Laparoscopic Trans-Abdominal Retromuscular (TARM) Repair for Ventral Hernia: A Novel, Low-Cost Technique for Sublay and Posterior Component Separation.

Background: The complications of intraperitoneal onlay mesh repair for ventral hernia has favored sublay mesh placement like open Rives-Stoppa repair (ORS). There was a need for low-cost laparoscopic trans-abdominal repair using a polypropylene mesh (PPM) with sublay, midline closure and addition of posterior component separation (PCS) by transversus abdominis release (TAR).

Methods: The techniques used three or six operating ports with triangulation. After adhesiolysis, a transverse incision was made on the peritoneum (P) and posterior rectus sheath (PRS). The retromuscular space was developed by raising a P-PRS flap. Midline closure was performed with No. 1 polydioxanone, and a PPM was placed in sublay, followed by closure of defect and P-PRS incision. For large hernias with divarication; myo-fascial medialization using PCS-TAR aided low-tension midline closure.

Results: Eighty-nine patients were operated from 2010 to 2019, 26 primary ventral; 63 incisional; and 22 recurrent hernias. Of the primary, 21 were umbilical, one Spigelian and four epigastric hernias. The incisional group had 57 patients with lower midline scars (C-section 25, open tubal ligation 15, abdominal hysterectomy 17), five lateral (appendicectomy), one post-laparotomy. The mean age, male/female sex ratio and BMI were 41.23 years, 1:10.1 and 29.2 kg/m2, respectively. Mean defect and mesh area were 110 cm2 and 392 cm2. Mean operating time was 192 min. Conversion to open, mesh infection and recurrence rates were 3.4%, 1.1% and 5.62%.

Conclusion: Laparoscopic TARM with PPM in sublay avoids mesh-bowel contact. It provides midline closure and PCS-TAR within the same port geometry with results comparable with ORS.