Complications after enhanced-view totally extraperitoneal ventral hernia repair: An augmented evidence review integrating Abdominal Core Health Quality Collaborative registry outcomes, published evidence, and expert-priority polling

Abstract

Background

Enhanced-view totally extraperitoneal (eTEP) repair enables minimally invasive retromuscular and preperitoneal mesh placement while avoiding contact with intraperitoneal mesh. Reported complication rates differ depending on the definition and data source. We developed an augmented evidence review (AER) to address "What are the key tips to avoid common eTEP complications?"

Methods

The AER integrated 3 evidence streams: (i) empiric, the Abdominal Core Health Quality Collaborative, including elective adult eTEP-consistent ventral hernia repairs with 30-day follow-up (N = 8434; October 2013 to December 2025); (ii) social media, an International Hernia Collaboration (IHC) expert poll ranking prioritized eTEP hazards; and (iii) artificial intelligence (AI), OpenEvidence synthesis with manual source verification. Outcomes were classified as consequential (readmission, reoperation, surgical site infection [SSI], surgical site occurrence or infection [SSO/I], and prolonged length of stay [LOS]) vs nonconsequential/burden. Adjusted analyses compared transeversus abdominis release (TAR) vs no-TAR and robotic vs laparoscopic approaches.

Results

The incidence of 30-day outcomes was as follows: readmission, 2.4%; reoperation, 1.3%; SSI, 1.1%; any SSO, 9.5%; and SSO/I, 1.8%. Defect width showed strong graded associations with adverse outcomes, with SSO/I rising from 0.5% (<4 cm) to 4.6% (>10 cm). In adjusted models, TAR was strongly associated with a LOS ≥ 2 days (odds ratio, 3.51; 95% CI, 2.96–4.16) but not with readmission or reoperation. After adjustment, the laparoscopic approach was not independently associated with the primary consequential endpoints compared with the robotic approach. The IHC poll prioritized posterior-layer disruption with intraparietal or internal herniation (29%), crossover-related linea alba injury (27%), midline bulging (23%), and trocar-exit bleeding (18%). OpenEvidence synthesis identified plane discipline and posterior-layer closure as primary prevention strategies, which were concordant with IHC poll priorities.

Conclusion

In a large cohort of elective minimally invasive surgery extraperitoneal sublay procedures, 30-day high-consequence events were uncommon, and most postoperative issues reflected nonprocedural wound occurrences. Defect width is the primary risk factor. Registry outcomes, expert polling, and AI synthesis all support eTEP as a safe and effective approach when performed with disciplined plane control and mechanism-based prevention strategies.