Peritoneal Rent: No Hindrance to Completing eTEP Hernia Repair

Background

The eTEP (extended totally extraperitoneal) approach to hernia repair has gained considerable traction in laparoscopic hernia surgery over the past decade. By working in the retromuscular space and extending across the midline, eTEP allows placement of a large mesh with excellent coverage — making it particularly suitable for bilateral inguinal hernias, recurrent hernias, and cases where an extended retromuscular space is required.

One of the commonly encountered intraoperative complications during eTEP is an inadvertent peritoneal rent — a breach in the peritoneal layer that creates communication between the extraperitoneal working space and the peritoneal cavity. When this occurs, CO₂ from the working space escapes into the peritoneum, the abdomen distends, and the working space can collapse — making dissection progressively more difficult.

The traditional response to a significant peritoneal rent has been conversion: abandoning the extraperitoneal approach and converting to a transabdominal procedure such as TAPP (transabdominal preperitoneal repair). However, conversion carries its own implications — change in mesh position, longer operative time, and potentially higher morbidity.

The Clinical Question

"Does an inadvertent peritoneal rent during eTEP necessitate conversion — or can the repair be safely completed in the same approach?"

This was the central question our study set out to answer. Our experience at PGIMER Chandigarh had shown that peritoneal rent, when managed correctly, need not be a reason to abandon the eTEP approach.

Our Approach to Managing the Rent

The key principles we established for managing peritoneal rent during eTEP are:

1. Early recognition — identifying the rent before the peritoneum fully tears and the working space is lost.
2. Controlled release of pneumoperitoneum — using a Veress needle or secondary port to decompress the peritoneal cavity, restoring the extraperitoneal working space.
3. Temporary occlusion of the rent — using a clip, suture, or surgical gauze to temporarily close the defect and maintain pneumoretroperitoneum.
4. Completion of dissection — proceeding with the dissection in a systematic manner, using the now-stabilised working space to place mesh as planned.
5. Definitive closure of the rent — suturing or clipping the peritoneal defect at the end of the procedure before closure.

Why This Matters for Surgeons

For laparoscopic surgeons performing eTEP, the fear of peritoneal rent is real — particularly for those earlier in the learning curve. The knowledge that this complication can be managed without conversion has two important implications:

• It reduces surgical anxiety and encourages surgeons to persist with the extraperitoneal approach rather than converting prematurely.
• It standardises the management of this complication, providing a clear stepwise protocol rather than an ad hoc response.

The peritoneal rent, when managed correctly, becomes a manageable intraoperative event rather than a reason to abandon the plan. This has direct implications for patient outcomes — avoiding conversion means smaller incisions, faster recovery, and the full benefits of the eTEP mesh positioning.

Clinical Implications for Hernia Patients in Ranchi

From my practice at Samford Hospital, Ranchi, the eTEP approach has become one of the preferred techniques for complex hernia cases — particularly bilateral inguinal hernias and recurrent hernias where a larger, more securely positioned mesh is required.

Patients who have had previous abdominal surgeries, those with bilateral hernias, or those who have had a previous hernia recurrence are often the best candidates for eTEP. The larger mesh footprint reduces the risk of long-term recurrence compared to standard TEP or TAPP in some anatomical situations.

About the Publication

This research was conducted during my time at PGIMER Chandigarh, alongside co-authors Srishti Swarupa, Leesa Misra, Nivedita Sahoo, Manash Ranjan Sahoo, and Sreeparna Ghosh. It was published in the Asian Journal of Medical Sciences in February 2024.

The full paper is accessible via DOI: 10.3126/ajms.v15i2.51501

My complete research profile, including both publications, is available on ORCID: 0000-0002-0344-1229