Aim In our series we analyze our experience in the subsequent separation of components with release of the transverse (TAR). Material & Methods Study of our series of retrospective cases since 2016 to the present. We analyzed 59 patients with large hernias (midline and sides) all with defects greater than 10 cm. We perform the technique accessing the Rossen space through down to up. We used two meshes as prostheses, one biodegradable and the other made of polypropylene low density. Results We present 59 patients (38 men/21woman), of mean age of 61 years old and average BMI 32.05 Kg/m2. The mean postoperative stay was 7 days. The technique was carried out bilateral in 39 patients, and 20 it was applied unilaterally. Mesh implant to retromuscular level in 56 of the cases and 4 preperitoneal. Reinterventions in 4 (6.78%) patients. As minor complications, 8 (13.56%) wound infections, 9 (15.25%) wound seromas, 7 (11.86%) patients with pain chronic with preserved management, 1 (1.69%) edge ischemia and 1 (1.69%) wound sinus. Readmissions 4 patients (6.78%). Average follow-up of 24 months, no recurrence has been detected in any of the patients. Conclusions TAR is a complex technique that requires a learning curve, and that, even in equipment experienced, is not exent from serious complications. Therefore, the indication must be individualized and in order for it to be definitive, because once the wall is remodeled with this technique, the surgical options that remain are few.

Aim To study complications in our e-TEP series in ventral and incisional hernias. Methods We reviewed all patients undergoing e-TEP for ventral or incisional hernias. We included 33 patients (14 M2 or M3W2 incisional hernias and 11 medium ventral hernias with rectus diastasis), in whom polypropylene mesh was used. Follow-up at least 6 months. Results We found 2 patients with interstitial hernia below the mesh, one of them in the acute postoperative period with intestinal obstruction. One patient with recurrence of incisional hernia in the subxiphoid area, one patient with asymmetry of the right hypochondrium, and one patient with a seroma requiring drainage and a hematoma in another (using drainage). Intensive postoperative pain in 6 patients with delayed discharge. Conclusion In our series, E-TEP is safe but not free of complications.We started the procedure very ambitiously with M3W2 incisional hernias, but we soon realized that this technique did not allow us to revise the cavity and perform adhesiolysis, so we changed the way we managed these patients, and became more selective, only indicating E-TEP in medium-sized primary hernias associated with rectus diastasis. We managed to improve surgical skill with the cases, reducing postoperative pain, surgical time and hospital stay.

Aim To show the effect on postoperative pain of direct instillation of ropivacaine into the retromuscular space. Method During the E-TEP Rives procedure, after mesh placement, we instilled ropivacaine into the retromuscular space via a working port. In our initial experience we compared only five patients from each group. We measured the decrease in postoperative pain with the visual analog pain scale 24 hours postoperatively. Results We achieved a decrease in postoperative pain, which we measured using the visual analog pain scale, with a reduction of 3 vs 5 in the control group, and which translates into a decrease in opioid consumption in the immediate postoperative period. Conclusion To decrease postoperative pain we implemented several actions, among the most important for us, was the technique of nerve block of the anterior abdominal wall with ropivacaine. This technique is easier and faster than ultrasound nerve localization and allows selectively blocking the nerve bundles of the rectus, having the same efficacy in our experience.

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