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Enhanced-view Totally Extraperitoneal Approach (eTEP) Access in Hernia Repair
Abordaje extraperitoneal de vista extendida (eTEP) para la reparación de hernias
Jorge Daes
Departamento de Cirugía de Mínima Invasión, Clínica Porto Azul, Barranquilla, Colombia
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Balibrea, Josep M. Badia, Inés Rubio Pérez, Esteban Martín Antona, Estíbaliz Álvarez Peña, Sandra García Botella, Mario Álvarez Gallego, Elena Martín Pérez, Sagrario Martínez Cortijo, Isabel Pascual Miguelañez, Lola Pérez Díaz, Jose Luis Ramos Rodriguez, Eloy Espin Basany, Raquel Sánchez Santos, Victoriano Soria Aledo, Ruth López Barrachina, Salvador Morales-Conde" "autores" => array:17 [ 0 => array:2 [ "nombre" => "Jose M." "apellidos" => "Balibrea" ] 1 => array:2 [ "nombre" => "Josep M." 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These maneuvers include remote access of the defect, creation of a large extraperitoneal space, and flexible placement of surgical trocars. This is complemented with the excision of the natural limits of the space, such as the arch of the transverse abdominal muscle, medial edge of the posterior lamina of the rectus abdominis muscle and the posterior fascia of the internal oblique muscle and transverse abdominal muscle. Most of these maneuvers are initiated medial to the semilunar line, although it is possible to access the extraperitoneal space directly lateral to the semilunar line (lateral eTEP), to repair a lateral lumbar hernia or to perform a high triple neurotomy.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The eTEP approach is more a concept than a technique. It has provided us a better understanding and use of the extraperitoneal space beyond the limits of the Retzius and Bogros spaces with which we are so familiar, rendering it unlimited once its divisions are dissected.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Origin of the eTEP Concept</span><p id="par0015" class="elsevierStylePara elsevierViewall">The most frequently used minimally-invasive technique to access the extraperitoneal space is perhaps the TEP for inguinal hernia repair, which has remained unchanged for almost 25 years.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Inspired by its limitations, including a reduced surgical space, restrictions for trocar placement, low tolerance to accidental pneumoperitoneum, poor ergonomics and the difficulty to teach and learn the technique, we conceived the enhanced-view totally extraperitoneal approach, or eTEP. The first procedures using the eTEP technique for inguinal hernia repair were carried out in 2009, and the first publications appeared in 2011.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1–4</span></a> Since then, it has been progressively standardized.</p><p id="par0025" class="elsevierStylePara elsevierViewall">A short time later, we described direct access using the eTEP approach outside the semilunar line for the repair of lumbar hernias.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> In describing the crossover maneuver, Igor Belyansky implemented the Rives-Stoppa eTEP technique and the eTEP-Transversus Abdominis Muscle Release, which have been evaluated in several hospitals in various countries around the world.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> Marc Miserez also deserves special mention for his description of an extraperitoneal endoscopic approach for the repair of small ventral hernias, without primary closure of the defect, in 15 patients in 2002.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> Although the technique did not obtain much relevance or diffusion, it was ahead of its time.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Advantages of the eTEP Approach</span><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The general advantages</span> of this approach are those of any extraperitoneal surgery, including:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0035" class="elsevierStylePara elsevierViewall">Reduced risk of intestinal injury</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0040" class="elsevierStylePara elsevierViewall">Less need for visceral retraction</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0045" class="elsevierStylePara elsevierViewall">Less frequent postoperative ileus</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0050" class="elsevierStylePara elsevierViewall">Fewer intraperitoneal adhesions and associated complications</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0055" class="elsevierStylePara elsevierViewall">Fewer adverse hemodynamic effects than with the intraperitoneal approach</p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">Advantages in <span class="elsevierStyleItalic">inguinal hernia repair</span></p><p id="par0065" class="elsevierStylePara elsevierViewall">The advantages of the eTEP approach for inguinal hernia repair include:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0070" class="elsevierStylePara elsevierViewall">Quick and easy creation of a large surgical workspace</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0075" class="elsevierStylePara elsevierViewall">Flexibility in the placement of surgical ports, which can be adapted to many circumstances and body types</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0080" class="elsevierStylePara elsevierViewall">Tolerance to accidental pneumoperitoneum</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">•</span><p id="par0085" class="elsevierStylePara elsevierViewall">Good ergonomics</p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">The importance of these advantages lies in their facilitating the steps necessary to achieve a critical view of the myopectineal orifice. These steps, which should be implemented in any minimally invasive technique for the repair of inguinal hernias, have been shown to reduce complications and recurrence, and allow the technique to be standardized.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The eTEP approach is indicated when the surgeon's training and experience, hospital conditions and resources, hernia type, and patient characteristics are suitable. Our group routinely performs the eTEP approach in most inguinal hernias. It is especially indicated when the navel-pubis distance is short, in obese or post-bariatric patients, when there is a history of previous pelvic surgeries, and in inguinoscrotal, sliding or incarcerated hernias. The technical details of the eTEP approach for inguinal hernia repair, including pros and cons of the procedure, have been described in other publications.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Advantages in the repair of <span class="elsevierStyleItalic">ventral and lumbar hernias</span></p><p id="par0105" class="elsevierStylePara elsevierViewall">The main advantage of the eTEP approach for the repair of ventral and lumbar hernias is that it allows all the current principles for the reconstruction of the abdominal wall to be applied. These include: primary closure of the defect and the reconstruction of the <span class="elsevierStyleItalic">linea alba</span> under physiological stress; extensive prosthetic reinforcement of the visceral sac (Stoppa); placement of a conventional mesh (without a surface allowing contact with the viscera) in a retromuscular position (reducing the complications associated with its exposure to intra-abdominal content, with better integration, less need for fixation, and at a lower cost); and finally, the minimally invasive approach, when indicated.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">It is reasonable to initiate the experience with small primary central hernias associated with diastasis of the rectus muscles or with pelvic hernias located on the midline. With experience, it is possible to continue with more complex hernias, such as incisional or lateral hernias (LI–L4).</p><p id="par0115" class="elsevierStylePara elsevierViewall">There are a multitude of possible maneuver combinations for the eTEP approach for ventral hernia repair, which go beyond the scope of this publication. The results of studies carried out in several countries show that the technique is safe, effective and has great advantages for patient quality of life.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> However, it is a laborious technique that requires detailed knowledge of the anatomy of the extraperitoneal space, including its natural divisions and its neurovascular structures, as well as and formal training, which should ideally include practice on fresh corpses, under a mentor.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> Although rare, complications inherent to this approach have been described, such as internal hernia due to dehiscence of the posterior closure, injury to the linea alba during crossover, and large bruises.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Although with common surgical steps, the different maneuvers of the eTEP technique vary for inguinal, ventral and/or lumbar hernias.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> The pending tasks are to refine the indications of the procedure, evaluate its reproducibility, its aesthetic results and the possible overuse of the subsequent separation of components-TAR.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Definition of the eTEP Approach" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Origin of the eTEP Concept" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Advantages of the eTEP Approach" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Daes J. Abordaje extraperitoneal de vista extendida (eTEP) para la reparación de hernias. Cir Esp. 2020;98:249–250.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Extended-view totally extraperitoneal (e-TEP) technique for inguinal hernia repair" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 367 | 8 | 375 |
| 2024 September | 672 | 31 | 703 |
| 2024 August | 640 | 48 | 688 |
| 2024 July | 621 | 39 | 660 |
| 2024 June | 361 | 26 | 387 |
| 2024 May | 484 | 30 | 514 |
| 2024 April | 476 | 23 | 499 |
| 2024 March | 585 | 34 | 619 |
| 2024 February | 586 | 32 | 618 |
| 2024 January | 617 | 29 | 646 |
| 2023 December | 367 | 7 | 374 |
| 2023 November | 276 | 25 | 301 |
| 2023 October | 383 | 29 | 412 |
| 2023 September | 293 | 17 | 310 |
| 2023 August | 236 | 22 | 258 |
| 2023 July | 179 | 12 | 191 |
| 2023 June | 114 | 13 | 127 |
| 2023 May | 135 | 14 | 149 |
| 2023 April | 130 | 25 | 155 |
| 2023 March | 135 | 20 | 155 |
| 2023 February | 92 | 14 | 106 |
| 2023 January | 80 | 24 | 104 |
| 2022 December | 115 | 14 | 129 |
| 2022 November | 78 | 15 | 93 |
| 2022 October | 57 | 17 | 74 |
| 2022 September | 63 | 16 | 79 |
| 2022 August | 87 | 7 | 94 |
| 2022 July | 43 | 14 | 57 |
| 2022 June | 42 | 15 | 57 |
| 2022 May | 58 | 23 | 81 |
| 2022 April | 70 | 14 | 84 |
| 2022 March | 75 | 20 | 95 |
| 2022 February | 45 | 9 | 54 |
| 2022 January | 82 | 9 | 91 |
| 2021 December | 49 | 32 | 81 |
| 2021 November | 50 | 21 | 71 |
| 2021 October | 58 | 19 | 77 |
| 2021 September | 72 | 25 | 97 |
| 2021 August | 59 | 18 | 77 |
| 2021 July | 50 | 7 | 57 |
| 2021 June | 56 | 15 | 71 |
| 2021 May | 25 | 11 | 36 |
| 2021 March | 0 | 22 | 22 |
| 2021 February | 0 | 28 | 28 |
| 2021 January | 1 | 25 | 26 |
| 2020 December | 0 | 12 | 12 |
| 2020 November | 0 | 14 | 14 |
| 2020 October | 3 | 9 | 12 |
| 2020 September | 12 | 19 | 31 |
| 2020 August | 10 | 13 | 23 |
| 2020 June | 2 | 2 | 4 |
| 2020 May | 0 | 2 | 2 |
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