Cranial approach for preperitoneal/pretransversalis enhanced-view totally extraperitoneal (PeTEP) hernia repair: a novel technique description and early outcomes

Minimally invasive techniques are widely used to treat abdominal wall defects. This study describes a cranial approach for performing the total preperitoneal/pretransversalis enhanced-view totally extraperitoneal (PeTEP) technique and presents early outcomes for treating primary ventral hernias (PVH), midline trocar site incisional hernias (IHs), both associated with rectus diastasis, as well as lateral IHs.

An observational study was conducted from October 2023 to September 2024, identifying cases where the cranial PeTEP technique was employed, using data from a multicentric prospectively maintained database. The cranial approach involved dissection of the preperitoneal fatty rhomboid, extending the dissection across the preperitoneal and transversalis fascial plane to the semilunar lines laterally and the pubis caudally. For lateral defects, the dissection extended beyond the ipsilateral semilunar line, surpassing the lateral edge of the defect.

Twenty-four patients underwent elective endoscopic hernia repair: 62.5% PVH, 29.2% midline IH, and 8.3% lateral IH. The mean defect area was 6.32 ± 6.13 cm², and the average mesh size was 497.21.41 ± 202.71 cm². The surgical site occurrences rate was 8.3%, with no surgical site infections or recurrences at a mean follow-up of 5.3 months.

The cranial PeTEP technique was a safe, effective, and reproducible method for repairing PVH and small-medium IHs associated with rectus diastasis in a selected cohort of patients. It facilitated large preperitoneal mesh placement without entering the retromuscular plane and avoided posterior component separation in lateral defects. Larger studies with extended follow-up are needed to confirm these promising results.