Aim Our principal aim is to determine the retraction distance (RD) of the transverse abdominis muscle after unilateral endoscopic transversus abdominis release (eTAR) for the treatment of midline and lateral hernias, and compare it with the same patient contralateral unreleased side. Material and Methods We performed a retrospective analysis of a prospective database collection. We defined the RD as the measure between the lateral edge of the rectus abdominis muscle and the medial edge of the transversus abdominis muscle at the level of L3-L4 and at the defect´s maximum diameter. RD was measured pre and postoperatively and compared in the eTAR side with the contralateral (non- eTAR) side. Results 94 midline and 63 lateral hernias underwent hernia repair via endoscopic totally extraperitoneal (eTEP). Thirtyfive patients required unilateral TAR, including 1 primary and 34 incisional hernias. Lateral (65,7%) and medial (34,3%) defects were both included. The mean hernia defect was 49mm transverse diameter and 52mm longitudinal. We compared the postoperative RD at L4, obtaining 45,8mm on the eTAR side and 42,2mm on the non-eTAR side (p=0,284). At the defect site a mean of 38,3mm on the eTAR side was compared with 35,5mm (p=0.363). In our series we didn't find any statistically significant differences in the transversus muscle retraction after unilateral eTAR when compared with the unreleased side. Conclusions eTAR is a safe technique especially during the treatment of lateral hernias, allowing a proper mesh placement without significant transverse muscle retraction.

Aim To compare postoperative results of two cohorts of patients with simple and complex incisional hernias, operated using the extended totally extraperitoneal technique (eTEP). Materials and Methods Retrospective comparative multicenter study based on prospective database conducted at the Fundación Jiménez Díaz University Hospital and La Paz Hospital in Madrid, including eTEP repairs performed between March 2019 and January 2023. Patients were classified as complex hernias if they met at least one criterion according to the Slater definition (1). If no criteria were met, it was classified as a simple hernia. Results 159 patients were operated on via eTEP during the study period, and 111 incisional hernias were analyzed according to the EHS classification: 38 complex cases and 73 simple cases. The median defect size was 50mm (40–97) in simple cases and 66mm (24–126) (p<0.01), the median surgical time was 130min (59–360) and 145min (63–240) respectively without significant differences. TAR was required in 26 (35.6%) simple cases versus 23 (60.5%) complex cases (<0.01). One (1.4%) recurrence was observed in simple cases and 2 (5.3%) in complex cases, as well as 7 (9.6%) complications in simple cases and 5 (13.2%) in complex cases, both without statistical significance. The median follow-up was 26 months in simple cases and 11 months in complex cases (p<0.01). Conclusions The application of the eTEP approach in selected complex cases can improve postoperative results close to simple hernias. 1. Slater NJ et al. Criteria for definition of a complex abdominal wall hernia. Hernia 2014, 18:7–17.

Objective To present the application of the extended totally extraperitoneal (eTEP) approach in lateral incisional hernias and to analyze the results in our series of cases. Materials and Methods Retrospective comparative multicenter study based on a prospective database conducted at Fundacion Jimenez Diaz University Hospital and La Paz Hospital in Madrid that includes eTEP incisional ventral hernia repairs performed between March 2019 and January 2023. The inclusion criteria were lateral incisional hernias W1 and W2 according to the classification of the European Hernia Society (EHS). Preoperative, intraoperative, and postoperative data were collected. Results In the study period, 159 ventral hernias were intervened by eTEP access and a total of 49 incisional hernias were analyzed. By location, 3 cases were L1, 25 cases were L2, 15 cases were L3, and 6 cases were L4. The median defect size was 48mm (11–126). The median surgical time was 115 minutes (45–237) and transverse muscle release was applied in 36 cases (73.5%). The median length of stay was 1 day (1–7) and 14 (28.6%) patients were intervened on an outpatient basis. Four (8.2%) postoperative complications and 1 (2%) recurrence were evident. The median follow-up was 21 months (3–46). Conclusions The treatment of lateral incisional hernias by eTEP approach is feasible and abdominal transverse muscle release may have to be applied in many cases. It presents excellent results in our series in terms of complication rate, recurrence rate, hospital stay, and proportion of outpatient treatment.

Introduction One of the limitations in extraperitoneal abdominal wall surgery is the reduced range of movements of conventional instruments. The aim of this video was to show the advantages of articulated instruments. Case presentation The first case was a laparoscopic totally extraperitoneal (TEP) inguinal hernia repair of a direct bilateral hernia in a male patient. In this intervention the articulated grasper assisted with the isolation of the hernia sac and allowed to modify the direction of the traction during the dissection. The second case was an extended totally extraperitoneal (eTEP) repair of a M3W2 incisional hernia associated to rectus diastasis in a female patient. The articulated instrument gave an increased traction adapted to the surface of the posterior rectus sheath and marked the limits for the section with the scissors. Conclusion The articulated instruments allowed an increased mobility in the extraperitoneal field. Note: the articulated instruments were manufactured by IMM, Mannheim, Germany.

Aim The retromuscular repair described by Pauli et al. (2016) dissects the retromuscular space, releases the transversus muscle, and lateralizes the stoma to place a retromuscular mesh. The aim was to show the results of the robotic approach for this intervention. Material & Methods Video description of a case report. The patient was a 71-year-old woman that underwent an abdominoperineal resection for rectal cancer in 2017 and presented with a 5.8 cm parastomal hernia without midline defects (type III of the EHS classification). Results Three robotic trocars were placed in the lateral of the right rectus sheath, and posteriorly a 12 mm assistance port was inserted in the left hypochondrium. The dissection began in the inferior preperitoneal space, until finding the left transversus muscle. Then, the rectus sheath was dissected superiorly and laterally. A posterior rectus sheath release was performed in a down–to–up direction, initially avoiding the parastomal hernia, which was later reduced. Posteriorly, the peritoneum was incised and then sutured to lateralize the stoma. The parastomal hernia defect and the posterior rectus sheath were equally sutured. Finally, a polyvinylidene difluoride (PVDF) mesh was placed in the retromuscular space, which was fixed with transfascial sutures to the sides of the stoma. Conclusions The robotic totally extraperitoneal retromuscular approach for parastomal hernias is safe and feasible, with the advantage of avoiding the intraperitoneal space.