Endoscopic Retromuscular(Sublay)/preperitoneal Approach Repair Of Lateral Abdominal Wall Hernia Diseases:A Clinical Research

Objective:The borders of the lateral area are defined as the costal margin cranially,iliac region caudally,the lateral margin of the rectus sheath medially and erector spinae laterally.It can be divided into two groups:primary lumbar hernias which typically arise in two areas of weakness,the superior triangle and inferior triangle;another group is acquired lateral(lumbar)hernias which are usually due to previous surgery,as well as trauma or viral infection.According to the EHS classification,the lateral hernias can be subdivided into 4 types(L1:subcostal hernia;L2:flank hernia;L3:iliac hernia;L4:lumbar hernia).Open surgery is once the gold standard of the treatment,but it bears massive trauma and pose the risk of high recurrence and severe postoperative pain.Referring to laparoscopic surgery,it is mainly repaired by intra-peritoneal onlay mesh repair(IPOM)which requires an expensive anti-adhesive coated mesh and traumatic fixation of tackers,then pose the risks of intra-abdominal foreign body related complications and refractory postoperative pain.The goal of our study is to explore appropriate minimally invasive techniques in the aim of creating a sufficient retromuscular/preperitoneal space,then accommodating a non-coated ordinary polypropylene mesh for hernia defect reinforcement repair.Finally,the aforementioned technical pitfalls could be eliminated.Methods:We perform a standardized and reproducible retroperitoneal totally endoscopic prosthetic(R-TEP)repair technique for primary lumbar hernias.However,for acquired lateral abdominal wall hernia,we perform a TES repair.This TES technique was previously developed for midline defects repair and now is naturally combined with a transverse abdominis release(TAR)maneuver to create a sufficient retromuscular/preperitoneal space that can accommodate a giant prosthetic mesh,to reinforcement repair of the hernia defect.Results:1.Ten adult patients with primary lumbar hernias underwent R-TEP repair from February 2019 to July 2020.Among them,nine patients had a primary superior lumbar hernia and one had a primary diffuse lumbar hernia.All operations were successfully performed without serious intraoperative complications.The mean defect area was 6.4±2.8 cm2,and the mean mesh area was 144.6 cm2(range 130-180 cm2).The average operative time(skin to skin)was 49.0± 5.7 min(range 40-60 min),and intraoperative bleeding was minimal.The mean visual analog pain scale score(VAS)at rest on the first postoperative day was 2.2(range 2-3).The average length of postoperative stay(LOS)was 1.5 days(range 1-2 days).No serious postoperative complications occurred.No recurrence,chronic pain,or mesh infection occurred during a mean follow-up period of 7.5 months.2.From December 2018 to November 2020,24 consecutive patients with an acquired lateral hernia underwent TES repair,including 8 cases of L1 hernia,3 cases of L2,6 cases of L3 and 7 cases of L4.The operations were successful in all but one patient who required a minor open conversion because of dense intestinal adhesion.The mean defect width was 6.7±3.9 cm.The mean defect area was 78.0±102.4 cm2(range 4-500 cm2).The mean mesh size used was 330.2±165.4 cm2(range 108-900 cm2).The mean operative time was 170.2±73.8 min(range,60-360 min).The mean visual analog scale score for pain at rest on the first day was 2.5(range 1-4).The average postoperative stay was 3.4 days(range 2-7 days).No serious complications(Dindo-Clavien Grade 2-4)were seen within a mean follow-up period of 13.3 months.Conclusions:Depending on the type of hernias,an appropriate R-TEP or TES repair could be adopted.These techniques revealed to be safe and reliable.The first results are promising,anti-adhesive coated meshes and fixation tackers are not required,making this a cost-effective procedure that is worthy of recommendation.In summary,one could utilizes a proper minimally invasive technique to break down the boundaries of each abdominal wall compartments,connecting the space which was previous separated,building a sufficient retromuscular/preperitoneal space that can accommodate a giant prosthetic mesh,to reinforcement repair hernia defect.We conclude this is the concept of totally visceral sac separation(TVS).