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Ventral hernia repair with enhanced-view totally extraperitoneal technique after a massive weight loss by laparoscopic sleeve gastrectomy



Ventral hernia repair (VHR) for obese patients is often associated with an increased risk of postoperative complications and hernia recurrences. Achieving preoperative weight loss is ideal before VHR; however, it is difficult to attain with medical treatment. Metabolic and bariatric surgery (MBS) offers the most effective and durable treatment for obesity. Therefore, massive weight loss occurring after MBS will improve the outcome of VHR.

Case presentation

A 49-year-old man (122.9 kg, BMI 39.1 kg/m2) presented to our hospital wishing to undergo laparoscopic sleeve gastrectomy and VHR. Physical examination revealed a tennis ball-sized lower midline defect. Computed tomography (CT) scans revealed a hernia orifice 5 cm in width and 10 cm in height. As the hernia orifice was large, mesh reinforcement was essential. We planned for him to undergo VHR after massive weight loss was achieved by MBS. VHR was performed using the enhanced-view totally extraperitoneal (eTEP) technique after weight loss of 38 kg was achieved 9 months following laparoscopic sleeve gastrectomy. His postoperative course was uneventful, and neither recurrence nor seroma was observed at 1 year follow-up.


eTEP repair of a ventral hernia after massive weight loss following MBS would appear to be the best combination treatment for obese patients with ventral hernias. However, long-term follow-up is necessary to establish its safety and efficacy.


Obesity is associated with a high risk for the development of ventral hernias [1], the prevalence of which was reported to reach 8% in patients undergoing laparoscopic Roux-en-Y gastric bypass [2]. In addition, obesity increases the risk of postoperative complications and recurrences after ventral hernia repair (VHR) [3, 4]. Therefore, obese patients who plan to undergo VHR are strongly encouraged to lose weight preoperatively; however, this is very difficult to achieve with currently available medical treatment [5] other than metabolic and bariatric surgery (MBS). MBS offers the best option for treating obesity and its associated comorbidities [5]. Massive weight loss after MBS facilitates VHR and reduces postoperative complications and recurrences. Here, we report a case of an obese patient with a ventral hernia repaired using the enhanced-view totally extraperitoneal (eTEP) technique 9 months after laparoscopic sleeve gastrectomy (LSG).

Case presentation

A 49-year-old man (122.9 kg, BMI 39.1 kg/m2) presented to our hospital wishing to undergo LSG and VHR. His medical history included diabetes mellitus, hypertension, and hyperlipidemia. He had undergone urgent surgery for an umbilical hernia with incarcerated small bowel 18 months ago. The surgery included small bowel resection and direct closure of the defect without mesh reinforcement. Six months later, the umbilical hernia recurred. Physical examination revealed a tennis ball-sized lower midline defect. Computed tomography (CT) scans revealed a hernia orifice 5 cm in width and 10 cm in height in the infra-umbilical region (Fig. 1). As mesh reinforcement was essential to repair the ventral hernia, we planned for him to undergo VHR after LSG.

Fig. 1
figure 1

Abdominal CT shows an incisional hernia orifice in the infra-umbilical region (M3, M4)

LSG was performed using a standardized surgical technique with a 37.5 Fr bougie. Intraoperative findings revealed adhesion between the omentum and the hernia sac, which was not dissected during LSG. His postoperative course was uneventful, and after 9 months, he showed satisfactory weight loss (84.2 kg, BMI 26.8 kg/m2) and his comorbidities such as diabetes mellitus, hypertension, and hyperlipidemia were in remission. We then performed VHR using the eTEP technique.

After induction of general anesthesia and intubation, he was positioned with the bilateral upper extremities tucked at his sides. Figure 2 shows the port placement in this case. A 1.5-cm skin incision was made just below the left costal margin, and the anterior rectus sheath was identified and incised sharply. A 12-mm trocar was inserted posterior to the rectus abdominis muscle, and the left retrorectus space was developed (Fig. 3) followed by insertion of two 5-mm trocars at the port 2 and port 3 positions medial to the linea semilunaris. The left posterior rectus sheath was incised close to the linea alba, and then the right posterior rectus sheath was opened over the falciform ligament. After the preperitoneal and two retrorectus spaces were connected, a 12-mm trocar was inserted at port 4, and lateral dissection of the right posterior rectus sheath was done. Two 5-mm trocars were inserted at the port 5 and port 6 positions. The sac was opened, and intraabdominal adhesions were dissected (Fig. 4). Bilateral transversus abdominis muscle release was performed (Fig. 5). The posterior layer defect was closed with 3-0 multifilament suture material (Fig. 6). Then, the linea alba was restored with 1-0 barbed sutures (Fig. 7). BARD™ Mesh (Davol Inc., Warwick, RI, USA 02,886), a medium-weight small-pore (0.44 mm) polypropylene mesh of 26 cm width × 35.5 cm height, was positioned to cover the dissected area with no fixation (Fig. 8). A 19 Fr drain was placed over the mesh. The operating time was 452 min, and the amount of blood loss was nearly 0 g. The patient’s postoperative course was uneventful, the drain was removed 4 days after the surgery, and he was discharged on the same day. A CT scan 4 months after eTEP repair did not show recurrence or seroma (Fig. 9). At 1-year follow-up, he was doing well.

Fig. 2
figure 2

Port positions

Fig. 3
figure 3

The left retrorectus space was developed

Fig. 4
figure 4

Intraperitoneal dissection and repositioning of hernia contents

Fig. 5
figure 5

Bilateral transversus abdominis muscle release was performed

Fig. 6
figure 6

The posterior layer defect was closed with 3-0 multifilament suture material

Fig. 7
figure 7

The linea alba was restored with 1-0 barbed sutures

Fig. 8
figure 8

Medium-weight small-pore polypropylene mesh of 26 × 35.5 cm was positioned

Fig. 9
figure 9

CT scan images at 4 months follow-up


The appropriate management of obese patients with ventral hernias is still controversial. If obese patients become bariatric candidates and agree to undergo MBS, massive weight loss will be guaranteed. In this situation, the main issue is mainly focused on the timing of VHR, which is performed during or after MBS. Another issue is what kind of MBS and VHR is optimal for this subgroup of patients.

VHR performed during MBS is a definite benefit for patients as they do not have to undergo two separate surgeries. In addition, complications from the untreated hernia, such as bowel obstruction, may be avoided. Smaller hernias can be closed with simple suturing during MBS. However, mesh repair should be performed for most bariatric candidates needing VHR because mesh repair is recommended even for an umbilical hernia > 1 cm [6]. It is controversial whether to place mesh in clean-contaminated fields. Some authors have insisted on the safety of placing prosthetic mesh during MBS [2, 7,8,9,10,11], but limited data were presented.

Several studies have reported that VHR after MBS could reduce wound complications and recurrence rates [12,13,14,15,16,17,18,19]. Consequently, the current 2022 ASMBS and IFSO guidelines recommend two staged repairs [20]. Ventral hernias in obese patients tend to be large, which adds to the complexity of repair. Massive weight loss after MBS will increase the chances of a successful repair in patients with large or complex hernias. However, Eid et al. reported that deferring VHR after MBS was associated with a high rate of small bowel obstruction [7]. Therefore, the waiting period should not be unnecessarily prolonged. As weight loss generally stabilizes 9–12 months after MBS, VHR should be considered at that time [21].

The choice of optimal MBS for this subgroup of patients is another controversial issue. Ventral hernias can affect MBS, either by preventing adequate visualization of the operative field or by limiting the mobility of the small bowel required to restore gastrointestinal continuity. In this situation, laparoscopic Roux-en-Y gastric bypass is often not feasible. As LSG avoids small bowel adhesiolysis and thus prevents adhesiolysis-related morbidity, we consider LSG to be the preferred technique.

The open sublay technique (Rives–Stoppa) and laparoscopic intraperitoneal onlay mesh (IPOM) technique are commonly used in VHR; however, these procedures have their specific disadvantages [22, 23]. Rives–Stoppa has a higher rate of surgical site infection than laparoscopic VHR [22]. Furthermore, patients following MBS have a higher risk of surgical site occurrence after surgery requiring a large skin incision [24]. These findings indicate that open VHR, such as Rives–Stoppa, should be avoided, especially after MBS when laparoscopic VHR is available. eTEP repair was introduced in 2018 [25]. This technique can be performed laparoscopically and allows a surgeon to place a large flat synthetic mesh in the retrorectus plane. When comparing IPOM and eTEP, the latter is better in terms of less early postoperative pain and earlier return to activities [26]. Therefore, we considered that eTEP would be the best method for VHR after MBS. However, eTEP is technically challenging and prolongs operative time, which increases the potential perioperative risk for obese patients. Furthermore, entering the abdominal cavity for MBS makes it very difficult to maintain insufflation of the retromuscular space unless all ports for MBS are placed lateral to the semilunar line. This would indicate that eTEP access repair during MBS is technically challenging. Therefore, eTEP repair should be performed after massive weight loss is achieved with MBS.


To our knowledge, this is the first case report describing the use of the eTEP technique after LSG. Although long-term follow-up is necessary to establish its safety and efficacy, eTEP repair after massive weight loss achieved with MBS may be the best treatment for obese patients with ventral hernia.

Availability of data and materials

All data generated or analyzed during this study are included in this published article.



Ventral hernia repair


Metabolic and bariatric surgery


Enhanced-view totally extraperitoneal


Laparoscopic sleeve gastrectomy


Computed tomography


Intraperitoneal onlay mesh


  1. HJ Sugerman 2001 Effects of increased intra-abdominal pressure in severe obesity Surg Clin N Am 81 5 1063 1075

    Article  CAS  PubMed  Google Scholar 

  2. T Datta G Eid N Nahmias RM Dallal 2008 Management of ventral hernias during laparoscopic gastric bypass Surg Obes Relat Dis 4 6 754 757

    Article  PubMed  Google Scholar 

  3. S Sauerland M Korenkov T Kleinen M Arndt A Paul 2004 Obesity is a risk factor for recurrence after incisional hernia repair Hernia 8 1 42 46

    Article  CAS  PubMed  Google Scholar 

  4. E Veilleux R Lutfi 2020 Obesity and ventral hernia repair: is there success in staging? J Laparoendosc Adv Surg Tech A 30 8 896 899

    Article  PubMed  Google Scholar 

  5. L Sjöström 2013 Review of the key results from the Swedish Obese Subjects (SOS) trial—a prospective controlled intervention study of bariatric surgery J Intern Med 273 3 219 234

    Article  PubMed  Google Scholar 

  6. NA Henriksen A Montgomery R Kaufmann F Berrevoet B East J Fischer 2020 Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society Br J Surg 107 3 171 190

    Article  CAS  PubMed  Google Scholar 

  7. GM Eid SG Mattar G Hamad DR Cottam JL Lord A Watson 2004 Repair of ventral hernias in morbidly obese patients undergoing laparoscopic gastric bypass should not be deferred Surg Endosc 18 2 207 210

    Article  CAS  PubMed  Google Scholar 

  8. R Schuster MJ Curet RS Alami JM Morton SM Wren BY Safadi 2006 Concurrent gastric bypass and repair of anterior abdominal wall hernias Obes Surg 16 9 1205 1208

    Article  PubMed  Google Scholar 

  9. P Praveen Raj P Senthilnathan R Kumaravel S Rajpandian PS Rajan N Anand Vijay 2012 Concomitant laparoscopic ventral hernia mesh repair and bariatric surgery: a retrospective study from a tertiary care center Obes Surg 22 5 685 689

    Article  CAS  PubMed  Google Scholar 

  10. DL Chan ML Talbot 2014 Synchronous ventral hernia repair in bariatric patients Obes Surg 24 6 944

    Article  PubMed  Google Scholar 

  11. G Sharma M Boules S Punchai A Strong D Froylich NH Zubaidah 2017 Outcomes of concomitant ventral hernia repair performed during bariatric surgery Surg Endosc 31 4 1573 1582

    Article  CAS  PubMed  Google Scholar 

  12. WL Newcomb JL Polhill AY Chen TS Kuwada KS Gersin SB Getz 2008 Staged hernia repair preceded by gastric bypass for the treatment of morbidly obese patients with complex ventral hernias Hernia 12 5 465 469

    Article  CAS  PubMed  Google Scholar 

  13. JE Varela K Kane 2009 Laparoscopic repair of large flank hernia staged with laparoscopic sleeve gastrectomy in the morbidly obese Surg Obes Relat Dis 5 4 513 516

    Article  PubMed  Google Scholar 

  14. JE Hidalgo M Roy A Ramirez S Szomstein RJ Rosenthal 2012 Laparoscopic sleeve gastrectomy: a first step for rapid weight loss in morbidly obese patients requiring a second non-bariatric procedure Obes Surg 22 4 555 559

    Article  PubMed  Google Scholar 

  15. MM Chandeze D Moszkowicz A Beauchet K Vychnevskaia F Peschaud JL Bouillot 2019 Ventral hernia surgery in morbidly obese patients, immediate or after bariatric surgery preparation: results of a case-matched study Surg Obes Relat Dis 15 1 83 88

    Article  PubMed  Google Scholar 

  16. Y Borbély J Zerkowski J Altmeier A Eschenburg D Kröll P Nett 2017 Complex hernias with loss of domain in morbidly obese patients: role of laparoscopic sleeve gastrectomy in a multi-step approach Surg Obes Relat Dis 13 5 768 773

    Article  PubMed  Google Scholar 

  17. AD Schroeder T Mukherjee N Tashjian M Siu R Fitzgibbons K Nandipati 2021 Staged complex abdominal wall hernia repair in morbidly obese patients Hernia 25 2 383 387

    Article  CAS  PubMed  Google Scholar 

  18. DJ Morrell EM Pauli JR Lyn-Sue RS Haluck AM Rogers 2021 Laparoscopic sleeve gastrectomy in patients with complex abdominal wall hernias Surg Endosc 35 7 3881 3889

    Article  PubMed  Google Scholar 

  19. S Olmi M Uccelli GC Cesana F Ciccarese A Oldani R Giorgi 2020 Laparoscopic ventral hernia repair in bariatric patients: the role of defect size and deferred repair Obes Surg 30 10 3905 3911

    Article  PubMed  Google Scholar 

  20. D Eisenberg SA Shikora E Aarts A Aminian L Angrisani RV Cohen 2022 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) Indications for Metabolic and Bariatric Surgery Obes Surg 33 1 3 14

    Article  PubMed Central  Google Scholar 

  21. UA Dietz OY Kudsi F Gokcal N Bou-Ayash U Pfefferkorn G Rudofsky 2021 Excess body weight and abdominal hernia Visc Med 37 4 246 253

    Article  PubMed  PubMed Central  Google Scholar 

  22. FP Hartog den D Sneiders EF Darwish Y Yurtkap AG Menon FE Muysoms 2022 Favorable outcomes after retro-rectus (Rives–Stoppa) mesh repair as treatment for noncomplex ventral abdominal wall hernia, a systematic review and meta-analysis Ann Surg 276 1 55 65

    Article  PubMed  Google Scholar 

  23. F Köckerling T Simon D Adolf D Köckerling F Mayer W Reinpold 2019 Laparoscopic IPOM versus open sublay technique for elective incisional hernia repair: a registry-based, propensity score-matched comparison of 9907 patients Surg Endosc 33 10 3361 3369

    Article  PubMed  PubMed Central  Google Scholar 

  24. E Hasanbegovic JA Sørensen 2014 Complications following body contouring surgery after massive weight loss: a meta-analysis J Plast Reconstr Aesthetic Surg 67 3 295 301

    Article  Google Scholar 

  25. I Belyansky J Daes VG Radu R Balasubramanian H Reza Zahiri AS Weltz 2018 A novel approach using the enhanced-view totally extraperitoneal (eTEP) technique for laparoscopic retromuscular hernia repair Surg Endosc 32 3 1525 1532

    Article  PubMed  Google Scholar 

  26. M Jain A Krishna O Prakash S Kumar R Sagar R Ramachandran 2022 Comparison of extended totally extra peritoneal (eTEP) vs intra peritoneal onlay mesh (IPOM) repair for management of primary and incisional hernia in terms of early outcomes and cost effectiveness–a randomized controlled trial Surg Endosc 36 10 7494 7502

    Article  PubMed  Google Scholar 

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The authors thank Prof. Tina Tajima for her assistance in presenting our findings in English.



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MA wrote the manuscript. YI, IM, MG, KN, and KS participated in the surgery. All authors read and approved the final manuscript.

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Correspondence to Manabu Amiki.

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Amiki, M., Ishiyama, Y., Mochizuki, I. et al. Ventral hernia repair with enhanced-view totally extraperitoneal technique after a massive weight loss by laparoscopic sleeve gastrectomy. surg case rep 9, 27 (2023).

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