Recent large sample size cohort studies reported that the incisional hernia incidence rate was higher with minimally invasive radical prostatectomy, including RARP, than with traditional open radical prostatectomy [3, 4]. The incidence rate of incisional hernia following RARP has been reported to be 4.4–8.6% [8,9,10,11]. It is speculated that the incisional hernia occurrence rate after RARP was higher than that after open prostatectomy, because the camera trocar and specimen extraction site were placed above or in the umbilical region in RARP, where the muscles are known to be weaker, as opposed to the infraumbilical incision in open prostatectomy [4]. Given the recent worldwide spread of RARP for the treatment of prostate cancer, the number of incisional hernia cases after RARP is expected to increase.
The laparoscopic approach to incisional hernia repair with the IPOM technique was first described by LeBlanc in 1993 [12]. It has been reported that the laparoscopic approach to ventral hernia, including incisional hernia repair, has lower wound complication rates and faster recovery than the open approach [12, 13]. Therefore, laparoscopic repair of ventral hernia is rapidly becoming widespread, especially laparoscopic IPOM, the most popular technique [14]. However, the IPOM technique has serious complications, such as mesh-related adhesive bowel obstruction, mesh erosion, enterocutaneous fistula, and tacker-related chronic pain [15,16,17]. Postoperative pain has also been reported to be associated with double crown fixation and transfascial sutures [18].
The eTEP technique, which is an endoscopically performed Rives–Stoppa technique, was first described by Miserez for ventral hernia repair [6]. The eTEP can avoid the aforementioned complications by placing a mesh in the retrorectus space, not only eliminating contact between the mesh and intra-abdominal organs, which can avoid mesh-related complications, but also facilitating the minimization of using penetrating fixation, thereby avoiding tacker-related chronic pain as well [7, 19]. In a retrospective comparative analysis, Penchev et al. reported that the differences between eTEP and laparoscopic IPOM for repair of ventral hernias were the reduction in mean postoperative video analog scale pain score and the longer operative time, both in favor of eTEP. They considered that a lack of fixation in eTEP led to a reduction in postoperative pain [19].
When dissecting the hernia sac for eTEP repair, careful procedures are required to avoid injury to intra-abdominal organs, such as the small bowel. We consider that dissecting the hernia sac with a laparoscopic scissors in small steps is useful to avoid damaging the intra-abdominal organs. It is controversial whether a prosthesis can use for the incisional hernia repair if a bowel resection is performed as a result of a bowel injury [20, 21]. Although no studies have been reported on post-RARP adhesions, some studies have reported that laparoscopic surgery reduced adhesion formations for reasons, such as reduced peritoneal incision size, introduction of fewer foreign bodies, and less tissue trauma and bleeding than open surgery [22, 23]. Therefore, we consider that eTEP repair is one of the best treatment procedures for incisional hernia after minimally invasive surgery. On the other hand, we consider that eTEP repair is challenging for incisional hernia patients with large defects, for post-laparotomy cases, and for recurrence cases. For those challenging incisional hernia cases, endoscopic transversus abdominis muscle release, which is one of the posterior component separation procedures, is useful as a minimally invasive surgery [24]. Belyansky reported that transversus abdominis muscle release was helpful in cases with wide (> 10 cm) defect, tension of the posterior layer, narrow retrorectus space (< 5 cm), or when dealing with a compliant abdominal wall [7].
