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. Weltzaweltz@aahs.org

Igor Belyansky

ibelyansky@aahs.org

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

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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