Overview
Definition:
The eTEP (Endoscopic Totally Extraperitoneal) Rives-Stoppa repair is a minimally invasive surgical technique for inguinal hernias, combining the principles of the Rives-Stoppa retromuscular mesh placement with the extraperitoneal approach
It involves creating a preperitoneal space without entering the abdominal cavity, allowing for placement of a large mesh to reinforce the posterior abdominal wall, thereby reducing recurrence rates.
Epidemiology:
Inguinal hernias are common, affecting approximately 25% of men and 2% of women
Recurrence rates after open inguinal hernia repair can range from 5-10%, making techniques that minimize tension and provide robust mesh support crucial
Minimally invasive approaches like eTEP are gaining popularity due to reduced postoperative pain and faster recovery.
Clinical Significance:
This technique offers significant advantages in managing large, recurrent, or bilateral inguinal hernias
By avoiding the peritoneal cavity, it reduces the risk of bowel injury and allows for easier dissection and mesh placement in the retromuscular space, which is ideal for prosthetic reinforcement
Its adoption is vital for surgical residents preparing for advanced hernia repair techniques relevant to DNB and NEET SS examinations.
Indications
Primary Hernias:
Suitable for primary inguinal hernias, especially large ones where tension-free repair is paramount.
Recurrent Hernias:
Excellent option for recurrent inguinal hernias, particularly after previous open repairs where scar tissue may be present.
Bilateral Hernias:
Allows simultaneous repair of bilateral inguinal hernias in a single procedure, minimizing operative time and patient morbidity.
Complex Hernias:
Can be used for complex hernias, including femoral hernias and those with a posterior wall defect, by providing adequate mesh coverage in the retromuscular space.
Patient Factors:
Considered in patients who can tolerate general anesthesia and for whom laparoscopic surgery is appropriate
may be preferred in patients with comorbidities that increase the risk of open repair complications.
Preoperative Preparation
Patient Evaluation:
Thorough history and physical examination to confirm diagnosis and assess hernia characteristics
Evaluation of comorbidities including cardiopulmonary status.
Imaging:
Ultrasound or CT scan may be used to confirm hernia anatomy and assess the extent of the defect, especially in recurrent or complex cases.
Informed Consent:
Detailed discussion with the patient regarding the procedure, potential risks (e.g., bleeding, infection, nerve injury, recurrence, mesh-related issues), benefits, and alternatives.
Anesthesia:
Typically performed under general anesthesia
Spinal anesthesia may be an option for select patients, but general anesthesia is preferred for better muscle relaxation and control.
Bowel Preparation:
Routine bowel preparation is generally not required unless deemed necessary by the surgeon based on patient factors or surgeon preference.
Procedure Steps
Patient Positioning:
Patient is placed in a supine position with legs slightly abducted
Surgeon stands between the patient's legs or to one side.
Port Placement:
Three small ports (typically 10-12 mm for camera and instruments, 5 mm for assistant) are placed in the infraumbilical or umbilical region and laterally in the lower abdomen.
Dissection:
CO2 insufflation is used to create a working space
Dissection proceeds in the preperitoneal space, dissecting the transversalis fascia anteriorly and the peritoneum posteriorly
The dissection is extended to expose the inguinal canal, Cooper's ligament, the pubic bone, and the vas deferens/round ligament.
Mesh Placement:
A large, dual-sided or unilateral mesh (e.g., polypropylene, composite mesh) is introduced and positioned to cover the entire myopectineal orifice, extending from the pubic symphysis medially to the anterior superior iliac spine laterally, and superiorly to the iliac vessels.
Herniorrhaphy:
The defect in the transversalis fascia is not typically sutured in the Rives-Stoppa technique
the mesh itself provides the posterior wall reinforcement
In some variations, the transversalis fascia may be incised and overlapped, or tacking devices may be used to secure the mesh edges, especially laterally.
Postoperative Care
Pain Management:
Multimodal pain management including NSAIDs and short-acting opioids as needed
Local anesthetic infiltration at port sites can be beneficial.
Ambulation:
Early ambulation is encouraged to reduce the risk of deep vein thrombosis and improve recovery.
Diet:
Oral intake can be resumed as tolerated, typically within a few hours postoperatively.
Activity Restrictions:
Avoid strenuous activity, heavy lifting (>10 kg), and prolonged sitting for 4-6 weeks
Gradual return to normal activities is advised.
Discharge Criteria:
Patients are typically discharged on the same day or the day after surgery if they are pain-free, tolerating oral intake, and able to ambulate independently.
Complications
Early Complications:
Bleeding, hematoma formation in the preperitoneal space, seroma formation, urinary retention, port site infection, trocar site hernia
Rare complications include bowel injury or vascular injury.
Late Complications:
Chronic pain, mesh infection, mesh migration, recurrence of hernia, foreign body sensation, paraesthesia due to nerve entrapment
Formation of adhesions.
Prevention Strategies:
Meticulous dissection to avoid vascular and nerve injury, adequate mesh coverage of the inguinal floor and pubic tubercle, judicious use of fixation devices, proper sterile technique, and appropriate postoperative care are key
Careful patient selection also plays a role.
Key Points
Exam Focus:
Understand the principles of TEP and Rives-Stoppa repair
Differentiate eTEP from TAPP
Know the anatomical boundaries of dissection and mesh coverage
Key indications include recurrent and bilateral hernias.
Clinical Pearls:
Adequate dissection space is crucial for safe and effective mesh placement
The goal is to cover the entire myopectineal orifice
Be mindful of the obturator nerve, iliac vessels, and genitofemoral nerve during dissection
Excellent visualization of Cooper's ligament is essential.
Common Mistakes:
Inadequate mesh coverage leading to recurrence
Injury to pelvic organs or major vessels
Insufficient dissection space leading to difficulty in mesh positioning
Poor fixation of mesh (if used) leading to migration
Misinterpretation of anatomical landmarks
Over-reliance on port site fixation instead of proper mesh overlap.