Introduction

Incisional hernias (IH) are a common long-term complication following abdominal operations which substantially impact patient’s quality of life (QoL), along with its potentially life-threatening sequelae of bowel incarceration and necrosis requiring emergent intervention [1, 2]. Assessing the true rate of IH is difficult, nonetheless large studies and meta-analysis estimate a rate as high as 12–35% following operations with various ventral abdominal incisions up to 3 years post-operatively [3,4,5]. Hernia recurrence following IH repair with mesh, regardless of technique, is estimated at up to 30% [6]. Though primary ventral hernias (PVH) share many common characteristics with IH in terms of complications, classification, and surgical repair options, they differ by their epidemiologic distribution, pathophysiologic features, technical complexity, and short- and long-term post-operative results [7].

The minimally invasive enhanced-view Totally Extra-Peritoneal Rives-Stoppa (eTEP-RS) approach, with or without transversus abdominis release (TAR), has gained popularity as a prominent technique for undertaking complex incisional and ventral hernia repairs [8,9,10,11,12,13,14]. Although encouraging data regarding outcomes of eTEP for ventral hernia repairs, its superiority and impact on QoL compared to other approaches are contested [15].

The purpose of this study was to evaluate the impact of eTEP-RS on QoL using the European Hernia Society Quality of Life (EuraHS-QoL) score [16] and to evaluate its post-operative course and early hernia recurrence rate. Our hypothesis was that eTEP-RS significantly improves QoL with acceptable post-operative complications and early hernia recurrence rates.

Materials and methods

Following IRB approval, patients undergoing eTEP-RS were prospectively followed between 2017 and 2020 in a large volume abdominal wall reconstruction center. Inclusion criteria was comprised of consecutive patients over the age of 18 with IH, PVH, or recurrent IH. PVH (epigastric or umbilical) with a diameter larger than 4 cm were included, while hernia defects with a diameter between 2 and 4 cm were included only in situations where large diastasis-recti was identified. If a concomitant inguinal hernia was identified, it was repaired in the same retro-muscular plane. Diastasis-recti was repaired with a running 3–0 non-absorbable barbed suture. Exclusion criteria included patients with signs of infected mesh, skin necrosis, history of previous TAR, or primary ventral hernias smaller than 2 cm. Surgical technique was performed as described by Radu et al. [17]. TAR was undertaken in situations where tension precluded closure of the posterior rectus sheath (PRS). A composite mesh was used in situations where the PRS could not be approximated to the midline. Fixation with non-absorbable tacks was made only in situations of a suprapubic hernia repair and was placed just above the ileo-pubic tract bilaterally. In cases where concomitant groin hernias were present, additional meshes were placed to cover each groin independently with fixation of the meshes to the cooper’s ligament, without fixation of the retro-rectus meshes.

Data retrieved included demographics, anthropometrics, co-morbidities, previous surgical history, hernia size, type of mesh used, post-operative course, hernia recurrence, and need for secondary surgery. All patients underwent a pre-operative abdominal & pelvic CT scan as well as a history and physical exam by a senior surgeon from the abdominal wall surgery service prior to eTEP-RS and hernias were classified according to the European Hernia Society (EHS) classification [18]. Hernia recurrence was defined as disruption of the previously repaired anterior rectus fascia and confirmed via physical exam and CT scan when suspected. Active smokers were counseled on cessation. Post-operative complications were graded according to the Clavien–Dindo Classification (CD) and major complications were considered at CD ≥ 3 [19]. Post-operative pain was assessed using the visual analogue scale (VAS). QoL was assessed using the EuraHS-QOL scale prior to and at 1 year following eTEP-RS. Questionnaires were answered via telephone, email, or during clinic visit. A separate analysis of IH and PVH was also performed to reduce confounding.

Statistical analysis

Data analysis was performed using SPSS version 28 (Armonk, NY) software with two-sided significance level of α = 0.05. Descriptive statistics are presented using prevalence and percentage values for categorical variables, while continuous variables are presented with means and standard deviation, and skewed distributed variables are presented by median and range. Questionnaire group comparisons were tested using Wilcoxon signed-rank test for non-parametric comparisons of dependent samples. For illustrative purposes, data are presented as median (mean ± SD).

Results

During the study period, 61 patients met the inclusion criteria out of 116 abdominal wall operations. Age and BMI were 62 (60.4 ± 13.8) years and 29.7 (30.4 ± 6) kg/m2, respectively. There were 40 females (65%) and 21 males (35%). IH was the most common pathology (n = 40, 65%) followed by primary ventral hernia (n = 21, 35%). Of the patients undergoing IH repair, 24 patients (39%) had a recurrent hernia following a previous ventral hernia repair. Eighteen patients (30%) had type 2 diabetes and 11 patients (18%) were actively smoking (Table 1). The majority of defects were classified as EHS M2-3 and W1-2 (Table 2). Operative time was 144 (148 ± 55) min. Diastasis-recti repair was undertaken in 34 patients (55%), a concomitant inguinal hernia was repaired in 6 patients (10%) and 13 patients (21%) underwent TAR. The majority (n = 48, 79%) of patients had a large (> 30 cm) mesh placed and had a partially absorbable mesh (n = 42, 69%; Table 3). Hospital stay was 2 (2.8 ± 1.5) days and maximal VAS score during admission was 1 (2.2 ± 2.6). There were no conversions to ‘open’ operations and there were no mortalities. Pre- and post-operative EuraHS-QOL questionnaire scores were available for 46 patients (75%) and showed significant improvement in pain (7 vs. 0.5, p < 0.0001; 5 vs. 0.5, p < 0.0001; 5 vs. 1.5; p < 0.006), restrictions (median of 5 vs. 0.5, p < 0.0001; 5 vs. 0, p < 0.0001; median of 5 vs. 1, p < 0.0001, of 6.5 vs. 1.5, p < 0.0001), and cosmetic appearance (8 vs. 4, p < 0.0001; Fig. 1a). Similarly, upon breakdown of the EuraHS-QoL scale into IH and PVH, patients undergoing eTEP-RS for IH had significant improvement in all parameters (Fig. 1b). There were no significant improvements in pain during rest and pain during physical activity for patients undergoing eTEP-RS for PVH (0 vs 1, p = 0.14 and 4 vs 0, p = 0.109). The rest of the parameters for patients undergoing repair of PVH all showed significant improvement (Fig. 1c). Median follow-up time was 12 ± 9 months and hernia recurrence were found in 4 patients (6.5%). There were 4 (6.5%) patients with major post-operative complications of CD ≥ 3 requiring emergent re-operation in the immediate post-operative period (Table 4). Three patients suffered from small bowel obstruction secondary to PRS dehiscence. The first of these was a 41-year-old lady with an M3W1R1 IH which underwent eTEP-RS without TAR who complained of abdominal pain on POD1 without signs of sepsis or peritonitis. Due to non-resolving abdominal pain, she underwent an abdominal CT scan on POD 2 which showed incarcerated bowel above the dehisced PRS (Fig. 2). An emergent laparotomy was followed which showed PRS dehiscence incarcerating a loop of necrotic small bowel. She underwent mesh removal and small bowel resection with primary anastomosis. The patient had hernia recurrence upon follow-up examination. The second and third patients underwent laparoscopic revision on POD 1 did not show evidence of bowel ischemia. Both patients underwent bowel reduction, re-suturing of the PRS and a composite mesh was placed to overlap the oversewn dehisced PRS. Both patients did not show evidence of recurrence on physical exam and CT at follow-up at 21 and 29 months post-op, respectively.

Table 1 Demographics, pre-operative data
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Table 2 Hernia characteristics
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Table 3 Intra-operative characteristics
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Fig. 1
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European Hernia Society Quality of Life Score before and after enhanced-view Totally Extra-Peritoneal Ventral Hernia Repair

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Table 4 Post-operative course
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Fig. 2
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CT scan showing a pathognomonic sign of incarcerated small bowel above a dehisced posterior rectus sheath

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The fourth patient requiring emergent re-operation was a 74-year-old lady with an M3W2R1 IH repair who underwent eTEP-RS without TAR presented 5 days following discharge with abdominal pain and sepsis on POD 7. The patient underwent an emergent laparotomy and found to have right colonic perforation secondary to thermal injury. She underwent right hemicolectomy with primary anastomosis and mesh removal. The patient had hernia recurrence on follow-up examination.

Late recurrences in our study included 2 patients; the first was an M1 IH which recurred at 4 months post-op and the second was an M23L2 IH which recurred at 16 months secondary to ovarian carcinomatosis.

Clinical and radiological signs of seroma were evident in 7 patients (11%), 2 (3.2%) of which underwent drainage, both subcutaneous, one with clear serous drainage and one with a hematoma which grew Staphylococcus aureus and treated with IV antibiotics. Of the patients who presented with seroma, 5 (9.8%) had undergone a unilateral TAR during the repair and none had hernia recurrence.

Discussion

eTEP-RS is emerging as a prominent approach for treating a large spectrum of abdominal wall defects. As the field of minimally invasive abdominal wall surgery is constantly advancing, specific guidelines on the approach to treating primary, incisional and recurrent ventral hernias have yet to uniformly advocate a single technique or approach to address the variety of defects [2, 9, 20]. While initial data on eTEP-RS demonstrate several advantages over other approaches, the literature regarding its efficacy and impact on QoL is scarce. Our study aims at assessing the efficacy of treating ventral hernias of any etiology with eTEP-RS, while evaluating QoL, post-operative complications, and hernia recurrence rate. To our knowledge, this is the first study addressing QoL following eTEP-RS.

The majority of patients included in our study were overweight, females, with a previous midline abdominal operation, an EHS classification of M2-3, W1-2 and nearly 40% suffered from recurrent hernias. Our results show significant improvement in all parameters of the EuraHS-QOL scores (pain, activity, and cosmesis) for patients undergoing eTEP-RS for IH and PVH, with an acceptable post-operative course and hernia recurrence rate at a short-term follow-up. While the EuraHS-QOL of IH showed similar results to the entire population, patients undergoing eTEP-RS for PVH did not show symptomatic improvement regarding pain during rest and physical activity.

Though IH and PVH carry risks of incarceration necessitating emergent operations, many patients resort to hernia repair due to QoL nuisances. Asencio et al. reported EuraHS-QoL following a randomized-controlled trial of laparoscopic intra-peritoneal on-lay (IPOM) vs ‘open’ repair showed no difference in QoL and a 21% hernia recurrence rate in both arms at 10 years of follow-up [21]. A randomized-controlled trial comparing IPOM to “open” ventral hernia repair using the short-form 36 (SF36) to evaluate QoL by Rogmark et al. showed that utilizing the laparoscopic approach for ventral hernia repair induced significant improvement of SF36 QoL parameters [22]. A prospective cross-sectional observation study by Cherla et al. measured QoL using the modified Activity Assessment Scale (AAS) following ventral hernia repair and showed improvement in QoL scores to levels similar to the general population [23].

As initial evidence shows that eTEP-RS is a feasible repair option for a large spectrum of ventral defects with acceptable post-operative outcomes [9, 20], there are several common post-operative complications that question its utilization. The management of early technical failures, such as early recurrence and PRS dehiscence [24], each pose challenging aspects regarding management, treatment options and timing of intervention if needed. Lu et al. have compared a laparoscopic to a robotic approach for eTEP-RS (120 vs 86 patients) and showed increased operative time, increased costs and less post-operative complications utilizing the robotic approach. The authors reported 2 complete fascial dehiscence (0.8% and 1.1%), one in each group and one PRS dehiscence in the laparoscopic eTEP-RS (0.8%) [25]. In a retrospective study by Parkhar et al. examining 170 eTEP-RS, there were no PRS dehiscence and 3 (1.7%) events of recurrence at 3 months post-op [26].

As the primary advantage of an eTEP approach entails creating a large pre-peritoneal space for maneuvering large meshes [8], utilizing this approach on a large area, i.e., the entire abdominal wall, provides a potential space for seroma formation with a further risk of seroma infection and subsequent surgical site infection (SSI) occurrence. The initial experience of robotic eTEP-RS with or without TAR by Belyanski et al. of 37 patients documented 2 patients (5%) in the group undergoing TAR which developed a post-operative seroma requiring drainage by interventional radiology without documenting any surgical site infections (SSI) [20]. Parkhar et al. have reported on 171 patients undergoing eTEP-RS which 50 of them (30%) underwent TAR with a 2.3% seroma rate and 3% SSI. The authors advocate the use of close suctions drains and the use of an abdominal binder to decrease this occurrence [26]. In a retrospective review comparing eTEP-RS with eTEP-TAR by Khetan et al., the rates of seroma occurrence and SSI were 12% and 2.3%, respectively [27].

Our study represents the first quantitative assessment of QoL using the EurasHS-QoL questionnaire following an eTEP approach for ventral hernia repairs, along with our initial experience and outcomes of post-operative complications and recurrences. Our results show significant improvement in QoL for the majority of patients with an acceptable hernia recurrence rate and post-operative complications. Our findings offer some insight on expected post-operative outcomes for patients undergoing complex abdominal wall repairs. Our findings of dissimilar results of EurasHS-QoL questionnaire scores between IH and PVH further advocate that aside from their classification by the EHS and the operative approach of eTEP-RS, IH, and PVH differ in many aspects [7]. Thus, due to the extensive dissection of the eTEP-RS approach, and the possibility of lack of symptomatic improvement following its utilization, it is our opinion that this technique for small, primary, EHS class M2/M3/M4 hernias should be applied in select situations. Conversely, for large, recurrent, and EHS class M1/M5 hernias, our opinion is that the eTEP-RS should be considered as the “gold-standard” approach.

While early recurrences in our study required emergent operative intervention with mesh removal, our thoughts regarding hernia repair following early recurrence are somewhat reserved and if an emergent operation is not indicated, planning ahead a definitive repair may be of benefit. As the retro-muscular planes have been violated, with or without TAR, the options of achieving a proper viable repair, in our opinion, are presumed low, and the timing of a repeat TAR, IPOM or on-lay repair as a salvage operation, should be carefully weighed. Nevertheless, in situations of PRS dehiscence, we advocate early minimally invasive intervention that includes reducing of visceral tissue into the abdominal cavity and re-suturing of the PRS to prevent bowel adhesion to the exposed mesh with risk

of bowel obstruction and fistulization. Furthermore, we believe the early PRS failures we have experienced occurred in part due to our learning curve and lack of awareness that these situations required a TAR relaxation, and thus, our recommendation is to err on the side of caution and implement TAR where doubted. When re-operating for PRS dehiscence with difficulty to achieve a sealed PRS barrier between the viscera and the exposed mesh, the use of an omentum patch or a composite mesh may be of help. An additional consequence of the learning observed in this study was apparent in our delayed diagnosis of our initial encounter with PRS dehiscence and bowel incarceration. This oversite occurred on POD 1, as the patient’s sole complaint was abdominal pain without objective findings in vital signs, physical examination, or lab studies. The CT scan performed on POD2 proved incarcerated bowel which lead to her re-operation. This event has lead us to perform early abdominal CT scans whenever a PRS dehiscence is suspected, which proved of benefit to the other two patients who suffered from PRS dehiscence with bowel incarceration and were reoperated on POD 1.

Due to the nature of the extra-peritoneal approach of eTEP-RS, the colonic perforation we encountered at POD 7 for an M3W2R1 hernia was unexpected. The late presentation of the patient and the location of the perforation have lead us to assume that it was induced from thermal injury during the lateral PRS dissection using the hook cautery.

Limitations of this study include its short-term follow-up and the low although expected follow-up rate. Our findings are limited to a laparoscopic approach by a dedicated abdominal wall service and the majority of patients treated were selected for a minimally invasive repair which may pose as a selection bias.

Conclusion

Abdominal wall repair using the eTEP-RS approach significantly improves subjective QoL variables with an acceptable post-operative complications and hernia recurrence rate in a short-term follow-up.