PREOPERATIVE LOCALIZATION OF LANDMARKS IN LAPAROSCOPIC ETEP VENTRAL HERNIA REPAIR BY CONVENTIONAL METHOD AND ULTRASOUND-GUIDED METHOD - A COMPARATIVE STUDY

Abstract

Background: The enhanced-view totally extraperitoneal (eTEP) technique is an innovative approach developed by Jorge Daes in 2012 for inguinal hernia repair. This eTEP procedure was latter used by Belyansky for management of ventral hernias. Laparoscopic intraperitoneal onlay mesh (IPOM) was the preferred technique for the past three decades in treating ventral hernias laparoscopically. It has revolutionized  hernia surgery by  minimally invasive techniques. Although IPOM has a short learning curve, it has many disadvantages including, high cost of the prosthetic materials and adhesions to intra abdominal organs  . Many of the pitfalls of IPOM procedure was overcome with the advent of eTEP procedure. But one of the main disadvantages of the eTEP retro-rectus (RS) technique is its longer learning curve. To overcome this, simplifying the critical steps of the procedure is essential. One such critical step in eTEP surgery is the introduction of the first trocar , which can be done in a ideal site , using ultrasound-based localization of abdominal wall landmarks. While traditional landmark-based techniques are commonly used to identify the primary port entry site, preoperative ultrasound guided marking  offers advantage of precise primary trocar entry, thereby facilitating  a smooth and successful completion of the procedure1. Methods: In this retrospective comparative study conducted between 2021 and 2024, 60 patients who underwent laparoscopic eTEP repair by single surgeon at Saveetha Medical College were analyzed. Thirty patients underwent conventional surface landmark–based localization of landmarks, while the remaining thirty underwent real-time preoperative ultrasound (US)–guided skin marking of key anatomical landmarks. Demographic and clinical variables assessed included type of hernia and body mass index (BMI), intraoperative parameters such as ideal trocar entry site , duration of surgery and intraoperative complications, and postoperative outcomes including pain scores, seroma formation, wound infection, and length of hospital stay. The primary outcome measures were ideal retro-rectus trocar placement and successful crossover, ease of suturing  in M1 area. Secondary endpoints included intraoperative complications such as accidental pneumoperitoneum, neurovascular bundle injury at the linea semilunaris, deep inferior epigastric (DIE) vessel injury, and total operative duration and succusful completion of the procedure. Results: A total of 60 patients were studied—30 in the USG-guided group and 30 in the conventional group. Both groups were comparable in age and hernia type distribution (p > 0.05). Gender distribution showed a significant difference (p = 0.001), with more females in the USG group and more males in the conventional group. The incidence of divarication was slightly higher in the USG group (40%) than in the conventional group (37%) (p = 0.016). Ideal primary port entry was achieved in all USG-guided cases (100%) compared to 70% in the conventional group (p < 0.001), where as in 30% of cases the trocar entry did not happen at the desired point. No neurovascular injuries occurred in either group. The mean time for anatomical landmark marking was significantly longer in the USG-guided group (7.5 ± 3.5 min) than in the conventional group (2.6 ± 1.8 min) (p < 0.001). Conclusion: Ultrasound seems to be a useful tool for localization of landmarks in eTEP procedure which ultimately helps the surgeon to perform a successful surgery and it helps in decreasing the learning curve of eTEP technique