Hernia Sac Preservation for Prevention of Transversus Abdominis Release in Laparoscopic Extended-Totally Extra Peritoneal Repair of Ventral Hernia: A Minimalistic Solution for a Formidable Challenge
Authors: Balachandran Premkumar , Tirunelveli Sivagnanam Subbiah , Swathika V. C. 
Published: November 2022

Background: Ventral hernia repair has always been an extensive and challenging surgery. The laparoscopic extended—Totally Extraperitoneal (E-TEP) technique of ventral hernia repair is gaining popularity due to the advantage of placing a large mesh in the retro rectus plane. When done through a Laparoscopic approach, the difficulty of the procedure is compounded by multiple factors such as obtaining retro muscular access, maintaining the retro muscular plane, crossing over to the contralateral retro muscular plane without entering intraperitoneally, suturing in a limited space, and manipulation of a large mesh in a constricted space for placement. In cases of large midline incisional hernias, dense adhesions to the previous surgical scar are often present. Despite having extremely satisfying outcomes, the aforementioned factors make the laparoscopic extended—total extraperitoneal repair of large midline ventral and incisional hernias an exceptionally challenging procedure. A tension-free midline approximation is the benchmark of ventral/incisional hernia surgery. In certain cases, this can be difficult to achieve due to multiple factors. For the purpose of attaining tension-free midline closure, component separation techniques (CST) have been explored and implemented. Of these, the posterior component separation technique of Transversus Abdominis Release (TAR) has gained popularity for reducing the tension of posterior rectus sheath during posterior midline closure in retro muscular repairs by adding a few centimetres of medial advancement. The main pitfall of TAR is its technical complexity, which may result in morbid complications when implemented incorrectly. Performing TAR laparoscopically compounds the complexity manyfold. Hence, to obviate the necessity to perform Laparoscopic TAR in cases of Laparoscopic E-TEP repair of large midline ventral and incisional hernias, we present that the technique of hernial sac preservation should be pre-emptively carried for all Laparoscopic ETEP repairs so that the necessity of performing TAR in select cases is reduced by aiding in the addition of final crucial centimetres of lengthening to the posterior rectus sheath for achieving posterior midline closure. This aids in the success of the procedure by preventing an additional complex procedure of TAR from being performed in an already challenging hernia repair technique of Laparoscopic E-TEP repair.

Methods: We hereby report three cases of Ventral hernia repair in which Laparoscopic E-TEP repair was carried out and Hernial sac preservation technique was implemented successfully. Midline closure of the posterior rectus sheath was attained under reduced tension and a medium-weight macroporous polypropylene mesh was placed in the retro-rectus plane after measurement of the potential space. Patients were discharged uneventfully.

Results: Patients were followed up for up to 6 months postoperatively and were found to have no complications.

Conclusion: In Laparoscopic E-TEP repair of midline ventral hernias, preservation of the hernial sac along with the posterior rectus sheath might aid in the prevention of performing a TAR in selected cases where posterior layer tension is present. Hernia sac preservation thereby aids in reducing operative time and preventing potential morbid complications.