Totally Extra-Peritoneal (TEP) Laparoscopic Ventral Hernia and Incisional Hernia Repair: Reverse TEP(R-TEP)

Laparoscopic ventral hernia and incisional hernia repair has now become a standard technique. However, the disadvantage of this technique is the contact between the mesh and tacks and the viscera. The objective of this article is to describe totally laparoscopic extra-peritoneal ventral and incisional hernia repair to avoid this problem. We developed a reverse Dulucq’s technique for lapa-roscopic inguinal hernia repair described as Reverse Totally Laparoscopic ExtraPeritoneal ventral hernia repair (R-TEP).

Laparoscopicventralhernia; Reverse TEP

Laparoscopic ventral hernia and incisional hernia repair has now become a standardtechnique.However, contact between meshand tacks with the viscera is a disadvantage of this technique. Dulucqet al. [1] describes totally laparoscopic extra-peritoneal inguinal hernia repair (Dulucq’s technique). Based on this in-novative method, we describe a modified Dulucq’s technique to apply to ventral and incisional hernia repair proposing the to-tally laparoscopicextra-peritonealventralandincisionalherniarepairto avoid this problem [1].We describe a reverse Dulucq’s technique called Reverse Totally Laparoscopic Extra-Peritoneal ventral hernia repair (R-TEP).

4. TechniqueThe patient is in French position with legs apart and an ex-tended left arm. The shoulder protection and bladder catheter are positioned. The operative field is prepared by leaving all of the abdomenuncoveredfromthepubicregiontotheribs.Theoperator is between thelegs, andthehelpingoperatorisindif-ferentlyto the rightortotheleft.TheVeressneedleisplacedinthesuprapubic region in Bogros’ Space insufflating CO2 of only 10 mmHg. Hasson positioning in thesupra pubic region with an open or blind technique changing CO2 to 12 mmHg. It is ac-cessed in Bogros’ space already insufflated with 30 degrees optic. Smooth mediumlateraldissection onlywith thesameopticde-vicein orderto place two more trocars in the right and in the left inguinal region. The dissection continues beyond Douglas’ arch

5. Discussion The Reverse TEP is a technique that is inspired by Dulucq’s technique for extra peritoneal inguinal hernia repair. However, it is not from the umbilicus to the inguinal region and pubic region but extends from these areas to the ribs. It permits wall dissection without passing through the abdomen. In this way, we avoid injuries of the intestinal loop, bleeding of the omentum in the hernia, postoperative ileus and unnecessary viscerolysis passing from an untrained space. Another significant advantage is that of having a totally extra peritoneal mesh, which avoids mesh and tack contact with the viscera. Mesh and tacks are totally covered by peritoneum. Thedisadvantages are represented bythedifficultyin learn-ing the technique and finding the right Bogros’ space, the increase in operating times and above all, by the difficulty in dissecting the region of the hernia defect if this one is not automatically reduced with CO2. The risks are intestinal lesions and intra peritoneal invisible bleeding. For these reasons, we recommend an advanced skill in laparoscopic techniques and to have previously performed Trans-Abdominal-Pre-Peritoneal hernia repair (TAPP) or Totally Extra-Peritoneal (TEP) in order to be extremely familiar with the extra peritoneal space [2,3]. We recommend the help of a tutor and an abdominal trocar placement to follow extra peritoneal dissection for the beginners in this technique. Reverse TEP is an excellent method that needs further comparative tests.

References 1. Meyer A, Dulucq JL, MahajnaA. Laparoscopic totally extraperitoneal hernioplasty with nonfixation of three-dimensional mesh: Dulucq’s technique. Arq Bras Cir Dig. 2013; 26(1): 59 - 61

2. Bamba1 R, Wolfson J, Bhanot P. A Laparoscopic extraperitoneal ap-proach to an incisional and inguinal hernia repair: A Case Report. SM Surgery Journal. 2015; 1(1): 1001.

3. Wake BL, McCormack K, Fraser C, Vale L, Perez J, Grant A. Two dif-ferent laparoscopic techniques for repairing a hernia in the groin. The Cochrane Library. 2005.

Danilo C. Totally Extra-Peritoneal (TEP) Laparoscopic Ventral Hernia and Incisional Hernia Repair: Reverse TEP(R-TEP). Annals of Clinical and Medical Case Reports 2019.