A Novel Modification of Subcutaneous Onlay Endoscopic Repair of Midline Ventral Hernias With Diastasis Recti: An Indian Experience.

Introduction A ventral hernia is a common problem in the population. Many patients with umbilical/epigastric hernia often present with diastasis recti (DR) too. Diastasis recti is the thinning of the linea alba with an abnormal increase in the distance between the recti without a concomitant fascial defect. The presence of diastasis recti complicates the repair of the existing umbilical/epigastric hernia. Repair of only the umbilical/epigastric hernia in the presence of DR results in incomplete repair and predisposes to recurrence. There are various options available for the repair of umbilical hernia with diastasis recti. Open hernia repairs often have unsatisfactory cosmetic outcomes and, furthermore, involve complications frequently associated with large incisions such as surgical site occurrences (SSO), pain, dermal flap necrosis, and delayed postoperative recovery, to name a few. The era of minimal access surgery leaves us with a vast array of creative solutions to the same. Laparoscopic onlay repair has been given various names in literature, e.g., minimally invasive linea alba reconstruction (MILAR), pre-aponeurotic endoscopic repair (REPA), endoscopic linea alba reconstruction (ELAR), subcutaneous onlay laparoscopic approach (SCOLA), and totally endoscopic assisted linea alba reconstruction (TESLAR), with similar principles for all the procedures. The average rate of seroma formation in these procedures varies from 5% to 40%. SCOLA has been used in our study, with an added modification of the operating port and limiting the extent of lateral dissection with the aid of spinal needles, resulting in restrained dissection and creation of smaller lipocutaneous flaps, leading to reduced incidence of seroma formation. Methods Patients with symptomatic primary ventral hernia with concomitant diastasis recti were enrolled in the participating center from the period of May 2020 to December 2021. Thirty patients were enrolled for this prospective study. The patients underwent subcutaneous laparoscopic onlay repair of midline ventral hernia with diastasis recti, with plication of the defect and onlay placement of a polypropylene mesh. Results Six point sixty-six percent (6.66%) of the patients developed seroma and SSO. The incidence is congruent with the results available in current literature. None of the patients had necrosis of umbilical skin. There were no recurrences at the three months follow-up. Conclusion Our modification of SCOLA is an ergonomically favorable procedure and has comparable outcomes to other approaches, with minimal complications.

SubCutaneous OnLay endoscopic Approach (SCOLA) for midline ventral hernias associated with diastasis recti.

INTRODUCTION: Minimally invasive surgery for diastasis recti has gained attention in the recent past, with several reports with different names and particularities being suggested by the authors. SCOLA (Subcutaneous OnLay endoscopic Approach) is an example of this technique, described here in standardized technique. DESCRIPTION OF THE TECHNIQUE: Basic steps to perform the procedure are detailed, beginning with patient and surgical team positioning, including trocar placement and tips and tricks of the subcutaneous dissection, steps needed to achieve full dissection of the preaponeurotic space, diastasis recti plication, mesh positioning and fixation and drain positioning with fixation of the umbilical stalk. DISCUSSION: Regardless of different names and small technical variations, endoscopic pre-aponeurotic mesh positioning can be performed with well-established steps on a reproducible fashion, aiming to achieve better results. Careful attention should be paid to appropriate patient selection and drain placement to reduce seroma rate, the most common complication.

SubCutaneous OnLay endoscopic Approach (SCOLA) mesh repair for small midline ventral hernias with diastasis recti: An initial US experience.

BACKGROUND: Patients presenting for evaluation of umbilical and epigastric hernias are often found to have diastasis recti (DR). As isolated hernia repair in these patients may be associated with higher rates of recurrence, prior international publications have described a prefascial mesh repair in combination with anterior plication of DR. We present our initial United States (US) experience with a SubCutaneous OnLay endoscopic Approach (SCOLA) to address these concurrent pathologies in a single hybrid procedure. METHODS: Between July 2018 and December 2019, a prospective cohort of 16 patients underwent the SCOLA procedure. Subcutaneous dissection was carried out from the suprapubic region superiorly to the xiphoid process and laterally to the linea semilunaris. Hernia contents were reduced and defects were incorporated into anterior DR plication, which was performed with running barbed suture. Onlay mesh was placed to cover the entire dissected space, and subcutaneous drains were placed. Three separate attendings performed cases with one supervising attending for standard technique. RESULTS: Of 16 patients, 14 (87.5%) were female. The mean age was 45.7 (11.9) years; mean BMI was 29.0 (3.6) kg/m2. The mean hernia defect size was 1.9 (0.7) cm. Mean operative time was 146 (46.3) minutes; two (15%) cases were performed robotically. The mean follow-up time was approximately two months (63 days). Three (18.8%) patients developed seroma, one (6.3%) patient developed an infected seroma, and two (12.5%) patients developed hernia recurrence. CONCLUSIONS: SCOLA technique is shown to be a safe and effective approach for patients presenting with small midline ventral hernias and concomitant DR. Our preliminary US data demonstrates higher rates of post-operative complication in patients with higher BMI, which suggests that patient selection and pre-operative counseling is essential to achieve better technical outcomes in our patient population.

Vasomotor changes in abdominal skin after endoscopic subcutaneous/Preaponeurotic Repair of Diastasis Recti (REPA).

INTRODUCTION: Diastasis recti is a common condition with functional and cosmetic effects that can occur in both female and male patients. However, it is more prevalent in females after pregnancies and can be associated with midline hernias. The preaponeurotic endoscopic repair (REPA) has become an emerging procedure for the surgical treatment of this condition. CASES REPORT: We present four cases of vasomotor changes in the abdominal skin, during physical activity or heat exposure, limited to the subcutaneous dissection area after REPA. All patients reported occasional skin redness (erythema) in the subcutaneous dissection area, triggered by exposure to heat or sunlight. The skin redness subsided completely in all the patients after a few minutes in a cool environment and after cessation of physical activity. DISCUSSION: Recently, subcutaneous preaponeurotic repair of diastasis recti has gained popularity. Changes in abdominal skin sensitivity have been reported, but to the best of our knowledge, this is the first report of what appears to be vasomotor skin changes after these procedures. CONCLUSION: Vasomotor changes can occur after endoscopic dissections of the abdominal skin and subcutaneous tissue. Incidence and causes remain unclear.