Intraoperative adverse events and management strategies in laparoscopic enhanced-view totally extraperitoneal repair (eTEP): a guide to safe introduction

BACKGROUND: Enhanced-view totally extraperitoneal repair (eTEP) is a promising minimally-invasive technique for ventral hernia repair, allowing extensive retromuscular dissection and large mesh placement with low rates of wound complications and a fast recovery. The learning curve, however, is substantial and technical expertise is crucial for satisfying outcomes. The aim of this study is to critically analyse intraoperative adverse events and provide guidance for safe introduction of eTEP. MATERIALS AND METHODS: All patients undergoing eTEP for primary or incisional ventral hernias between October 2023 and December 2024 at three centres were included in this prospective study. eTEP was divided in 10 surgical steps and each was rated for its difficulty (1-5 points) and analysed for the incidence of adverse events. Surgeon workload was measured using the NASA-Task-Load-Index (0-100) and perioperative outcomes were reported. RESULTS: and 30% female sex were included. Dissection of the hernia and steps involving suturing of the hernia orifice or posterior defects were rated as most difficult. The most common minor adverse events were peritoneal injury during hernia dissection (52%) and minor bleeding during rectus sheath dissection (up to 45%). Critical intraoperative events were common and included injury to the linea alba (6.4%), major bleeding during posterior rectus sheath dissection (up to 4.8%), conversion to open surgery (2.4%) or hybrid procedure (5.6%). Median operation time was 92 min, median length of stay was 2 days. Surgical revisions were necessary in 3.4%. Median overall procedural workload using the NASA raw score was 39.5/100, strongly correlating with operative time. CONCLUSION: Hernia dissection and defect closure in laparoscopic eTEP are particularly technically challenging and associated with a high surgeon workload. Due to its technical complexity and frequent intraoperative adverse events, laparoscopic eTEP should be adopted within structured training pathways and appropriate case selection.