Abdominal wall contour and muscle changes after eTEP repair for small ventral hernias and diastasis: A quality...

The enhanced-view totally extraperitoneal (eTEP) Rives approach has gained popularity for ventral hernia repair because it aligns with modern principles of abdominal wall reconstruction. This study addresses unresolved questions related to changes in abdominal contour, rectus muscle behavior, and rehabilitation as part of an ongoing quality improvement initiative.

Forty-five patients underwent a standardized eTEP repair for small ventral hernias with diastasis recti. Structured core training and electrostimulation were implemented postoperatively for the last 15 patients, while the first 30 received routine care. CT scans analyzed with the Ellipse 9 tool provided abdominal contour, eccentricity (c/a), semilunar line distance (X2), and rectus muscle width. Rectus muscle areas were measured pre- and postoperatively in 29 patients, and bulging during Valsalva was assessed in a subgroup of 17 patients. A mathematical formula for bulging was tested for its sensitivity and specificity.

Postoperative bulging occurred in 11.1% of non-stressed and 23.5% of Valsalva CT scans. The last 15 patients showed no bulging under non-stressed conditions (0% vs. 16.7%, p = 0.067) and demonstrated a significant improvement in eccentricity (p = 0.035). Postoperatively, the distance between the lateral borders of the rectus muscles (X2) decreased while the width increased, suggesting a curvilinear configuration. Rectus muscle atrophy was more pronounced on the right side across the entire group (p < 0.05) but was reversed in the last 15 patients. Rehabilitation improved contour and muscle recovery. The mathematical formula demonstrated high diagnostic accuracy, achieving 100% sensitivity and 95% specificity.

Postoperative bulging after eTEP repair is infrequent under non-stressed conditions but more prevalent during stress maneuvers. Structured rehabilitation reduced bulging and improved rectus muscle recovery. Changes in X2 and muscle length challenge traditional hypotheses regarding bulging mechanisms. This study underscores the importance of standardized imaging protocols, mathematical criteria for bulging identification, and structured recovery protocols.