Abdominal Wall Reconstruction: A Comparison of Totally Extraperitoneal and Transabdominal Preperitoneal Approaches

Background Abdominal wall reconstruction for complex ventral and incisional hernias is associated with significant complications. Commonly, the peritoneal cavity is opened and adhesiolysis is performed with the potential for enterotomy. A totally extraperitoneal (TE) approach to abdominal wall reconstruction is feasible in many ventral hernia repairs and can reduce visceral injuries without impacting other outcomes. This study compares outcomes after retro-rectus ventral hernia repairs with TE and transabdominal (TA) preperitoneal approaches. Study Design An IRB-approved review of a prospective hernia database was performed for all ventral hernia repairs between 2009 and 2013. Preoperative patient characteristics, including demographics and comorbidities; operative variables, including surgical technique, operative duration, type/size/location of mesh, concomitant procedures, and incidence of inadvertent injury; and patient outcomes in terms of length of stay, wound and nonwound complications, and readmissions or returns to the operating room were obtained. Groups were compared using t-tests, Mann-Whitney U tests, chi-square tests, and Fisher's exact tests as appropriate. Significance was set at p <.05. Results One hundred and seventy-five complex abdominal wall reconstructions were performed between 2009 and 2013. Of those, 85 patients underwent hernia repair for CDC grade 1 hernias with retro-rectus mesh placement performed (n = 45 TA, n = 40 TE). Groups did not differ in age, BMI, sex, smoking status, hernia defect size, history of COPD, asthma, hypertension, cancer, or renal failure. More TA patients had diabetes (36% vs 13%; p = 0.02) and previous hernia repair (73% vs 45%; p = 0.01) than TE patients. Mesh size was larger in the TE group (625 ± 234 cm² vs 424 ± 214 cm²; p <.001). There was no difference in enterotomy between TA and TE groups (0% vs 2%; p = 1.0). However, there was a reduced operative time with TE (170 ± 49 minutes vs 212 ± 49 minutes; p <.001). Conclusions Abdominal wall reconstruction can be performed safely in a TE fashion. The extraperitoneal approach results in shorter operative duration, but had similar complications when compared with TA preperitoneal approach.