Robotic Retromuscular eTEP Repair of Ventral Incisional Hernias and Diastasis

A 55-year-old female has a history of multiple abdominal surgeries including laparoscopic cholecystectomy, appendectomy, laparoscopic hysterectomy, tubal ligations, and multiple cesarean sections through a low transverse (Pfannensteil) incision. Cross-sectional imaging demonstrated multiple midline hernias ranging from 1–3 cm, a rectus diastasis measuring 4 cm wide, and intraparietal cesarean section (C-section) hernia (Zanellato Type II). She underwent a robotic retromuscular extended totally extraperitoneal (eTEP) repair wherein her ventral midline hernias, rectus diastasis, and intraparietal hernia were all repaired and reinforced with wide mesh overlap. This case highlights the strengths of an eTEP approach, the decision making behind considering all of a patient’s abdominal wall pathology, and the considerations with intraparietal hernias post C-section.

Hernia repair; robotic surgery; rectus diastasis.

Ventral hernias are a common surgical problem in the United States. There are roughly 1.3 million people living with a ventral hernia, and abdominal wall hernias account for almost US$3.2 billion in yearly healthcare expenditures.^1,2 Recurrent hernia surgeries account for a substantial number of these cases, and reducing recurrence rates by 1% alone would result in US$32 million dollars per year.² Given this substantial burden, there have been major advances in surgical techniques in hernia repair to (1) prevent hernia recurrence; and (2) minimize length of stay using minimally invasive techniques.

In the 2012, Dr. Jorge Daes first described the extended totally extraperitoneal (eTEP) technique for inguinal hernia repair, which took advantage of the retrorectus plane as a potential space that could be accessed and extended into the preperitoneal plane for extraperitoneal inguinal hernia repairs.³ Later, this technique was further expanded to address ventral hernias, wherein the left and right retrorectus planes would be joined through a midline preperitoneal crossover.⁴ This technique achieves many of the principles of a high quality hernia repair including (1) an extraperitoneal pocket for mesh placement with wide mesh overlap; (2) musculofascial release for fascial advancement and primary defect closure; and (3) minimally invasive approach.⁵ When appropriately employed, eTEP retromuscular repairs have a long-term recurrence rate of < 1%.⁶

In addition to new techniques, attention has been directed to abdominal wall pathologies that were previously minimally regarded or largely unknown. Rectus diastasis is a condition wherein there is separation of the rectus muscles leading to a widening and thinning of the linea alba. Whereas it was previously considered a cosmetic condition without functional consequences for a patient, contemporary abdominal wall specialists now understand that diastasis can lead to significant abdominal core dysfunction causing back pain, bowel and bladder dysfunction, and altered respiratory dynamics.⁷ Most importantly, concurrent rectus diastasis is a substantial risk factor for hernia recurrence if not addressed during the index hernia repair.⁸ Another pathology that has been recently highlighted is the development of intraparietal hernias after low transverse (Pfannenstiel) incisions used commonly in cesarean sections (C-sections). Obstetricians often do not close the peritoneum during C-section closures, which leaves a potential for the herniation of viscera between the peritoneum, rectus abdominis, and overlying anterior fascia.⁹ These intraparietal hernias that develop after C-sections have recently been described in the Zanellato Classification system, which describes the contents and degree of herniation between and beyond the peritoneum and rectus muscles. While more research is still required into the incidence and functional consequences of these types of hernias, it is clear that these hernias are encountered and need to be taken into account during extraperitoneal ventral hernia repairs.  

When approaching a patient with a ventral hernia, it is therefore important to complete a comprehensive history, physical exam, and imaging review to uncover all their abdominal wall pathologies, and choose a technique that, within reason, can address all of these issues holistically with a goal of minimizing recurrence and maximizing patient satisfaction. In this video, we demonstrate a robotic eTEP retromuscular repair of a patient with ventral hernias, rectus diastasis, and a C-section hernia. We highlight the decision making during the evaluation of this patient and the strengths of an eTEP repair in addressing all these pathologies.

The patient is an otherwise healthy and active 54-year-old female who has a history of multiple abdominal surgeries including a laparoscopic appendectomy, laparoscopic tubal ligation, laparoscopic hysterectomy, laparoscopic cholecystectomy, a laparoscopic lysis of adhesions for an adhesive bowel obstruction, and two C-sections. She presented to our clinic with multiple small bulges at and below her umbilicus, as well as a large bulge in her upper midline. She experienced poor core strength and instability, causing back pain and discomfort with exercises. She was a non-smoker, did not have diabetes, and her body mass index (BMI) was < 30. She had tried physical therapy and core strengthening to address her rectus diastasis, but this has not been successful.

Her physical exam demonstrates a 1-cm primary umbilical hernia, a 2-cm infraumbilical hernia, and a 4-cm wide rectus diastasis. She had multiple laparoscopic scars and a Pfannenstiel scar.

CT scan of the abdomen demonstrated (1) an M3 1-cm umbilical hernia; (2) an M3, 2-cm infraumbilical hernia; (3) a large midline rectus diastasis, 4 cm wide; and (4) an M4 intraparietal hernia with a 2.5-cm separation of the rectus and fat herniation between the rectus muscles.

Ventral hernias generally get larger with time if left untreated. Rectus diastases that appear after pregnancy generally regress and can improve with physical therapy. However, if they persist despite physical therapy, rectus diastases can cause bulging, loss of core stability, and lead to back pack, pelvic dysfunction, and diaphragmatic dysfunction. Little is known about the natural history of C-section hernias.

Small ventral hernias alone can be treated with tissue-based repairs or mesh-based repairs. Mesh can be placed in an onlay, sublay, or underlay position with open or minimally invasive techniques, each with its own risks and benefits.

Rectus diastasis can be treated conservatively with observation alone or core strengthening with physical therapy. If surgery is required, surgical techniques include plication alone or plication with mesh reinforcement, and can be done in a minimally invasive or open fashion.

C-section hernias are typically treated with mesh reinforcement in a preperitoneal, retromuscular fashion either with minimally invasive or open techniques.

In the instance where all three of these processes coexist and should be addressed at the same time, options are limited. Repair options include (1) primary repair alone with plication of the diastasis and primary closure of the ventral and C-section hernias; (2) plication of the diastasis and closure of the hernias with underlay intraperitoneal mesh reinforcement; or (3) plication of the diastasis and closure of the hernias with preperitoneal/retromuscular mesh reinforcement. The third option is presented in this video and has the ideal risk benefit profile for minimizing recurrence, wound morbidity, visceral adhesions/complications, and other hernia complications.

The goals of treatment here are to (1) close the ventral hernias to prevent visceral herniation; (2) restore abdominal core function by restoring the integrity of the abdominal cylinder; (3) provide wide permanent reinforcement with mesh to prevent recurrence; and (4) take a minimally invasive approach to minimize wound morbidity.

The standard eTEP retrorectus approach is ideal for patients who have multiple abdominal pathologies along the midline abdomen that need to be addressed with wide mesh overlap. The eTEP technique is a technically challenging approach and practitioners should have a basic mastery of open complex hernia repairs before attempting minimally invasive retromuscular repairs. Patients who have had previous violation of the retrorectus plane are not ideal candidates for this approach as the entry and dissection in this plane becomes challenging.

In this video, we demonstrate a robotic eTEP retromuscular repair for midline ventral hernias, rectus diastasis, and a C-section hernia. The patient was discharged the same day. She had no postoperative complications and has not had a recurrence after 1 year of follow-up.

This present video demonstrates the importance of a thoughtful and detailed preoperative assessment of a patient’s abdominal wall complaints. Repairing this patient’s diastasis alone, midline hernias alone, or her C-section alone would have led to much different repair choices. The operator would run into problems, either with recurrence down the road or challenges with performing a limited scope repair (i.e., a robotic transabdominal preperitoneal, TAPP, ventral hernia repair is challenging with C-section hernias present). 

The utility of the eTEP technique is well demonstrated in this video. Using a minimally invasive approach, we were able to achieve excellent mesh overlap, closure of the midline without significant tension, and recruit enough lateral peritoneum to close the posterior peritoneum defect associated with the C-section hernia. Moreover, the eTEP gives an excellent view of the entire linea alba, which often hides occult or nascent hernias, particularly along the upper midline diastasis. It is important to recognize that the eTEP technique has evolved from a minimally invasive retrorectus repair, and is now thought of more as one of many entry techniques for performing extraperitoneal hernia repairs. It can now be performed from a precostal approach or suprapubic approach, extended into the transversus abdominis release planes, used to cross into the preperitoneal plan contralaterally (Carolina’s cross-over), or keep entirely preperitoneal from entry (preperitoneal, extended totally extraperitoneal repair or PeTEP).⁵

The eTEP is just one of many techniques where a rectus diastasis can be addressed. Other minimally invasive diastasis repairs include transabdominal preperitoneal approach (TAPP), transabdominal retromuscular approach (TARM), or subcutaneous approaches (subcutaneous onlay laparoscopic approach or SCOLA; or preaponeurotic endoscopic repair or REPA). The indications and contraindications to these techniques are beyond the scope of the present video, but each have their own considerations with regards to the size of the diastasis, rectus width, concomitant pathology, and patient comorbidities. 

One of the challenges of C-section hernias is the limited understanding of them including incidence, natural history, and attributable symptoms. Non-closure of the peritoneum was extensively studied in the obstetrics and gynecology literature and shown to lead to short closure times and less early post-op morbidity without substantially affecting adhesions.⁹ However, long-term outcomes including the incidence of intraparietal or full-thickness hernias, abdominal discomfort, bulging, or otherwise has not been well studied. For hernia surgeons, C-section hernias are often encountered once you are performing an extraperitoneal repair for a hernia in proximity. However, it is still unclear whether one should design a surgical plan to fix incidental C-section hernias. Further research is required.

• 5-mm disposable optical trocar
• 5-mm, 0-degree laparoscope
• 30 x 30 cm reduced-weight macroporous polypropylene mesh

Dr. Fung has the following disclosures: speaker for Becton-Dickinson.

Dr. Pauli has the following disclosures: speaker for Becton-Dickinson and Medtronic, consultant for Boston Scientific Corp., Actuated Biomedical, Inc., Cook Biotech, Neptune Medical, Surgimatix, Noah Medical, Allergan, Intuitive Surgical, ERBE, Integra, Steris, Vicarious Surgical, Telabio and Mesh Suture Inc. He has royalties in UpToDate, Inc. and Springer and financial interests in IHC, Inc., Cranial Devices Inc, Actuated Medica.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.