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Background <p>The enhanced-view totally extraperitoneal (eTEP) approach has broadened the applicability of retrorectus abdominal wall reconstruction (AWR). However, medium-to-large midline ventral and incisional hernias (VIH) often preclude primary fascial closure, requiring transversus abdominis release (TAR). Reliable preoperative predictors of TAR are essential for surgical planning.</p> Methods <p>Seventy-nine consecutive patients with midline VIH underwent laparoscopic eTEP-AWR between April 2020 and August 2025. TAR was performed when posterior sheath approximation was impossible despite adequate retrorectus dissection. Preoperative CT parameters included hernia width, rectus-to-defect ratio (RDR), and component separation index (CSI). Reproducibility was tested in 20 random cases by two blinded observers using intraclass correlation coefficients (ICC) and Bland–Altman analysis. Univariable and multivariable logistic regressions identified independent predictors, and diagnostic accuracy was assessed for RDR cutoffs of 2.0 and 2.35.</p> Results <p>TAR was required in 45 patients (57%). The TAR group had greater hernia width (6 vs. 4&#xa0;cm, p &lt; 0.0001), lower RDR (1.64 vs. 2.67, p &lt; 0.0001), and higher CSI (0.12 vs. 0.09, p = 0.0004). Reproducibility was excellent (ICC = 0.94 for RDR; 0.91 for CSI). Multivariable analysis identified hernia width &gt; 5&#xa0;cm (OR 6.64, p = 0.0021) and RDR &lt; 2.35 (OR 6.51, p = 0.0043) as independent predictors. No significant interaction with hernia type was found for RDR &lt; 2.35 (p = 0.84) or hernia width &gt; 5&#xa0;cm (p = 0.39).</p> Conclusions <p>Preoperative CT assessment of hernia width and RDR predicts the need for TAR in laparoscopic eTEP-AWR. RDR &lt; 2.35 provided superior diagnostic accuracy and may optimize surgical planning and patient counseling.</p>

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Predictive factors for transversus abdominis release in laparoscopic enhanced-view totally extraperitoneal repair of midline ventral and incisional hernias

  • 期刊论文

  • 发表日期：

    2026年1月26日

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  • Katsuhito Suwa,
  • Shigemasa Sasaki,
  • Takahiro Kitagawa,
  • Kentaro Chikaraishi,
  • Tomoyoshi Okamoto,
  • Ken Eto

摘要

Background

The enhanced-view totally extraperitoneal (eTEP) approach has broadened the applicability of retrorectus abdominal wall reconstruction (AWR). However, medium-to-large midline ventral and incisional hernias (VIH) often preclude primary fascial closure, requiring transversus abdominis release (TAR). Reliable preoperative predictors of TAR are essential for surgical planning.

Methods

Seventy-nine consecutive patients with midline VIH underwent laparoscopic eTEP-AWR between April 2020 and August 2025. TAR was performed when posterior sheath approximation was impossible despite adequate retrorectus dissection. Preoperative CT parameters included hernia width, rectus-to-defect ratio (RDR), and component separation index (CSI). Reproducibility was tested in 20 random cases by two blinded observers using intraclass correlation coefficients (ICC) and Bland–Altman analysis. Univariable and multivariable logistic regressions identified independent predictors, and diagnostic accuracy was assessed for RDR cutoffs of 2.0 and 2.35.

Results

TAR was required in 45 patients (57%). The TAR group had greater hernia width (6 vs. 4 cm, p < 0.0001), lower RDR (1.64 vs. 2.67, p < 0.0001), and higher CSI (0.12 vs. 0.09, p = 0.0004). Reproducibility was excellent (ICC = 0.94 for RDR; 0.91 for CSI). Multivariable analysis identified hernia width > 5 cm (OR 6.64, p = 0.0021) and RDR < 2.35 (OR 6.51, p = 0.0043) as independent predictors. No significant interaction with hernia type was found for RDR < 2.35 (p = 0.84) or hernia width > 5 cm (p = 0.39).

Conclusions

Preoperative CT assessment of hernia width and RDR predicts the need for TAR in laparoscopic eTEP-AWR. RDR < 2.35 provided superior diagnostic accuracy and may optimize surgical planning and patient counseling.