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Postoperative abdominal bulging after eTEP rives-stoppa repair despite posterior rectus sheath closure: a CT-based
Micaela Milagros Rossi1, Digby Aylen Montechiari1, Ignacio Portela1
1General Surgery Department, Hospital Privado Universitario de Córdoba, Córdoba, Argentina.
Purpose:
Postoperative bulging has been reported after enhanced-view totally extraperitoneal (eTEP) repair, but its underlying mechanisms remain unclear. This study aimed to objectively evaluate postoperative abdominal wall contour changes after eTEP repair with systematic posterior rectus sheath (PRS) closure and to identify factors associated with postoperative bulging using the Ellipse 9 tool.
Methods:
A retrospective observational study was conducted including patients who underwent eTEP repair with systematic posterior rectus sheath closure for midline hernias with rectus diastasis between 2019 and 2024 and had available preoperative and postoperative computed tomography scans. Abdominal morphometric parameters were analyzed using the Ellipse 9 tool at standardized anatomical levels. Rectus muscle density was assessed. Patients were classified into bulging and non-bulging groups. Preoperative and postoperative measurements were compared within and between groups.
Results:
Thirty-three patients were included: 24 patients (73%) did not develop postoperative bulging (non-bulging group), whereas 9 patients (27%) developed bulging (bulging group). In the overall cohort, a significant bilateral reduction in rectus muscle density was observed (p<0.001), with no relevant modifications in global abdominal contour. The non-bulging group showed decreased muscle density (right: p=0.036; left: p=0.012) without significant geometric contour changes. In contrast, the bulging group demonstrated significant increases in abdominal dimensions (p≤0.002) and greater reductions in eccentricity (p<0.001), indicating a rounder contour, along with a predominant reduction in right-sided rectus muscle density (p=0.036).
Conclusion:
Postoperative bulging may occur despite systematic PRS closure, supporting a multifactorial origin. Rectus atrophy was insufficient as a sole mechanism, suggesting additional contributions from surgical and functional factors. Structured rehabilitation may improve postoperative outcomes.
