Laparoscopic Trans-Abdominal Retromuscular (TARM) Repair for Ventral Hernia: A Novel, Low-Cost Technique for Sublay and Posterior Component Separation

Background The complications of intraperitoneal onlay mesh repair for ventral hernia has favored sublay mesh placement like open Rives-Stoppa repair (ORS). There was a need for low-cost laparoscopic trans-abdominal repair using a polypropylene mesh (PPM) with sublay, midline closure and addition of posterior component separation (PCS) by transversus abdominis release (TAR). Methods The techniques used three or six operating ports with triangulation. After adhesiolysis, a transverse incision was made on the peritoneum (P) and posterior rectus sheath (PRS). The retromuscular space was developed by raising a P-PRS flap. Midline closure was performed with No. 1 polydioxanone, and a PPM was placed in sublay, followed by closure of defect and P-PRS incision. For large hernias with divarication; myo-fascial medialization using PCS-TAR aided low-tension midline closure. Results Eighty-nine patients were operated from 2010 to 2019, 26 primary ventral; 63 incisional; and 22 recurrent hernias. Of the primary, 21 were umbilical, one Spigelian and four epigastric hernias. The incisional group had 57 patients with lower midline scars (C-section 25, open tubal ligation 15, abdominal hysterectomy 17), five lateral (appendicectomy), one post-laparotomy. The mean age, male/female sex ratio and BMI were 41.23 years, 1:10.1 and 29.2 kg/m(2), respectively. Mean defect and mesh area were 110 cm(2) and 392 cm(2). Mean operating time was 192 min. Conversion to open, mesh infection and recurrence rates were 3.4%, 1.1% and 5.62%. Conclusion Laparoscopic TARM with PPM in sublay avoids mesh-bowel contact. It provides midline closure and PCS-TAR within the same port geometry with results comparable with ORS.