EXTENDED TOTALLY EXTRAPERITONEAL (eTEP) ASSOCIATED TO TRANSVERSUS ABDOMINIS RELEASE (TAR) IN THE MULTI-RECURRENCE VENTRAL HERNIA

Abstract Aim Minimal invasive surgery of the abdominal wall has evolved in the last years. Endoscopic extraperitoneal approach shows a good vision in the reparation of ventral hernias. Complex hernias can be repaired in this way with a low rate of recurrence and postoperative pain. Our objective is to show the advantages of this endoscopic approach to solve the multi-recurrence ventral hernia. Methods A male 58 years old who underwent 3 prior surgeries of a umbilicus hernia (herniorraphy, hernioplasty with polipropilene (PPL) onlay mesh, onphalectomy and new hernioplasty with PPL mesh) is examinated for a new recurrence M2 M3 M4 W3 (following EHS Classification) and a diastasis associated. A Computerized Tomography (CT) is performed to plan the procedure showing a 10 cm width defect. Botuline toxin were applied (Ibarra´s technique) 30 days before planning a totally endoscopic approach (eTEP). We used three ports in the left side of the abdomen (optic 12 mm and BTT 11 mm and 5 mm in the border of the left rectus muscle. A Spacemaker is used to dissect the retrorectus space. Cross over is performed to dissect the contralateral retrorectus space. Three ports are positioned in the right side. A TAR is performed in both sides (Down to up). Posterior fascia was sutured using a 3.0 barbed suture. Anterior fascia was sutured using a barbed suture 0 to close the defect. A PVDF mesh (40 × 30 cm) was positioned using an autramatic fixation with cianocrilate. Conclusion eTEP is a safe procedure with good results in middle line hernias, even in those cases with large defects. It is possible to associate this technique to prehabilitation using Toxine to get a higher overlap mesh/defect ratio with the mesh. More studies are needed to reach more conclusions.