Down-to-Top Enhanced View-Totally Extraperitoneal Repair for Upper Midline Ventral Hernia Repair: Initial Experience and Surgical Technique.

Abstract

Purpose: The extended totally extraperitoneal (eTEP) approach is a novel repair method for ventral hernias. This study evaluated the feasibility and initial outcomes of a down-to-top eTEP repair technique for upper midline ventral hernias, addressing the challenges of subxiphoid midline crossing.

Materials and methods: The clinical data of 14 patients who underwent down-to-top eTEP surgery for upper midline ventral hernias at Seoul National University Hospital between January 2018 and December 2022 were retrospectively studied. Patients with M1 or M2 components according to the European Hernia Society classification were included.

Results: The mean age was 55.9 ± 13.6 years, and mean BMI was 25.9 ± 3.5 kg/m2. The mean defect area was 41.1 ± 22.5 cm2. Five patients underwent transversus abdominis release (TAR). Mean operative time was 178.3 ± 50.3 minutes in the non-TAR group and 288 ± 89.7 minutes in the TAR group. Mean hospital stay was comparable between non-TAR (5.2 ± 2.5 d) and TAR (4.8 ± 1.3 d) groups. Mean postoperative pain scores (VAS) were 3.8 on day one and 2.6 on day 3. The hernia sac was preserved in 5 patients (33.3%). No major postoperative complications occurred. No hernia recurrence was observed during the mean follow-up of 20.4 months.

Conclusion: The down-to-top eTEP approach for upper midline ventral hernia repair appears feasible and safe. This technique can be performed with TAR when necessary and is effective for repairing defects in all cases. Hernia sac preservation may reduce the need for TAR. This approach may be particularly beneficial when subxiphoid midline crossing is challenging.