A novel approach using the enhanced-view totally extraperitoneal(eTEP) technique for laparoscopic retromuscular hernia repair
Igor Belyansky1 • Jorge Daes2,3 • Victor Gheorghe Radu4 • Ramana Balasubramanian5 •
H. Reza Zahiri6 • Adam S. Weltz6 • Udai S. Sibia6 • Adrian Park6,7 •
Yuri Novitsky8
Received: 21 March 2017 / Accepted: 22 August 2017 / Published online: 15 September 2017
� Springer Science+Business Media, LLC 2017
Abstract
Background The enhanced-view totally extraperitoneal
(eTEP) technique has been previously described for
Laparoscopic Inguinal Hernia Repair. We present a novel
application of the eTEP access technique for the repair of
ventral and incisional hernias.
Methods Retrospective review of consecutive laparoscopic
retromuscular hernia repair cases utilizing the eTEP access
approach from five hernia centers between August 2015
and October 2016 was conducted. Patient demographics,
hernia characteristics, operative details, perioperative
complications, and quality of life outcomes utilizing the
Carolina’s Comfort Scale (CCS) were included in our data
analysis.
Results Seventy-nine patients with mean age of 54.9 years,
mean BMI of 31.1 kg/m2, and median ASA of 2.0 were
included in this analysis. Thirty-four percent of patients
had a prior ventral or incisional hernia repair. Average
mesh area of 634.4 cm2 was used for an average defect
area of 132.1 cm2. Mean operative time, blood loss, and
length of hospital stay were 218.9 min, 52.6 mL, and
1.8 days, respectively. There was one conversion to
intraperitoneal mesh placement and one conversion to open
retromuscular mesh placement. Postoperative complica-
tions consisted of seroma (n = 2) and trocar site dehis-
cence (n = 1). Comparison of mean pre- and postoperative
CCS scores found significant improvements in pain (68%,
p\ 0.007) and movement limitations (87%, p\ 0.004) at6-month follow-up. There were no readmissions within
30 days and one hernia recurrence at mean follow-up of
332 ± 122 days.
Conclusions Our initial multicenter evaluation of the eTEP
access technique for ventral and incisional hernias has
found the approach feasible and effective. This novel
approach offers flexible port set-up optimal for laparo-
scopic closure of defects, along with wide mesh coverage
in the retromuscular space with minimal transfascial
fixation.
Keywords Ventral and incisional hernia repair �Abdominal wall reconstruction � Retromuscular meshplacement � Transversus abdominis release � Enhanced-view totally extraperitoneal technique
Presented at the SAGES 2017 Annual Meeting, March 22–25, 2017,
Houston, Texas.
& Adam S. [email protected]
Igor Belyansky
1 Department of Surgery, Anne Arundel Medical Center, 2000
Medical Parkway, Belcher Pavilion, Suite 106, Annapolis,
MD 21401, USA
2 Department of Surgery, Clinica Bautista and Clinica
Portoazul, Barranquilla, Colombia
3 Minimally Invasive Surgery Department, Clinica Portoazul,
Barranquilla, Colombia
4 Surgical Department Life Memorial Hospital, Bucharest,
Romania
5 Department of Comprehensive Hernia Surgery, Medica
Superspecialty Hospital, Kolkata, India
6 Department of Surgery, Anne Arundel Medical Center,
Annapolis, MD, USA
7 Johns Hopkins School of Medicine, Baltimore, MD, USA
8 Department of Surgery, University Hospital Cleveland
Medical Center, Cleveland, OH, USA
123
Surg Endosc (2018) 32:1525–1532
https://doi.org/10.1007/s00464-017-5840-2
and Other Interventional Techniques
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Prior to 1993, ventral hernias were repaired exclusively
through open approaches. Pioneers including LeBlanc,
Booth, Heniford, Park, Ramshaw, and Voeller subse-
quently described the laparoscopic approach to ventral
hernia repair (LVHR), where a barrier mesh is placed in the
intraperitoneal underlay position [1, 2]. This repair relies
on wide mesh overlap, penetrating fixation with tacks and
transabdominal stitches without defect closure. Soon the
advantages of LVHR over the open approach became
obvious, most notably, reduced wound complication rates
and faster recovery. With further experience, some sur-
geons began incorporating primary closure of the defect in
LVHR [3]. The decision of whether to close the primary
fascial defect at the time of hernia repair may still be
debatable. However, defect closure is gaining support due
to presumed restoration of the anatomy, physiology, and
cosmesis of the abdominal wall [4, 5].
While the LVHR repair has lasted more than two
decades, it has not been without limitations. These
include rare but serious complications such as adhesive
bowel obstruction, mesh erosion, and enterocutaneous
fistula from direct contact between the mesh and
intraperitoneal viscera [6, 7]. To address this, the trans-
abdominal preperitoneal (TAPP) approach to ventral and
incisional hernias has been described [8]. This technique
has the difficulty of elevating and closing thin peritoneal
flaps, a laparoscopic technique that is challenging to
reproduce even in the most experienced hands. Belyansky
et al. recently described laparoscopic Transversus Abdo-
minis Release (l-TAR), a reconstructive technique
restoring the linea alba with retromuscular mesh rein-
forcement. Similarly to TAPP repairs, l-TAR prevents
direct mesh contact with viscera [9]. Despite early suc-
cess, we found the intracorporeal closure of the defects
challenging with traditional port placement lateral to
linea semilunaris.
The enhanced-view totally extraperitoneal (eTEP)
technique has been previously described for laparoscopic
inguinal hernia repair [10, 11]. The salient features of this
technique are rapid and facile creation of extraperitoneal
domain, large operative space, flexible port set-up, and
improved tolerance of pneumoperitoneum. It was designed
to facilitate learning and mastering of the procedure for the
novel surgeon and for complex cases such as large
inguinoscrotal, sliding, or incarcerated inguinal hernias, as
well as obese or post-bariatric patients and those with
previous pelvic surgeries or a short distance between
umbilicus and pubic tubercle [10, 11].
This study aims to present a novel application of the
Enhanced-view Totally Extraperitoenal access technique
for the repair of ventral and incisional hernias.
Methods
Study design
Institutional review board approval was obtained to per-
form a retrospective review of electronic medical records
in order to identify all patients who underwent laparoscopic
eTEP repair of their ventral or incisional abdominal wall
hernias between August 2015 and October 2016. Five
hernia centers participated in this study: Anne Arundel
Medical Center in Annapolis, Maryland (n = 50);
University Hospital Cleveland Medical Center in Cleve-
land, Ohio (n = 8); Clinica Bautista and Clinica Portoazul
in Colombia, South America (n = 4); Life Memorial
Hospital in Bucharest, Romania (n = 6); and Medica
Superspecialty Hospital, Kolkata, India (n = 11).
Patient demographics, hernia characteristics, and peri-
operative and postoperative data were analyzed. Main
outcomes measured included perioperative complications,
length of stay, 30-day readmissions, and hernia recur-
rences. Wound and systemic complications included ser-
oma, hematoma, cellulitis, abscess, skin necrosis, wound
dehiscence and mesh infection, ileus ([5 days post-sur-gery), urinary tract infection (UTI), acute renal insuffi-
ciency (ARI), venous thromboembolism (VTE), respiratory
complications (atelectasis, pneumonia, etc.), myocardial
infarction (MI), and congestive heart failure (CHF), as well
as perioperative complications.
CCS surveys were routinely prospectively collected for
hernia patients at Anne Arundel Medical Center. The other
centers had not incorporated CCS surveys into their prac-
tice. Subset analysis was performed to assess quality of life
(QOL) outcomes utilizing the Carolinas Comfort Scale
(CCS) for all patients from Anne Arundel Medical Center
[12]. The CCS is a validated hernia-specific survey that
utilizes a 0–5 scale to assess pain, mesh sensation, and
limitations in mobility. A significant score in any of the
three measured CCS parameters has been previously
defined as C2 out of 5 [13] and was used for our analysis.
Preoperative workup/patient selection
The preoperative workup for all hernia patients is stan-
dardized at our centers beginning with a detailed history,
physical examination, and biochemical studies to assess
their baseline health. Specific to this patient population,
defect location and size, prior or current wound compli-
cations, presence of ostomy, excess skin, and contour
abnormalities are part of the physical exam and are con-
sidered in selection of the proper operative approach for the
patient.
1526 Surg Endosc (2018) 32:1525–1532
123
Given frequent incidence of recurrent hernias, special
effort and attention is paid to review of prior medical and
surgical records to gain a thorough understanding of their
previous interventions, anatomy, and the presence of any
mesh or fixation devices. All patients undergo a computed
tomography (CT) study of their abdomen and pelvis for
preoperative hernia measurement and operative planning.
Patients with previous incision extending from xiphoid
process to the pubic bone are a relative contraindication to
eTEP access technique and are typically addressed with
transabdominal laparoscopic approach. Those with loss of
domain and dystrophic or ulcerated skin are also consid-
ered to have a relative contraindication for eTEP access
approach. Patients with active mesh infection and fistula
presence have an absolute contraindication to eTEP and
MIS intervention. All other patients are considered candi-
dates for the eTEP access retromuscular approach with or
without TAR.
Operative technique
After induction of general anesthesia and intubation, Foley
catheter is routinely placed and bilateral upper extremities
are tucked at patient’s sides. The OR table is flexed as
demonstrated in Fig. 1. The eTEP access approach relies
on initiating the dissection in one of the retrorectus spaces
and then crossing over to contralateral retrorectus space,
thus connecting the two spaces. The decision where to
crossover as well as initial port set-up depends on the
defect location and described in the sections that follow.
Upper midline defects
When dealing with upper midline defects, we prefer to
perform the crossover below the level of the umbilicus,
developing preperitoneal and retromuscular space that has
not been previously violated. Figure 2 demonstrates the
port position for upper midline defects. The first incision is
made just 2 cm bellow a horizontal line drawn through
umbilicus and just medial to linea semilunaris. The anterior
rectus sheath is identified and incised sharply. Single-site
balloon dissector is used to develop the retrorectus space in
cephalad and caudal directions. It is critical to avoid over-
inflation which may rupture the linea semilunaris and
consequently injure rectus abdominis muscle. Once the
space of Retzius is developed, ports #2 and 3 are placed
under direct vision in the lower abdomen. A 30-degree
scope is placed through port #3 and we then proceed with
the retrorectus dissection heading in the cephalad direction
(Fig. 3). Bilateral posterior rectus sheathes are identified
and released from caudal to cephalad direction thus con-
necting retrorectus spaces (Fig. 4).
Fig. 1 Proper flexion of OR table
Fig. 2 Port position for upper midline defects
Fig. 3 Dissection heading in cephalad direction
Surg Endosc (2018) 32:1525–1532 1527
123
Lower midline defects
For a right-handed surgeon, we found that lower midline
defects are easier to address by initiating the dissection in
the upper portion of left retrorectus space. Figure 5
demonstrates the typical port position that we chose to use
for this approach. Balloon dissector is used at port 1
position to develop left retrorectus space, under direct
vision ports 2 is placed into the developed space, and port 3
can be optional. Blunt dissection in the left retrorectus
space is performed in caudal direction and pubis is iden-
tified. Considering that upper midline has not been previ-
ously violated, above the level of umbilicus, medial aspect
of left posterior rectus sheath is incised and preperitoneal
space is entered, just superficial to Falciform ligament
(Fig. 6). Right posterior rectus sheath is identified and
medial aspect of it is incised and released from cephalad to
caudal direction (Fig. 7) followed by blunt dissection in the
right retrorectus space. Port 4 is then placed under direct
vision through the upper aspect of right rectus abdominis
muscle; this then becomes the camera port. The retrorectus
dissection is carried out in the caudal direction completing
bilateral release of posterior rectus sheathes. When
encountering the hernia sac, we try to sharply dissect the
distal attachments of the sac, thus mobilizing it down.
Alternatively, the sac can be sharply entered and laparo-
scopic adhesiolysis is performed as needed.
For more challenging defects that require large mesh
placement, the TAR procedure is added [9, 14]. The
incorporation of TAR was found beneficial in cases with
wide ([10 cm) defect, tension on the posterior layer, nar-row retrorectus space (\5 cm), or when dealing with a
Fig. 4 Connecting retrorectus spaces
Fig. 5 Port placement for lower midline defects
Fig. 6 Medial aspect of left posterior rectus sheath is incised andpreperitoneal space is entered, just superficial to Falciform ligament
Fig. 7 Right posterior rectus sheath is identified and medial aspect ofit is incised and released from cephalad to caudal direction
1528 Surg Endosc (2018) 32:1525–1532
123
poorly compliant abdominal wall. Any defects in posterior
layer are closed with 2-0 absorbable suture. The abdominal
wall defect is primarily closed using 0 barbed suture in
running fashion, while pneumoperitoneum is dropped to
8 mm Hg (Fig. 8).
Finally, the developed retrorectus/preperitoneal space is
measured for appropriate mesh size selection. Our prefer-
ence is medium weight macroporous polypropylene mesh,
deployed through our 12-mm trocar. Mesh is positioned to
widely cover the developed space. Mesh can be secured
with several transfascial sutures, tacks, or 10 mL fibrin
sealant glue. In our more recent experience, some of us
have migrated to no fixation. Pneumoperitoneum is
released under direct vision assuring that the mesh is laying
flat between the posterior and anterior layers.
Results
Seventy-nine patients (n = 34 Male, n = 45 Female) with
mean age 54.9 years, mean BMI 31.1 kg/m2, and median
ASA score 2.0 were included in this review. Thirty-four
percent of patients had prior ventral or incisional hernia
repairs. The most frequent comorbidities in our patients
were hypertension (46%) and diabetes (19%). Table 1 is a
complete summary of relevant patient demographics.
Primary operations performed were eTEP access Rives
Stoppa Repair n = 38 (48%) and eTEP access TAR
n = 41 (52%). A variety of mesh fixation techniques were
utilized, with fibrin glue used in the majority of cases
(75%) to secure the mesh to the posterior fascial layer.
Mean operative time, intraoperative blood loss, and LOS
for the entire cohort were 218.9 min, 52.6 mL, and
1.8 days, respectively (Table 2). Mean defect width, area,
and LOS were also broken down for both Rives Stoppa and
TAR cases (Table 3).
Table 4 lists complications. Intraoperative complica-
tions included one muscle rupture during initial balloon
dissection requiring conversion to LVHR procedure and
Fig. 8 Abdominal wall defect is primarily closed using 0 barbedsuture in running fashion under conditions of reduced
pneumoperitoneum
Table 1 Patient demographics
Variable eTEP approach
N 79
Age (years) 54.9 ± 13.9
Body mass index (kg/m2) 31.1 ± 6.0
ASA score 2.3 ± 0.6
Prior incisional hernia repair 34%
Gender (male/female) 43%/57%
Hypertension 46.0%
Diabetes mellitus 19.0%
Hyperlipidemia 14.0%
Active smoker 6.0%
Coronary artery disease 4.0%
COPD 4.0%
History of stroke/CVA 3.0%
History of myocardial infarction 3.0%
Congestive heart failure 3.0%
Immunocompromised 1.0%
Alcoholism 1.0%
ASA American Society for Anesthesiologists
Table 2 Perioperative data
Variable eTEP approach
Surgical procedure
Rives Stoppa n = 38 (48.0%)
TAR n = 41 (52.0%)
Mean surgical time (mins) 218.9 ± 111.2
Mean estimated blood loss (mL) 52.6 ± 39.5
Mean defect area (cm2) 132.1 ± 134.2
Mean mesh area (cm2) 634.4 ± 319.7
Median defect area (cm2) 100
Mean LOS (days) 1.8 ± 1.8
Mesh fixation
None 7.0%
Fibrin glue alone 75.0%
Tacks 1.0%
Suture 9.0%
Fibrin glue and suture 4.0%
Fibrin glue and tacks 1.0%
Suture and tacks 3.0%
Surg Endosc (2018) 32:1525–1532 1529
123
one conversion to open transversus abdominis release to
facilitate excision of a suspicious bone fragment in a
patient with a recurrent incisional hernia and prior history
of bowel obstructions.
The incidence of 30-day wound-related complications
was 3.8%. There were no non-wound-related complica-
tions. Two patients presented with retromuscular seromas
within 30 days of their index operation, one managed with
observation and one required percutaneous drainage by
interventional radiology. Another patient presented with
wound dehiscence of a trocar site requiring local wound
care. There were no readmissions or reoperations at a mean
follow-up of 322 ± 122 days. There was one recurrence in
a TAR patient that was diagnosed at 1-year follow-up.
More than half of our patients reported pain (58.5%) and
movement limitations (46.3%) prior to surgery according
to CCS data analysis. Comparison of mean pre- and post-
operative CCS scores (Table 5) found significant
improvements in pain (60%, p\ 0.002) and movementlimitations (66%, p\ 0.004) at 1-month follow-up. At6-month follow-up, 68% of patients reported complete
resolution of their pain (p\ 0.007) and 87% had completeresolution of their movement limitations (p\ 0.004). Nopatients reported significant mesh sensation at their
6-month follow-up visit.
Discussion
While continuing to confer the benefits of minimally
invasive surgery to patients, the eTEP access VHR tech-
nique offers use of retromuscular space and allows for
complete exclusion of mesh from the peritoneal cavity,
thus avoiding direct contact between mesh and visceral
contents. Furthermore, penetrating transfascial fixation has
been minimized as wide-size mesh is sandwiched in
between posterior and anterior layers of the abdominal
wall. Primary defect closure has been routinely performed
in this case series and has been facilitated by the medial
trocar placement achieved with eTEP access.
As anticipated, our study supports the protective role
of the minimally invasive techniques as compared to
operative morbidity seen with traditional open hernia
repair. It is difficult to determine the actual number of
cases that would have undergone open Rives Stoppa or
TAR procedures in the past prior to eTEP access
implementation in our practice. Specifically considering
that the average width of our eTEP access TAR cases
Table 3 RS and TAR
Variable eTEP approach
RS mean defect width (cm) 6.2 ± 3.7
RS mean defect area (cm2) 70.1 ± 43.3
TAR mean defect width (cm) 11.1 ± 7.6
TAR mean defect area (cm2) 205.3 ± 164.6
Mean LOS (days)—RS 1.0 ± 0.7
Mean LOS (days)—TAR 2.7 ± 1.3
RS Rives Stoppa, TAR transversus abdominis release, LOS length of
stay
Table 4 Complications
Variable eTEP approach
Wound-related complications n = 3 (3.8%)
Seroma 2.5%
Wound dehiscence 1.3%
Surgical site infection 0.0%
Hematoma 0.0%
Deep abscess 0.0%
Non-wound-related complications n = 0 (0%)
Stroke 0.0%
Pneumonia 0.0%
UTI 0.0%
Myocardial infarction 0.0%
CHF 0.0%
Intraoperative complications n = 2 (2.5%)
30-day readmissions n = 0%
Hernia recurrence n = 1 (1.3%)
Table 5 Quality of Life survey information using the Carolina Comfort Scale
Variable Before surgery % symptomatic at 1 month p value % symptomatic at 6 months p value
N 41 (51.9%) 38 (48.1%) 16 (20.3%)
Sensation of mesh –
Pain 58.5% 23.7% 0.002 18.0% 0.007
Movement limitation 46.3% 15.8% 0.004 6.3% 0.004
1530 Surg Endosc (2018) 32:1525–1532
123
was 11.7 cm, historically in this subgroup we would have
reconstructed the linea alba via an open approach. Studies
from other institutions report complication rates of
20–30% after open AWR surgery [15, 16]; these findings
have been confirmed at our center as well [17]. These
invasive methods would translate to greater LOS and data
from our institutions show open AWR patients spent a
mean of 5 days in the hospital [17]. Several other large
series show hospital length of stay for complex open
ventral and incisional hernia repair patients ranging from
5 to 10 days [18, 19]. The mean LOS for our eTEP
patients was 1.8 days; when broken down by Rives
Stoppa technique and TAR, our mean LOS was 1.0 and
2.7 days, respectively, highlighting benefits for patients
and the current cost-containment environment of health
care for both of these procedures.
Chronic pain and movement limitations are among the
main complaints of hernia patients, promoting a cycle of
inactivity, weight gain, and progressive loss of function.
Six months after eTEP access VHR, most patients in our
series showed significant relief from pain and movement
limitation. Utilizing the same methodology, Colavita et al.
have previously used CCS to report on QOL outcomes in
patients that underwent ventral hernia repairs. The mean
defect area and percent of patients with prior ventral hernia
repair in their study were 89.4 cm2 and 21.7%, respec-
tively. They reported that 57% of their patients had clini-
cally significant pain prior to surgery, and at 4 weeks after
LVHR, 56% of patients continued to report clinically sig-
nificant symptoms. After 6 months of follow-up, that
number went down to 25% [13]. In our cohort of patients,
we observed similar degree of symptomatic patients in the
preoperative setting, with 58.5% of patients having sig-
nificant pain prior to surgical intervention. Following our
cohort at 1 months and at 6 months, only 23.7 and 18.8%
of patients, respectively, reported some pain symptoms.
Although there is lack of direct patient comparison
between the two study groups, we believe that we are
observing less pain in the immediate postoperative period
because mesh placement in the retromuscular space has
enabled us to minimize the aggressive use of penetrating
fixation. The relationship of penetrating fixation to chronic
pain is well established [20–24]. When performing a
retromuscular repair, Weltz et al. have recently described
that transfascial fixation of mesh is 12-fold more likely to
result in chronic pain at 6 months as compared to non-
penetrating fixation with Tisseel fibrin glue [17]. Perhaps
one of the biggest benefits of the eTEP access approach is
the use of retromuscular space for placement of large
macroporous mesh, thus nearly eliminating penetrating
fixation in our cohort.
The multi-institutional nature of our study supports that
eTEP access VHR is a reproducible technique among
experienced laparoscopic surgeons. As discussed in our
methodology, five centers participated in this study from
four different continents across the globe. The sharing of
expert insight, imaging, and educational videos among
centers has afforded a unique partnership that has aimed to
not only rapidly advance the science and surgical care of
complex hernia patients but also to improve their out-
comes. While these observations are experiential not
experimental at this point, they do offer potential pathways
to expedite safe technical adoption of this approach.
There are several important limitations to this study
that bear emphasis. This is a retrospective review of 79
patients that have undergone an eTEP access laparoscopic
approach to AWR. This review did not perform any direct
comparison of our eTEP cohort to our historic laparo-
scopic VHR or open AWR patients. Thus, it is difficult to
determine how many of the patients in our cohort would
have undergone lap VHR or open approach if operated
prior to introduction of eTEP access technique to our
practice. Also consideration should be given that not all
complex hernia cases can be addressed with eTEP access
technique and certainly as described in our methods sec-
tion some complex cases are still addressed via open
approach. Thus, based on this early experience it is dif-
ficult to truly scale the importance of this minimally
invasive reconstructive approach. In addition, inherent to
all studies that rely on any retrospective data collection is
the possibility of recall bias. We attempted to counter this
by collecting all of our CCS scores prospectively at
specific time intervals to gain a more comprehensive
perspective of outcomes for our patients. However,
another limitation of our study was that only one center
(AAMC) participated in QOL assessment which limits the
generalizability of outcomes in this study. Finally, this
case series is work representative of surgeons with
advanced laparoscopic training and results may not be
translatable to the general population of hernia surgeons.
To determine the true applicability, reproducibility, and
benefits of eTEP access in AWR patients, randomized
multicenter prospective studies are needed.
Conclusions
Our initial multicenter evaluation of the eTEP access
technique for ventral and incisional hernias demonstrated
the approach to be safe and feasible when performed in
ventral and incisional hernia cases. This novel approach
offers an extraperitoneal suture closure of defects, wide
sublay mesh coverage with minimal penetrating fixation
during the repair of ventral and incisional hernias. While
long-term follow-up is needed to confirm applicability and
efficacy of eTEP access VHR, we believe this approach
Surg Endosc (2018) 32:1525–1532 1531
123
offers an important addition to armamentarium of hernia
surgeons.
Financial support No financial support was received for this study
Compliance with ethical standards
Disclosures Dr. Belyansky is a consultant for Lifecell corporation,Intuitive Surgical, Covidien Medtronic, and Bard Davol. Dr. Daes is a
consultant for Winner, Medtronic, and Bard. Dr. Novitsky is a con-
sultant for Cooper Surgical, Intuitive Surgical, and Bard. Dr. Park is a
consultant for Stryker. Dr’s Zahiri, Weltz, Sibia, Balasubramanian,
and Radu declare that they have no relevant conflicts of interest or
financial ties to disclose.
Ethical approval All authors certify that they accept responsibilityas an author and have contributed to the concept, data gathering,
analysis, manuscript drafting, and give their final approval.
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http://dx.doi.org/10.1002/bjs.10268http://dx.doi.org/10.1002/bjs.10268http://dx.doi.org/10.1089/lap.2008.0212
A novel approach using the enhanced-view totally extraperitoneal (eTEP) technique for laparoscopic retromuscular hernia repairAbstractBackgroundMethodsResultsConclusions
MethodsStudy designPreoperative workup/patient selectionOperative techniqueUpper midline defectsLower midline defects
ResultsDiscussionConclusionsReferences