Robotic Preperitoneal eTEP Repair for Umbilical Hernia and Diastasis

Robotic extraperitoneal approaches have expanded the possibilities of minimally invasive abdominal wall reconstruction. The suprapubic preperitoneal eTEP (PeTEP) technique offers an alternative for selected patients with small-to-medium midline hernias, with or without rectus diastasis, in whom preservation of the retrorectus plane is desirable. This article describes the application of PeTEP in a 58-year-old male with a 3-cm primary umbilical hernia and a 5-cm rectus diastasis, using a suprapubic robotic extraperitoneal approach to achieve functional midline reconstruction while maintaining the integrity of the retrorectus space. The procedure includes pretransversalis access, development of the preperitoneal and pretransversalis planes, midline restoration, and placement of a preperitoneal polypropylene mesh. This technique avoids posterior sheath division, neurovascular bundle manipulation, and retromuscular dissection, thereby reducing potential morbidity in selected patients. This case illustrates the feasibility of PeTEP in a carefully selected patient. The authors do not propose this approach as a replacement for open or transabdominal techniques, but rather as an additional option within a broader reconstructive spectrum.

Preperitoneal eTEP; PeTEP; robotic hernia repair; umbilical hernia; diastasis recti; extraperitoneal access; abdominal wall reconstruction; pretransversalis plane; minimally invasive surgery.

Extraperitoneal access surgery has undergone significant refinement in the last decade. Since Daes described the eTEP approach for inguinal hernias in 2012, enhanced visualization of the extraperitoneal planes has facilitated a global shift toward anatomical, tension-free abdominal wall reconstruction.¹

eTEP Rives–Stoppa has emerged as a reliable and reproducible method for addressing midline hernias, providing excellent biomechanical reinforcement by allowing retromuscular mesh placement—widely considered the optimal anatomical plane for durable integration.^2,3 Although powerful, this approach requires posterior sheath opening and navigation near neurovascular bundles, steps that may be excessive in patients with small midline defects or isolated rectus diastasis.

To address this, transabdominal preperitoneal (TAPP) ventral hernia repairs have gained popularity. These procedures rely on peritoneal flap creation and transabdominal access but face technical challenges in areas where the peritoneum is thin.^4,5 Robotic platforms facilitate this dissection but do not preserve the retrorectus plane.

PeTEP builds on extraperitoneal principles to create a functional reconstruction while fully preserving the retromuscular space.

A 58-year-old male (BMI 34) with a history of well-controlled hypertension and no prior abdominal surgery presented with progressive mid-abdominal bulging and occasional discomfort. Over the preceding year, he noted worsening core instability and low back pain, attributing this to changes in posture. He denied gastrointestinal symptoms or obstructive signs.

Preoperative laboratory evaluation was normal for age and sex.

Examination revealed a visible bulge at the umbilicus and a reducible 3 × 3 cm umbilical hernia. A supraumbilical bulge became evident during a sit-up maneuver. Core instability and diastasis were suspected clinically.

Bedside ultrasound confirmed a 3-cm umbilical hernia containing omentum and a 5-cm rectus diastasis.

Primary umbilical hernias may enlarge over time and can lead to discomfort, functional impairment, and progressive weakening of the linea alba. When associated with rectus diastasis, abdominal wall dysfunction may worsen, leading to posture-related symptoms and back pain.

Treatment options included:

1. Open repair with or without mesh: avoided due to increased morbidity and limited functional reconstruction.
2. Conventional laparoscopic IPOM repair: although intraperitoneal mesh placement with contemporary coated meshes remains an acceptable and widely used alternative with generally favorable outcomes, extraperitoneal mesh positioning has gained increasing interest due to the theoretical advantages related to avoidance of direct visceral contact and its relation to higher incidence of bowel obstruction due to adhesions.^6,7
3. Robotic TAPP ventral hernia repair: technically feasible but requires extensive and delicate peritoneal flap creation.
4. eTEP Rives–Stoppa: reliable but would sacrifice the retrorectus plane for a defect that did not require myofascial releases.
5. Suprapubic PeTEP: allows complete midline reconstruction, preperitoneal mesh placement, and preservation of the retrorectus space.

Given the patient’s anatomy, age, absence of prior surgery, and diastasis location, PeTEP offered the best balance of reconstruction, function, and tissue preservation.

The goals were:

• Restore linea alba continuity under physiologic tension.
• Repair the umbilical hernia.
• Improve core stability and posture.
• Preserve the retrorectus space.
• Avoid unnecessary myofascial sacrifice.

Patients who may benefit the most from PeTEP include:

• Those with small-to-medium midline hernias with rectus diastasis.
• Patients without prior pelvic surgery.
• Patients in whom preserving the retrorectus space is advantageous.

Relative contraindications include:

• Extensive prior pelvic or preperitoneal surgery, which increases technical complexity.
• Large defects requiring mesh placement beyond the preperitoneal limits.
  

PeTEP represents an evolution in minimally invasive extraperitoneal abdominal wall reconstruction. By relying on the preperitoneal and pretransversalis planes rather than the retrorectus compartment, the technique reduces the need for posterior sheath division, avoids neurovascular bundle manipulation, and preserves the retromuscular space for future interventions. The zones of dissection are illustrated in Figure 1. This case illustrates the feasibility of PeTEP in a carefully selected patient. The authors do not propose this approach as a replacement for other techniques, but rather as an additional option within a broader reconstructive spectrum.

Figure 1. Zones of dissection for preperitoneal eTEP.

Understanding regional peritoneal thickness, the relationship between the falciform ligament, posterior rectus sheath, and pretransversalis plane is crucial. The ability to transition from preperitoneal to pretransversalis plane allows for wide mesh overlap comparable to retrorectus repairs.

Instead of closing tears under tension, which often enlarges them, further lateral dissection reduces traction and enables tension-free closure.

PeTEP is well suited for patients with:

• Midline defects < 4–5 cm.
• Supraumbilical diastasis.
• Low-risk anatomy for peritoneal violation.

It is less ideal for patients requiring myofascial releases or those with large incisional hernias that may also require soft tissue management such as skin redundancy, pannus, and aesthetic contour as primary concerns. In this regard open repairs will be the a valid and effective option providing both functional and cosmetic advantages.

In this case, operative time was 110 minutes. The patient was discharged the next morning and experienced no surgical-site occurrences on follow-up. Functional improvement is expected due to restoration of the linea alba and correction of the diastasis.

• Da Vinci Xi robotic platform.
• 3 (8-mm) robotic trocars.
• Robotic monopolar scissors.
• Robotic bipolar forceps.
• Robotic needle holder.
• Macroporous midweight polypropylene mesh.
• Articulated stirrups (recommended but not mandatory).

Nothing to disclose.

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.