Hernia | 2021
Comment to: “Endoscopic retromuscular technique (eTEP) vs conventional laparoscopic ventral or incisional hernia repair with defect closure (IPOM\u2009+) for midline hernias: a case–control study”—a longer follow-up would have been useful
Abstract
We read with great interest the article by Bellido Luque J [1] recently published in Hernia. In a case–control study, the authors reported that the endoscopic retromuscular technique (eTEP) shows significant lower postoperative pain and better functional recovery and cosmesis than the laparoscopic intraperitoneal mesh placement with defect closure (IPOM +) approach, without differences in intra/postoperative complications (except seroma rate) or recurrences. We agree with this conclusion in the present study during the relative short-term follow-up (15.9 ± 4.5 months in the eTEP group). However, we have a few comments on this study, as well as on the indication and on several technical aspects of this eTEP technique in ventral hernia repair. First, both the eTEP and the IPOM approaches are laparoscopic procedures and they both have the benefit of being minimally invasive. The differences between these two approaches lie in two aspects: (1) the mesh position is either intraperitoneal or extraperitoneal and (2) the division or not of the posterior rectus sheaths. Therefore, the advantage of the eTEP technique is clearly based on the sacrifice of the bilateral division of the posterior rectus sheath. During the eTEP procedure, a bilateral division/damage of the posterior sheath as long as 25 cm is necessary even for small hernias. As Sharma pointed out, after a posterior sheath division, the subsequent repair of the divided posterior rectus sheath with suture is a poor substitute to native functionally designed collagen tissue in vivo [2]. Furthermore, in the short-term follow-up of the present study, the subsequent abdominal wall function could not be easily measured, and the function could not be reflected [1]. Second, concerning the mesh position and postoperative complications, a mesh placed intraperitoneally has always been a big concern; however, recently, a large registry-based, propensity score-matched study including 9907 patients, comparing two different techniques of laparoscopic IPOM and open sublay, showed that a mesh placed in the intraperitoneal position was not associated with increased postoperative mesh-related complications [3]. Based on the potential advantages and disadvantages of these two techniques, the long-term follow-up of the new technique would have been useful to gather more information. Third, concerning the technical aspects of the eTEP procedure, in the present study, the hernias were less than 8 cm wide [1] and the authors state that “the radius of the mesh was four times the radius of the defect”; therefore, in some large hernias (e.g., defect size of 7–8 cm), a large mesh of 30 cm was needed. Is this large size really necessary? And how could this mesh be placed in the retroperitoneal space without laparoscopic Transversus Abdominis Release (l-TAR)? Or were there no cases needing a TAR approach due to small defect or small sized-mesh? We wonder, because the TAR technique is not only useful, but also necessary in some large hernias when a mesh is placed in the preperitoneal space [4, 5]. Even though we felt the need to discuss these few points, we congratulate Bellido Luque J et al. for their study, and we hope that their contribution, together with others, will be useful to other surgeons who are interested in this new technique.