Chapters Transcript ETEP: The Basic Technique and Pitfalls Course: 3rd Annual NYU Langone Hernia Symposium: Beyond the Defect - The Big Picture in Hernia Surgery Uh, thank you to the course directors for inviting me back. So, uh, I'm gonna talk today about basic technique of ETAP and possible pitfalls. So, uh, this procedure, we're now in terms of thinking of the abdominal wall, one layer more superficial than the tap plane that was just discussed, and trying to stay completely into the, uh, retro rectus plane. Airline disclosures. So, uh, for me, the indications for doing an ETAP. is going to be uh defect size is usually 3 to 8 centimeters, um, as well as hernias, uh, multiple defects, uh, associated with diastasis. Around that size of 3 to 8 centimeters. Um, incisional hernias as well, because this procedure allows you to stay completely in the extraperitoneal retrorectus plane, uh, should you choose, and, um, so there's a, uh advantage there in terms of avoiding the possible need for extensive lice of adhesions, um, dealing with any intraabdominal. Um, hostile abdomens, prior intraabdominal meshes, etc. Pre-op planning is uh is I'd say one of the most important parts of this procedure in terms of planning because it could make or break your case. Um, well known Carbonell rule gives you the likelihood that you can perform, uh, this procedure. Um, with having adequate visualization and not, uh, possibly requiring something beyond just a retro rectus dissection and, uh, trying to avoid a possible component separation. So that formula as shown in the CT scan picture on the right, you take the, uh, rectus muscle width on each side and Uh, add them up and that, uh, width should be at least 2 times the size of the, uh, hernia defect. If that's the case, then you have a good success rate of completing a complete retrorectus dissection. So I'd say I'd have a CT scan, non-con uh done on all of my patients, uh, that are potential candidates. And then pre-optimization, um, prehab, optimization of glucose control, um, smoking cessation, etc. uh, weight loss reduction are all, um, necessary aspects as well. So access uh for this procedure, there are a few options, the dealer's choice. You can do an open cut down classic and create a retrorective space bluntly and put in a trocar. Um, you can uh come in with uh a balloon trocar such as, uh, how you do with a laparoscopic, uh, tap inguinal repair, uh, and you can Uh, blow up this the ipsilateral rectus retro rectus space with that option. My, uh, go to, uh, choice is to use the applied trocar, the key files, because it has a, um, insufflating tip, so I'm able to come in with an opt to view technique and, uh, be able to start insufflating. As soon as I think that I am uh just deep to the rectus muscle into that retrorectus space, and typically I'm about 2 centimeters medial to the semi-unar line, and 2 centimeters inferior to the costal margin. Um, when I first started, I was, you know, having the ultrasound in the room and doing a lot of markings, but, um, Uh, you know, basically if you have good, uh, good CT scan pre-op, you're able to measure, uh, just with the CT scan how far laterally you need to go off midline to get into that space pretty, uh, consistently. So just a demonstration of the basic concepts of the technique is that, uh, you know, we're entering the ipsilateral retro rectus space, and where we cannot cross over to the other side until we incise the uh um just uh the linear alba on the ipsilateral side. And then And then uh create a preperitoneal space in the midline. Uh, and make a nick on the contralateral, uh, posterior, uh, fascia so that we can cross over into the contralateral retrorective space. So, uh, that allows us to create this entire retroactive space and allow us to close the midline defects, uh, with minimal tensions. Those are the key steps. As demonstrated here as well. See if Pink works. So here's the entry with the optical trocar. Um, as soon as I see the rectus muscle red, I'm stopping. I'm allowing about 1010 to 15 seconds of insufflation. Uh, to continue to create that, uh, space. I like to see the darkness and those spider web, um, flimsy tissue that's basically Uh, and you can have some, uh, you know, blood coming into the fields, so really making sure that it's all clean and, um, Your visualization is uh adequate, so it just shows some of the struggles sometimes that you can have. Um, but once you see those spider web kind of flimsy tissue, that's what I'm going for. I'm using blunt dissection with the camera to, uh, continue to create that space. I come in with a 0 degree scope and uh quickly switch to a 30 degree, um, and then I'm able to start to palpate. So this is my top trocar, um. In the left subcostal area, and that stays in there. It's actually a balloon trocar, so it's nice because I keep the insufflation on that the entire case and uh doesn't allow any leakage of air into the subcu area. So I use a finder needle to uh try to find a place the first trocar in the left upper quadrants. As soon as I have that, I have two hands to work with. I can start to use um You know, you can use either uh um Maryland with energy. I like to use a hook, um, making sure I can continue to make the space. Pneumo dissection was uh is your friend as well, and um You can continue to do this entire dissection epsilaterally laparoscopic, if you would like. I like to dock as early as I can, so I focus mostly on making sure that I have enough space for my next troll cars. So again, making sure we're not going too deep with that, if you're coming in sharply, because you don't want to cause a hole in the posterior sheath. If you do that, you're really fighting against the intraabdominal pressure, pushing up in the space, and then um like sometimes you can lose and collapse that space, and it can make the rest of the beginning of the case difficult. So again, once I'm docked early, you can see that trocar stays up there, and um Try to create the dissection of the ipsilateral space and try to cross over as early as I can. This is how I was taught by Doctor Malscher is that if I cross over early, I'm able to basically have a greater distribution of the uh air of the pneumo uh um dissection, and in case there are any holes or anything, then I have a greater surface area to work with. Again, I cross over as early as I can. I have, I try to identify based off the CT scan and also intraoperatively where that contralateral uh rectus muscle is starting. So one of the pitfalls is that if you're uh misjudge that, you could cause a linear alba injury, which you should fix at that time, so otherwise you could be causing a potential incisional hernia. Uh, there is a little bit of color discoloration. You can see the rectus muscle, it's a little bit darker there, uh, where the rectus starts, that's also another clue of where you should make your neck, uh, and once you see muscle, you're able to easily cross over. It's just a pretty fast speed here just to fast forward to the dissection. Now we're looking down, just to orient you down into the pelvis, um, to create the, uh, um. Uh, space of Bogros as well as space of Retzius and working our way up, um, uh, to find where the the arcuate line is on the contralateral side and making sure we complete our dissection. Other important aspects uh to focus on, uh, to not, um, other pitfalls, you know, making sure that you'd clearly delineate the neurovascular bundles on the, uh, edges and, uh, preserve those. Uh, you will have some perforated branches, so this was an incisional hernia, and the midline peritoneum was quite thin. It's not a big deal at this point if there are holes because I have, uh, you know, equalization of pressure, so I'm not losing my space, and it also allows me to do a little sneak and peek into the abdomen, make sure there's no bowel or adhesions, uh, and those, uh, small holes and fenestrations, um, will be closed at the end. Um, For, so, uh, closing your defect of, uh, starting off with, uh, basically is a zero barb suture. Uh, 18 inches, um, and using the Venetian blinds technique, taking some parts of the hernia sac, uh, as well, and coming back, uh, over multiple iterations to cinch to allow the distribution of tension. Um, this is I try to lay out the sutures altogether. Um, once I've maxed out what I can do, I start focusing on the closure of the floor here, and then I, this is when I come down on the insufflation pressures. Uh, down to about 8 or so, um. Give some time for the uh fascia, um. And the muscles to accommodate um the tension, and then I'll go back to the roof again. To the ceiling and, and then, uh, close all the defects and it comes together pretty nicely. Here I'm just closing the fenestrations. I'm not closing the posterior, I'm not re-approximating the posterior fascia. Um, I wanna take away the thunder on next top with Doctor Halpern, so I'll save that controversy. Um, Measuring the space with a ruler to allow and uh then trimming the mesh appropriately uh into this space and uh securing the Going back to the ceiling to secure the defects. So here's again the Venetian the lines technique. Uh, unrolling my mesh, and then, uh, I just use a hemostatic agent, so I don't really use any fixation, um, for this, unless, uh, if I'm doing bilateral inguinals at the same time, and I have to place separate inguinal meshes, then I will fixate, um, with a stitch coming, uh, or like a, a suture passer coming through the suprapubic area. Otherwise, I don't really use any fixation routinely. Using the pneumostatic agent, and then I don't uh leave a drain into the space. And uh some Local anesthesia. Here's a pic a picture of a video of uh what can go wrong if you Go a little bit too deep or um uh one of the pitfalls. So here I thought I was in the right space, and then I see, you know. Not so friendly bile, possible small bowel movement. So, um, very thin elderly gentleman, I think he was 80 or so, had a history of multiple abdominal surgeries, so definitely wanted to stay out of the abdomen and then the opposite happened. So what you do, you know, you, uh, you leave the trocar in place, try to find come in on the opposite side of the abdomen, somewhere safe. Um, And um So we get our other arms in there, we're unable to get some uh space in there, start to dissect out closer to where the trocar is. A lot of adhesions to the abdominal wall. Then I find this loop of bowel, which was stuck to the anterior abdominal wall here, and that's where the uh trochar is. And uh, Once I identified that, then uh it was a small enterotomy that I was able to repair primarily. Um, And then, uh, I believe I proceeded with that case, uh, just staying in this transabdominal plane, um. And fortunately, the patient uh did well ever since um you'll exchange the instruments and continue with placing the mesh in the extraperitoneal plane. Let's go back to Tetu. So again, just to highlight some pitfalls, we talked about, make sure you're closing all the fenestrations, posterior sheath closure, uh, question mark, uh, do we need to do that or not? So there's a hot topic in ETAs right, uh, these days, um, avoiding tension is a tenets of any, um, complex hernia repair. Um, some things that can go wrong is an intraparietal hernia. So if you have a breakdown of your posterior fascia of your posterior, um, peritoneum or your posterior sheath, you can have, uh, incarceration of bowel in there, um, between the two layers of your rectus muscle and posterior fascia that may not, um, show up as a hernia on a CT scan, will just show up as a bowel obstruction post-op, so you'd have a very high index of suspicion. And that and something like that is happening. Um, anterior closures go to is barbed suture, uh, for me as well, and lowering the pressures, um, and then we talked about the Venetian blinds technique as well to try to go, uh, and, and help uh assist with your, um, fascial defect closure. Uh, pneumoperitoneum, if you have that, like I said, if you make a hole accidentally, you can collapse for space, make the procedure a little bit of fighting battle in the beginning. Preserving the neurovascular bundles, again, very important to, um, as that could be a a pitfall in terms of the bulge that can happen after these procedures, as well as a denervation injury. Uh, we talked about the linear alba, really making sure you identify that and avoiding any injury to that. Um. Uh, bowel injury, which was very well shown in my video, and then other things that can happen is seroma hematoma, and infections. And uh that's all I have. Published September 19, 2025 Created by
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