Abdominal contents pass through the femoral ring, traverse the femoral canal, and exit through the saphenous opening. The hernia assumes a “retort” shape — downwards up to the saphenous opening, then upwards once it exits.
The tendency of a femoral hernia to extend upwards is attributed to: the firm, unyielding fascia lata; attachment of the cribriform fascia just below the saphenous opening; and repeated flexion of the thigh.
| McEvedy High Operation | Lotheisen Operation | Lockwood Low Operation |
|---|---|---|
| Vertical incision over femoral canal and upper portion ½ inch medial to linea semilunaris. Rectus abdominis retracted medially, fascia transversalis opened. Sac seen going beneath the inguinal ligament, is dissected, opened, contents assessed, and the sac is also opened and excised. Femoral canal repaired from inside by approximating inguinal ligament to Cooper’s ligament without compressing the femoral vein. Procedure of choice for strangulated femoral hernia. | Inguinal incision similar to inguinal hernia repair. EOA opened, inguinal canal entered. Cord structures retracted upwards. Fascia transversalis opened. Neck of sac identified at the femoral ring. Sac dissected, opened and reduced. Femoral ring is obliterated by suturing the conjoint tendon to the pectineal ligament of Cooper. | Incision 1 cm below and parallel to the medial portion of the inguinal ligament. Sac isolated, freed up to neck and opened at fundus (care must be taken while inverting lacunar ligament medially to see the abnormal obturator artery). Femoral hernia reduced — stitches placed between iliopubic tract/inguinal ligament and lacunar ligament/Cooper’s ligament without compressing the femoral vein. Remaining gap reinforced with a plug of mesh. |
“W” loop of bowel present in the hernia sac. It can be reduced, while the loop bridging it remains within the abdominal/pelvic cavity and can become strangulated unnoticed (hernia-en-W / retrograde strangulation).
Only part of the circumference of the bowel is present in the hernia sac, and that part can become gangrenous without producing complete intestinal obstruction. Commonly seen in femoral hernia.
A Meckel’s diverticulum is present in the hernia sac.
The appendix is present in the hernia sac (classically an inguinal hernia sac).
| Parameter | Classification | Definition |
|---|---|---|
| Location — Midline (M) | M1 | Subxiphoidal: xiphoid to 3 cm caudally |
| M2 | Epigastric: 3 cm below xiphoid to 3 cm above umbilicus | |
| M3 | Umbilical: 3 cm above to 3 cm below umbilicus | |
| M4 | Infraumbilical: 3 cm below umbilicus to 3 cm above pubis | |
| M5 | Suprapubic: 3 cm above pubis to pubic bone | |
| Location — Lateral (L) | L1 | Subcostal: costal margin to 3 cm above umbilicus |
| L2 | Flank: 3 cm above to 3 cm below umbilicus | |
| L3 | Iliac: 3 cm below umbilicus to inguinal region | |
| Size — Width (W) | W1 | <4 cm |
| W2 | 4–10 cm | |
| W3 | >10 cm |
Example: a large umbilical hernia with a 12 cm defect = M3W3.
Biological: sterilized, non-immunogenic, decellularized connective tissue, derived from:
e.g. Acellular dermal matrix.
Synthetic:
Sheet/net materials: ePTFE (expanded polytetrafluoroethylene), silicone, polyurethane sheet, Prolene, composite mesh.
| Sheet | Net | |
|---|---|---|
| Advantage | Less tissue reaction, smooth — low infection | Low cost, more flexible |
| Disadvantage | High cost, less flexible | Adhesions, infections |
| Large pore (macroporous, >1mm) | Small pore (microporous, <1mm) | |
|---|---|---|
| Tissue ingrowth | ↑↑ | ↓↓ |
| Handling | Easy | Stiff / not flexible |
| Bacteria | Low risk | Increased risk (→ sepsis) |
| Pain | Decreased | Increased |
| Light mesh | Heavy mesh |
|---|---|
| <70 g/m² — less tissue reaction | >70 g/m² — more tissue reaction, more stiffness |
Xylocaine 2% (20 mL) + Bupivacaine 0.5% (10 mL) + NS (50 mL) + Adrenaline (1 mL of 1:10000); hyaluronic acid added to improve spread. Injected layer by layer — dermal, subcutaneous, subaponeurotic, canal.
Early ambulation, oral analgesia, scrotal support if needed. Light activity immediately; avoid heavy lifting for 4–6 weeks. Watch for: urinary retention, haematoma, wound issues, seroma.
Early: haematoma/seroma (adequate haemostasis, compression; aspirate only if tense/infected); urinary retention (limit fluids, timely voiding, catheterize if needed); wound infection (prophylactic antibiotic, asepsis, treat early to protect mesh); cord or vas injury (gentle dissection near sac).
Late:
| Step | What to fix | Where exactly | Point |
|---|---|---|---|
| First stitch | Mesh medial edge | Strong tissue just medial to pubic tubercle | Ensure overlap across midline |
| Inferior row | Mesh to inguinal ligament | Pubic tubercle to just lateral to internal ring | Avoid deep bites lateral to ring (nerves) |
| Neo-ring | Mesh tails | Crossed around cord, no constriction | Avoid tight tails causing cord compression |
| Superior row | Mesh to conjoint/transversus arch | 2–3 interrupted sutures | Avoid nerve entrapment under bites |
An irreducible hernia in which the blood supply of the contents (bowel/omentum) is compromised, leading to ischaemia, necrosis, and risk of perforation and peritonitis. (Bailey & Love, Sabiston)
Local: tense, tender, irreducible swelling; no cough impulse; skin erythema/warmth.
Systemic: pain out of proportion, persistent; features of intestinal obstruction if enterocele (colicky pain, vomiting, distension, constipation); rebound tenderness → peritonitis; shock, toxicity.
Preoperative resuscitation: NG tube aspiration; IV fluids and electrolyte correction; broad-spectrum antibiotics; Foley catheter for urine output; analgesia, oxygen.
Surgical steps (emergency herniotomy + herniorrhaphy):
Early: sepsis, peritonitis; anastomotic leak, fistula formation; paralytic ileus; wound infection, abscess (inguinal/pelvic/subphrenic).
Systemic: electrolyte imbalance; respiratory complications (pneumonia, ARDS); DIC in severe sepsis.
Late: recurrent hernia (repair under contaminated field).
Protrusion of peritoneal contents through the umbilical ring. In cirrhotic patients with ascites, increased intra-abdominal pressure and poor abdominal wall musculature predispose to its development. Occurs in up to 20% of cirrhotics with ascites.
Symptoms: reducible umbilical swelling, discomfort, cosmetic concern.
Signs: soft, expansile swelling at umbilicus, often reducible.
Complications: incarceration; strangulation; rupture with ascitic leak (spontaneous paracentesis through skin) — high mortality; infection/peritonitis.
Elective herniorrhaphy after ascites control: preferred technique is primary tissue repair (suture repair); mesh repair carries high infection risk if ascites persists, but is sometimes used if ascites is well controlled.
Emergency repair (incarceration/rupture): resection of gangrenous bowel if needed; simple closure without mesh; high perioperative morbidity/mortality.
The inguinal canal is an oblique fibro-muscular passage in the lower anterior abdominal wall transmitting the spermatic cord (male) or round ligament (female). In laparoscopy the surgeon works deep/behind the transversalis fascia — in the preperitoneal (retromuscular) plane for TEP, or enters the peritoneal cavity and then the preperitoneal space for TAPP. Knowledge of the myopectineal orifice (MPO) and nearby vascular/nerve triangles is essential.
Skin → superficial fascia (Camper/Scarpa) → external oblique aponeurosis (superficial ring) → internal oblique → transversus abdominis → transversalis fascia → preperitoneal fat/space → peritoneum.
Arcuate (Douglas) line: posterior rectus sheath ends here — important laparoscopic landmark (below this line, posterior rectus sheath is absent).
Essential concept for mesh coverage. Bounded laterally by iliac crest/femoral canal, medially by rectus sheath, inferiorly by pectineal (Cooper’s) ligament. Contains all hernia sites: indirect (deep ring lateral to IEV), direct (Hesselbach’s triangle), femoral (below inguinal ligament).
In females, the round ligament partly replaces cord contents.
| Topic | TEP | TAPP |
|---|---|---|
| Initial access | Preperitoneal balloon/trocar; works outside peritoneal cavity | Enter peritoneal cavity, make peritoneal flap to access preperitoneal space |
| Visualization | Limited space; crisp view if created well | Excellent panoramic view of both groins, peritoneum, intra-abdominal structures |
| Common advantages | No intra-abdominal entry → less visceral injury, fewer adhesions | Easier to convert, larger working space, useful for large/complex hernias |
| Dissection planes | Space of Retzius medially, Bogros laterally | Incise peritoneum 3–4 cm above defect, expose same spaces |
| Key anatomical risks | Peritoneal tears → loss of working space; blind lateral dissection may injure IEV/corona mortis | Risk of intra-abdominal adhesions; peritoneal flap must be closed to prevent bowel-mesh contact |
| Mesh placement | Flat in preperitoneal space covering MPO; often no fixation | Mesh placed preperitoneally, then peritoneal flap closed over it |
Triangle of Doom — below the internal (deep) inguinal ring, in the preperitoneal space. Boundaries: medial — vas deferens; lateral — gonadal vessels; base (inferior) — peritoneal reflection. Contents: external iliac artery and vein, deep circumflex iliac vein, sometimes genital branch of genitofemoral nerve. Never place tacks or sutures here — risk of catastrophic vascular injury.
Triangle of Pain — lateral to spermatic vessels, below the iliopubic tract. Boundaries: medial — gonadal vessels; superior — iliopubic tract; inferior — peritoneal reflection. Contents (mainly nerves): lateral femoral cutaneous nerve, femoral branch of genitofemoral nerve, occasionally femoral nerve at base. No fixation here — risk of chronic postoperative neuropathic pain.
Hesselbach’s Triangle — medial inguinal fossa. Boundaries: medial — lateral border of rectus abdominis; lateral — inferior epigastric vessels; inferior — inguinal ligament. Site of direct inguinal hernia (through weak transversalis fascia) — must be covered by mesh.
Myopectineal Orifice (Fruchaud’s) — not a triangle but essential. Boundaries: superior — arched fibres of internal oblique and transversus; medial — rectus abdominis; inferior — pectineal (Cooper’s) ligament; lateral — iliopsoas muscle. Contains all groin hernia sites; the target area for a single prosthetic mesh to prevent recurrence.
Corona Mortis (“crown of death”) — a vascular hazard, not a true triangle. Located over the superior pubic ramus near Cooper’s ligament; aberrant/accessory obturator vessels connecting external iliac/inferior epigastric with the obturator system. Accidental injury during Cooper’s ligament dissection causes difficult-to-control bleeding.
| Feature | TAPP | TEP |
|---|---|---|
| Approach | Enters peritoneal cavity | No entry into peritoneal cavity |
| Ease of dissection | Easier, larger working space, clearer anatomy | Technically more demanding, smaller space |
| Learning curve | Shorter | Longer, steeper |
| Intra-abdominal organ injury | Possible (bowel, bladder, vessels) | Minimal — peritoneum not breached |
| Peritoneal tears | Intentional peritoneal incision | Accidental tears possible, difficult to manage |
| CO₂ leak | Rare (cavity sealed) | Common if peritoneum torn → loss of space |
| Visualization | Excellent exposure of MPO | Limited if space not adequately created |
| Adhesion risk | Possible (entry into peritoneum) | Nil (no entry to peritoneum) |
| Conversion to open | Easier if needed | Difficult due to limited access |
| Indications | Suitable for recurrent and bilateral hernia, easier in obese | Preferred if avoiding peritoneal entry (e.g. prior lower abdominal surgery) |
| Operative time | Slightly shorter | Longer initially |
Access & spaces: subumbilical incision → balloon or blunt dissection → preperitoneal space. Spaces defined intraop — Retzius space (medial, between pubic symphysis and bladder, exposes Cooper’s ligament) and Bogros’ space (lateral, between transversalis fascia and peritoneum lateral to IEV, extends to ASIS). Arcuate line: posterior rectus sheath ends ~4–5 cm below umbilicus; below this, only transversalis fascia covers the rectus — balloon expansion is easier here.
Key landmarks: IEV (separate direct from indirect hernias); deep ring (lateral to IEV); Hesselbach’s triangle (medial to IEV); femoral canal (below Cooper’s ligament); Cooper’s ligament (strong medial fixation landmark).
| Feature | TEP | TAPP |
|---|---|---|
| Entry | Extraperitoneal | Transperitoneal |
| Initial dissection | Retzius space first | Peritoneal incision, then Retzius/Bogros |
| Risk | Peritoneal tears (loss of working space) | Need for peritoneal flap closure |
| Visualization | Limited but focused | Wider, easier |
| Adhesion risk | Less (no peritoneal entry) | More (intra-abdominal) |
Laparoscopic transabdominal preperitoneal repair — placement of a large prosthetic mesh in the preperitoneal space over the MPO to reinforce all potential hernia sites.
Indications: primary or recurrent inguinal hernia (direct/indirect/femoral); bilateral hernias; recurrent hernia after previous open repair; obese patients (better laparoscopic exposure).
Contraindications — absolute: unfit for general anaesthesia; previous major lower abdominal surgery (dense adhesions); peritonitis/bowel obstruction. Relative: large scrotal hernias; irreducible hernia; lack of laparoscopic expertise.
Steps:
Postoperative care: early ambulation and oral fluids same day; analgesics and antibiotics; discharge after 24 hours.
Placement of a large prosthetic mesh in the preperitoneal space without entering the peritoneal cavity, reinforcing the MPO.
Indications: primary unilateral/bilateral inguinal hernia; recurrent hernia after previous open anterior repair; patients where peritoneal entry should be avoided (e.g. prior midline laparotomy); early bilateral hernias.
Contraindications — absolute: unfit for GA; previous preperitoneal/TEP repair; peritonitis/intra-abdominal pathology. Relative: large irreducible scrotal hernia; prior lower midline/suprapubic surgery causing dense fibrosis; lack of laparoscopic expertise.
Steps:
| Intraoperative | Postoperative | |
|---|---|---|
| TAPP | Injury to inferior epigastric/iliac vessels; bladder or bowel injury; peritoneal tear → CO₂ leak; nerve injury (triangle of pain) | Seroma/haematoma; chronic groin pain; mesh infection/recurrence; adhesions/bowel obstruction (rare) |
| TEP | Peritoneal tear → CO₂ leak/loss of working space; injury to inferior epigastric or iliac vessels; inadequate dissection/conversion to TAPP; injury to vas/nerves | Seroma/haematoma; chronic groin pain; mesh infection/recurrence; subcutaneous emphysema (rare) |
A large ventral/incisional hernia where a significant portion of viscera permanently reside outside the abdominal cavity. Reduction risks abdominal compartment syndrome (ACS) and respiratory compromise.
| Ratio | Formula | Cut-off for LOD |
|---|---|---|
| Tanaka | Hernia sac volume / abdominal cavity volume | ≥0.25 |
| Sabbagh | Hernia sac volume / total peritoneal volume | >0.20 |
LOD ratio ≥0.25 is clinically significant — needs preoperative preparation.
Chronic hernia → abdominal cavity shrinks, viscera adapt outside. Lateral wall muscles shorten and lose elasticity. Sudden reduction → high intra-abdominal pressure → ACS + respiratory failure.
Clinical: size, reducibility, skin condition, contamination, prior repairs.
CT scan (most important): defect size, hernia contents, muscle condition; calculate LOD ratio.
Other workup: pulmonary (spirometry, ABG if COPD); nutrition (albumin, HbA1c, BMI); infection screen (wound/stoma/fistula).
| Aim | Method |
|---|---|
| Improve lung & general fitness | Breathing exercises, incentive spirometry |
| Optimize nutrition & control DM | Protein supplements, albumin >3 g/dL |
| Expand abdominal cavity | Botulinum toxin A (BTA) and/or progressive pneumoperitoneum (PPP) |
Botulinum Toxin A (BTA): temporarily paralyzes lateral muscles to relax and stretch the wall. Given 4–6 weeks before surgery; dose 200–300 U bilateral injection under USG; gains ~5–7 cm medial advancement.
Progressive Preoperative Pneumoperitoneum (PPP): gradually stretches the abdomen by daily air insufflation. Catheter into peritoneum, inject 800–1000 mL air/day for 7–15 days; stop when patient comfortable and can lie supine; watch for pain, dyspnoea, pneumothorax.
| Technique | Key point | Pros | Cons |
|---|---|---|---|
| TAR | Posterior component separation | Excellent medialization, strong retro-rectus mesh | Technically demanding |
| Posterior CS (no TAR) | Limited medialization | Less morbidity | Not enough for very large LOD |
| Anterior CS (Ramirez) | Cut external oblique | Simpler | High skin morbidity |
| eTEP / Robotic TAR | Minimally invasive TAR | Lower SSI, early recovery | Needs expertise |
TAR is the gold standard for LOD — best medialization with the least skin issues.
Abdominal compartment syndrome; respiratory failure; SSI/seroma; enterotomy; recurrence; chronic pain.
Purpose: medially advance rectus–myofascial units for tension-free midline closure in large/complex ventral or incisional hernias.
Common indications: large midline hernia (defect >8–10 cm); loss of domain/failed primary closure; need for anatomical restoration with durable mesh-reinforced repair; recurrent or complex incisional hernias.
Common contraindications: active infection/contaminated field needing permanent synthetic mesh; unfit patient; extensive prior dissection/fibrosis precluding safe plane creation; uncontrolled sepsis or enteric fistula.
| Aspect | Anterior CS (ACS, Ramirez) | Posterior CS (PCS / TAR) |
|---|---|---|
| Type/approach | Classic Ramirez (external oblique release) | Transversus Abdominis Release |
| Purpose | Medial advancement when posterior plane unavailable | Medial advancement via posterior rectus sheath and TA plane |
| Indications | Large midline hernias; posterior plane not available; preferred anterior approach; endoscopic/perforator-sparing modification possible | Large or complex/recurrent hernias; need for retromuscular mesh placement; anterior tissues weak/scarred; avoids large skin flaps |
| Contraindications | Poor skin perfusion; thin/scarred anterior wall; active superficial infection; prior lateral dissection/scarring; when TAR is feasible (ACS has higher wound morbidity) | Destroyed posterior plane (prior mesh, fibrosis, infection); gross contamination needing biologic mesh; not fit for GA; very thin/damaged tissues |
| Mesh plane | Onlay / limited sublay | Retromuscular (ideal) |
| Flap requirement | Large subcutaneous skin flaps (↑ wound complications) | Minimal flap dissection |
| Wound morbidity | Higher (esp. open ACS) | Lower |
The rectus abdominis muscle sits in the midline, with the posterior rectus sheath behind it (only above the arcuate line). Incising that posterior sheath and entering behind it reaches the retrorectus space (the classic Rives–Stoppa plane), which normally stops at the linea semilunaris. To go beyond, the transversus abdominis (TA) muscle must be released — creating a huge new retromuscular plane extending laterally to the psoas, superiorly to the diaphragm, inferiorly to the space of Retzius. A massive retromuscular mesh with excellent overlap can then be placed in this plane.
TAR = open the back wall of the rectus sheath, divide TA fibres, gain massive space for mesh.
| Step | ACS (Ramirez) | TAR |
|---|---|---|
| Release incision | External oblique aponeurosis incised lateral to linea semilunaris | Posterior rectus sheath incised near linea semilunaris + TA division |
| Release incision closure | EO aponeurosis NOT closed (left open to maintain length) | TA division NOT repaired (left open) |
| Midline closure | Yes — anterior rectus sheaths closed in midline | Yes — anterior rectus sheath closed in midline |
| Posterior sheath/peritoneum | Not entered — no posterior closure issue | Closed to cover mesh (if possible) |
| Mesh position | Onlay (above closed anterior sheath, beneath subcutaneous flaps); sometimes sublay | Retromuscular sublay (between rectus/TA anteriorly and posterior sheath/transversalis fascia posteriorly) |
| Skin/subcut closure | Yes, over drains (large flaps increase wound risk) | Yes, minimal flaps (lower wound morbidity) |
In ACS, work happens on the front of the abdominal wall (unlike TAR, which works behind rectus). The external oblique (EO) aponeurosis is divided and separated from the internal oblique (IO), allowing the rectus + IO + TA complex to slide medially towards the midline, gaining several cm of advancement. Downside: needs large subcutaneous flaps, with high wound complications.
ACS = cut the external oblique aponeurosis, slide the rectus block inwards from outside.
Its division is what provides the length to advance the rectus block medially — closing it would undo the gain in length and bring the hernia back under tension. The rectus edges and midline are closed instead, usually with mesh reinforcement.
What is closed at the end: midline fascial closure (rectus sheaths approximated); mesh reinforcement (onlay or retrorectus if feasible); skin and subcutaneous tissue, with drains in the flap space.
In classic Ramirez ACS, the release plane is between EO and IO — but this plane is not used for mesh placement; it is only a release plane to allow the rectus–IO–TA block to slide medially. Mesh placement is usually onlay, above the repaired anterior rectus sheath beneath subcutaneous flaps (most common, since posterior sheath is undisturbed). Sometimes retrorectus/sublay if a Rives–Stoppa space is also created (a different repair combined with ACS).
By contrast, in TAR mesh is placed in the retromuscular plane — a much more stable, well-vascularised location.
Advantages: large medial advancement (up to 10 cm at umbilicus); simple to learn, well-established technique.
Disadvantages: needs big skin flaps → high wound morbidity (SSI, seroma, skin necrosis); perforator sacrifice → skin ischaemia; often requires onlay mesh → higher recurrence than retrorectus sublay.
| Step | Detail |
|---|---|
| Approach | Open, midline |
| Dissection | Raise flaps to expose EO |
| Release | External oblique aponeurosis, 1–2 cm lateral to semilunaris |
| Mobilization | RA + IO advanced medially |
| Closure | Midline fascial closure ± mesh reinforcement |
| Complications | Flap necrosis, seroma, recurrence |
Incisional hernia: abdominal wall defect, with or without a bulge, in a postoperative scar, perceptible or palpable on examination.
Ventral hernia: protrusion of peritoneal contents through a spontaneous defect in the abdominal wall.
Modern paradigm: anatomic fascial closure plus large extraperitoneal mesh, using open, endoscopic, laparoscopic, or robotic platforms; minimizing intraperitoneal mesh contact; risk-factor optimization, prehabilitation, and wound-morbidity reduction.
Indications: symptomatic hernia pain, functional limitation, progressive increase in size; skin changes or risk of rupture/ulceration; intermittent incarceration or obstruction after appropriate resuscitation; cosmesis and core instability with rectus diastasis in selected patients; failure of conservative management (binders, weight loss); complex or loss-of-domain defects after CT volumetry planning.
Contraindications: uncontrolled sepsis, active SSI, gross contamination without a staged strategy; unoptimized comorbidities (severe cardiopulmonary disease, decompensated diabetes, ongoing smoking); morbid obesity prior to optimization; pregnancy/planned imminent laparotomy (relative); intolerance to pneumoperitoneum, severe COPD, hostile/frozen abdomen (relative, for laparoscopy); enterocutaneous fistula, contaminated field (relative, for intraperitoneal mesh).
Complications: Early — seroma, haematoma, SSI/SSO, ileus, urinary retention, DVT/PE, enterotomy with bowel injury. Late — recurrence, chronic/neuropathic pain, mesh infection/exposure, bowel adhesion/obstruction (more with intraperitoneal planes), bulging/laxity, lateral wall denervation deformity after extensive releases, rare enterocutaneous fistula.
| Plane | Techniques using this plane |
|---|---|
| Retromuscular sublay preperitoneal | Rives–Stoppa, eTEP-RS, MILOS, EMILOS, TAR / TARM end state |
| Preperitoneal / extraperitoneal | TAPP ventral, TAPE, SCOLA, low midline |
| Intraperitoneal underlay | IPOM, IPOM-Plus, Hybrid IPOM |
| Onlay | ELAR, onlay reinforcement after linea alba plication for selected diastasis |
| Inlay (bridging) | Avoid if possible — used only when closure is impossible |
| Acronym | Full form |
|---|---|
| IPOM / IPOM-Plus | Intraperitoneal Onlay Mesh (Plus = with primary fascial defect closure before mesh placement) |
| TAPP | Trans-Abdominal Pre-Peritoneal Repair |
| TARM | Trans-Abdominal Retro-Muscular Repair |
| TAPE | Trans-Abdominal Partially Extraperitoneal Repair |
| IPRA | Intraperitoneal Rectus Aponeuroplasty |
| eTEP-RS / eTEP-TAR | Enhanced-view Totally Extraperitoneal — Retro-Rectus Sublay / Transversus Abdominis Release |
| MILOS / EMILOS | Mini-/Less-Open Sublay Repair / Endoscopic variant |
| SCOLA | Subcutaneous Onlay Laparoscopic Approach |
| ELAR | Endoscopic-Assisted Linea Alba Reconstruction |
| ACS / E-ACS | Anterior Component Separation / Endoscopic ACS |
| TAR / r-TAR | Transversus Abdominis Release / Robotic TAR |
| CS | Component Separation |
| PPP | Progressive Preoperative Pneumoperitoneum |
| BTA | Botulinum Toxin A (chemical component separation) |
IPOM — Intraperitoneal Onlay Mesh. Indications: small–medium midline/incisional hernias (≤6 cm); recurrent hernias where extraperitoneal dissection is risky. Contraindications: contaminated field, ECF, dense adhesions, young patients needing re-laparotomy. Steps: laparoscopic access away from scar; reduce sac, clear 5 cm overlap zone; place composite/anti-adhesive mesh intraperitoneally; fix by transfascial sutures ± tackers. Mesh plane: intraperitoneal underlay. Complications: adhesion, chronic pain, mesh erosion, recurrence if inadequate overlap.
IPOM-Plus. Same indications as IPOM but when fascial closure is possible — restores the linea alba and reduces bulge/seroma. Steps: laparoscopic intracorporeal closure of the fascial defect with barbed suture, then IPOM mesh fixation. Complications similar to IPOM but with less bulging and lower recurrence.
Hybrid IPOM. For large defects (>10 cm) unsuitable for pure laparoscopic repair. Small open incision for adhesiolysis/defect closure, then laparoscopic intraperitoneal mesh placement. Combines open closure with minimal-access mesh delivery; wound contamination increases mesh infection risk.
TAPP (ventral) — Trans-Abdominal Pre-Peritoneal Repair. Indications: midline/paraumbilical defects 3–8 cm, thin mobile peritoneum. Contraindications: fragile/absent peritoneum, previous multiple laparotomies. Steps: laparoscopic transabdominal entry; create bilateral peritoneal flaps; close defect; place mesh preperitoneally with 5 cm overlap; re-approximate peritoneum to isolate mesh. Mesh plane: preperitoneal. Complications: peritoneal tears, seroma.
TARUP — Trans-Abdominal Retro-Rectus Umbilical Prosthetic Repair. A laparoscopic/robotic transabdominal approach recreating the retromuscular (retro-rectus) sublay space by opening the posterior rectus sheath from inside the peritoneal cavity — extraperitoneal mesh placement similar to open Rives–Stoppa, avoiding large incisions and intraperitoneal mesh contact. Indications: midline/incisional ventral hernias 3–10 cm; recurrent hernia after IPOM/onlay; durable repair with minimal wound morbidity. Contraindications: contaminated/infected field, frozen abdomen, massive LOD (prefer TAR/r-TAR). Effectively the laparoscopic Rives–Stoppa — inside-out retromuscular repair.
TARM — Trans-Abdominal Retro-Muscular Repair. A more extensive laparoscopic transabdominal sublay repair than TARUP, with wider/deeper retromuscular dissection (approaching a mini-TAR), enabling closure of larger or complex midline defects when eTEP or formal TAR aren’t feasible. Used for 6–12 cm or complex midline hernias, or after failed IPOM. More complex, higher risk of peritoneal breach; robotic variant r-TARM simplifies the extended dissection.
eTEP-RS — Enhanced-view Totally Extraperitoneal Retro-Rectus Sublay. Indications: small–large midline hernias, avoiding IP mesh. Contraindications: massive LOD, inability to tolerate pneumoperitoneum. Steps: entry via lateral port to retro-rectus space; develop both retro-rectus planes, cross midline; close defect; insert large mesh retromuscularly. Advantages: avoids peritoneal violation, low pain, early recovery.
eTEP-TAR — Enhanced-view Totally Extraperitoneal Transversus Abdominis Release. For large or LOD midline hernias. Same as eTEP-RS plus posterior sheath incision medial to linea semilunaris, dividing transversus for 8–10 cm advancement. Mesh plane: extended retromuscular. Advantages: tension-free closure via minimal access, excellent core restoration. Complications: bleeding, lateral wall bulge if over-dissected.
Open/Robotic TAR. For giant midline, complex recurrent hernias, LOD. Steps: retro-rectus dissection → posterior sheath incision → transversus division → posterior layer closure → midline closure → large retromuscular mesh. Robotic TAR (r-TAR) performs the same steps intracorporeally. Advantages: large mesh, tension-free closure, low recurrence. Complications: seroma, lateral wall bulge.
MILOS — Mini- or Less-Open Sublay Repair. For medium–large midline hernias needing reduced wound morbidity. Steps: 4–6 cm transhernial incision; endoscopic dissection of retromuscular/preperitoneal space; posterior reconstruction + fascial closure; large mesh placement. Advantages: combines open durability with minimal-access morbidity.
EMILOS — Endoscopic Mini- or Less-Open Sublay. Evolution of MILOS with the entire retromuscular dissection done endoscopically. Advantages: small scars, minimal wound morbidity, early discharge. Limitation: longer operative time.
SCOLA — Subcutaneous Onlay Laparoscopic Approach. For low midline or suprapubic hernias (below arcuate line). Steps: subcutaneous working space via suprapubic ports; develop preperitoneal space anterior to rectus; close defect and place mesh with fixation to Cooper’s ligament. Mesh plane: preperitoneal. Complications: injury to inferior epigastric vessels or bladder.
ELAR — Endoscopic-Assisted Linea Alba Reconstruction. For epigastric hernia or rectus diastasis with small defects. Steps: small midline incision; plicate linea alba to reconstruct midline; place mesh as onlay reinforcement. Advantages: excellent cosmetic result, restores core function. Complications: seroma, reduced by quilting sutures.
IPRA — Intraperitoneal Rectus Aponeuroplasty. For midline hernias with rectus diastasis. Steps: laparoscopic approach, incise posterior rectus sheath intraperitoneally; create retro-rectus pocket; close posterior layer; onlay mesh. Status: experimental, limited adoption.
| Technique | Description | Mesh plane |
|---|---|---|
| r-TARUP | Robotic access through peritoneal cavity → posterior sheath incision → retro-rectus mesh; essentially robotic TARM | Retromuscular |
| E-MILOS with peritoneal flap | Combines EMILOS with partial peritoneal flap for giant hernias | Retromuscular–preperitoneal |
| PLOR (Pre-rectus Laparoscopic Onlay Repair) | Mesh anterior to rectus, beneath skin, via laparoscopic ports; used when posterior plane inaccessible | Onlay |
| LIRA | Combines laparoscopic anterior plication and IPOM reinforcement | Intraperitoneal/onlay mix |
| Robo-SCOLA | Robotic variation of SCOLA for low midline defects | Pre-peritoneal |
| Robo-eTEP | Robotic enhancement of eTEP, improved ergonomics for suturing | Retromuscular |
| Technique | Approach | Mesh plane | Key step |
|---|---|---|---|
| IPOM / IPOM-Plus | Laparoscopic | Intraperitoneal | Mesh on peritoneum; Plus adds defect closure |
| TAPP | Laparoscopic | Pre-peritoneal | Peritoneal flap raised and closed |
| TARM / r-TARUP | Laparoscopic/robotic | Retromuscular | Posterior sheath incision from inside |
| eTEP-RS / eTEP-TAR | Endoscopic/robotic | Retromuscular | Totally extraperitoneal retromuscular dissection ± TAR |
| MILOS / EMILOS | Mini-open/endoscopic | Retromuscular/pre-peritoneal | Small transhernial access with large sublay mesh |
| TAR (open/robotic) | Open/robotic | Retromuscular | Transversus division, posterior reconstruction |
| SCOLA | Laparoscopic | Pre-peritoneal | Subcutaneous suprapubic access |
| ELAR | Hybrid | Onlay | Linea alba plication + mesh |
| ACS / E-ACS | Open/endoscopic | Onlay or sublay | External oblique release |
| Plane | Frequent complication |
|---|---|
| Intraperitoneal | Adhesion, fistula, chronic pain |
| Pre-peritoneal / retromuscular | Seroma, haematoma (minor) |
| Onlay | Seroma, infection |
| Extended posterior (TAR) | Lateral wall bulge |
| Anterior CS | Skin necrosis |
Modern incisional and ventral hernia surgery has transitioned from intraperitoneal bridging to anatomic midline restoration with large extraperitoneal mesh reinforcement. Techniques such as eTEP-RS, eTEP-TAR, MILOS, EMILOS, robotic TAR, and SCOLA provide durable, low-morbidity options tailored to hernia size and location, while BTA, PPP, and ciNPWT enhance safety and outcomes.