 6 months when compared to IPOM+ (p 0,002). The average follow-up was 20,6 +/- 10,6 months in eTEP group and 60,6 +/- 10,6 months in IPOM+ group. During the follow-up, 1 recurrences (4%) and 2 (9%) were identified in eTEP and IPOM groups respectively. Conclusions eTEP-TAR for incisional hernia is an optimal approach due the benefits of the extraperitoneal approach. It does not enter the cavity and there is no need to release adhesions due to previous surgery. Postoperative pain, surgical stay and activities restrictions are improved due to non-traumatic fixation was used. Conventional PPL mesh is placed in retromuscular position, decreasing the cost of the procedure when compared to expensive intraperitoneal mesh in IPOM technique. eTEP-TAR approach is more complex to perform than IPOM. That´s the reason of the higher surgical time.