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Aim The eTEP approach for ventral hernia is becoming a promising treatment option for obese patients as a scheduled procedure, in specialized high volumen centers. Is it feasible also in emergency surgey? M&M We present a case of a 73 year old female patient with an incarcerated ventral hernia, presenting itself as a bowel obstruction on the early postoperative period after a prosthetic knee surgery. The patient had a previous midline laparotomy (Cesarian), two onlay ventral hernia repairs, and body mass index of 32. The CT imaging findings revealed a bowel obstruction close to incarcerated ventral hernia. We performed an endoscopic retromuscular sac exploration, reduced the incarcerated hernia, ruled out bowel damage, completed intraperitoneal adhesiolysis and followed through with an eTEP procedure, closing anterior and posterior rectus sheat running sutures. We began closing supraumbilical abdominal wall using inferior trocars and finished closing infraumbilical part using superior trocars. Then we introduced and deployed a polypropylene 26×15 cm mesh. No mesh fixation or drains were used. Results Bowel obstruction was solved after surgery. Oral liquids intake started on the second postoperative day. Despite of knee pain, sedentary lifestyle, depressive disorder and obesity, the patient started walking, assisted by physiotherapist also on second postoperative day. Intravenous naproxen and acetaminophen were used as painkillers. Discharged on postoperative day 10 because of knee wound celulitis. Conclusions eTEP approach seams feasible also in emergency surgeries in specialized centers.

This is a case presentation of a preperitoneal repair of a bilateral Spigelian hernia and a recurrent left inguinal hernia. A 71 year old male patient was admitted in the Emergency department after a 3 hour right quadrant acute pain. On his medical record he had an anterior left inguinal repair (Lichtenstein) 6 months before. The physical examination revealed a bulge on the right lower quadrant. The Spigelian hernia was incarcerated but easily reduced. The CT scan findings include a bilateral Spigelian hernia (bowel content), a small umbilical and a left inguinal omental hernia. The patient did not suffer any other incarceration episodes before the surgery, programmed 10 days later. We present the video of the surgical TEP repair, a preperitoneal access, triple hernia reduction, double 15×20cm polypropilene tailored mesh placement. The patient was discharged on the second postoperative day, and had an uneventful recovery with no recurrence after 3 months followup.

Aim Laparoscopic total extraperitoneal approach (TEP) is a widely recognised treatment for hernia repair. As a reference group in minimally invasive hernia repair, with more than 1200 TEP cases performed in the last 5 years, and with more than 25 years of experience, we want to share our TEP systematisation in 10 steps, as we teach in our international courses. Material and Methods We describe the technique in 10 simple steps, attaching small video-clips to illustrate each one. Results Demostration of the 10 TEP steps: Conclusions Together with proctoring, this systematic way of teaching TEP technique allows a safer and shorter learning curve, by providing a series of simple steps to follow and repeat.

Aim Laparoscopic totally extraperitoneal (TEP) repair of inguinal hernia can be technically challenging. The learning curve is long, unless you have supervision and systematisation of the procedure. After learning curve of TEP is achieved, it is time to broaden horizons, and repair ventral hernias using the extended totally extraperitoneal laparoscopic technique (ETEP). The purpose of this paper is to describe the key points and pitfalls in the ETEP learning curve, coming from the expertise of TEP hernia repair. Material and Methods After overcoming the learning curve of laparoscopic TEP inguinal hernia repair, with more than 110 consecutives procedures performed in an experienced centre, and having reduced operative times and maintaining a minimal complication rate, I start my learning curve of ETEP with supervision and systematisation of the technique. We will move from the key points already known from the TEP learning curve, identifying similarities to the more complex points of ETEP learning curve. Results and conclusions The extrapolable key points from TEP are: The critical points, which need enhanced surveillance, are: It is important to emphasise that this technique requires patience and proctoring.

We present the clinical case of a 58 year old patient with a left subcostal incisional hernia, years after an emergent aortic thrombectomy and aortobifemoral bypass. The physical examination revealed a lateral subcostal bulge near the anterior axillary line. CT findings showed a left lateral 5 cm defect without significant muscular atrophy. An endoscopic ipsilateral transversus abdominal release (TAR) and preperitoneal mesh repair was successfully performed. 1: Port placement. We used one 10 mm port and two 5 mm ports in a left near-midline position. 2: Retrorectal and Bogros space dissection. Locating the arcuate line and opening the posterior rectus sheath we then proceeded with the left transversus abdominal release (in a down to up direction). 3: Hernia dissection. After the hernial sac is identified we opened it to explore the peritoneal cavity and release the possible adhesions if encountered. 4: Full space dissection. Once the defect dissection is finished, we fully completed the TAR in order to achieve a satisfactory space for the mesh placement. 5: Defect closure. We performed a two-plane resorbable continuous barbed suture. 6: Mesh placement. We measured the surgical space in order to insert a tailored mesh and lay it without fixation or drain. Clinical outcome: The patient is discharged on postoperative day 1 and took acetaminophen 3 times daily for 48 hours, due to good pain control. On the first postoperative followup (10 days) the patient had resumed usual activities, driving and was already back to work. He was advised to avoid heavy efforts.

Aim The purpose of the study is to analyze whether a previous medical history of lower abdominal surgery (or pelvic radiotherapy) involves a different postoperative outcome in TEP inguinal repairs. Material & Methods We performed a retrospective analysis of 1252 TEP procedures included from 2015 to 2019 at our institution. We compared the short-term intraoperative difficulties and the postoperative outcome in patients with and without previous lower abdominal surgeries. The postoperative data collected included variables such as comorbidities, hernia classification, intraoperative complications, rate of conversion to open surgery, admission status, postoperative follow-up, chronic pain, and hernia recurrence. We defined a “surgical success” dichotomous variable only for patients in an outpatient setting. It included cases with no complications during surgery, no need for conversión, and no chronic pain, no readmission or recurrence during followup. Results Out of the 1252 TEP procedures, 250 (19%) had previous lower abdominal surgery (or pelvic radiotherapy). At the time of applying the “surgical success” variable we found a statistically significant difference in the conversion to open surgery rate between both groups (0.7% versus 5.6% p value 0.005). No differences were found in complications, readmissions, chronic pain, functional recovery or recurrence rates. Conclusions TEP procedure in patients with previous lower abdominal surgery showed a higher rate of conversion to open surgery compared to previously non operated patientes. The fact of having previous surgery did not imply however a worse postoperative outcome after a TEP procedure.