Daes Jorge, Hanssen Andrés, Luque Elika, Rocha Jose
Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Clínica Iberoamérica, Barranquilla, Colombia.
Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Clínicas Portoazul e Iberoamérica, Carrera 50 No 79-223 PH B., 850020, Barranquilla, Colombia.
Surg Endosc. 2025 May 29. doi: 10.1007/s00464-025-11816-z.
The enhanced-view totally extraperitoneal (eTEP) Rives approach has gained popularity for ventral hernia repair because it aligns with modern principles of abdominal wall reconstruction. This study addresses unresolved questions related to changes in abdominal contour, rectus muscle behavior, and rehabilitation as part of an ongoing quality improvement initiative.
Forty-five patients underwent a standardized eTEP repair for small ventral hernias with diastasis recti. Structured core training and electrostimulation were implemented postoperatively for the last 15 patients, while the first 30 received routine care. CT scans analyzed with the Ellipse 9 tool provided abdominal contour, eccentricity (c/a), semilunar line distance (X2), and rectus muscle width. Rectus muscle areas were measured pre- and postoperatively in 29 patients, and bulging during Valsalva was assessed in a subgroup of 17 patients. A mathematical formula for bulging was tested for its sensitivity and specificity.
Postoperative bulging occurred in 11.1% of non-stressed and 23.5% of Valsalva CT scans. The last 15 patients showed no bulging under non-stressed conditions (0% vs. 16.7%, p = 0.067) and demonstrated a significant improvement in eccentricity (p = 0.035). Postoperatively, the distance between the lateral borders of the rectus muscles (X2) decreased while the width increased, suggesting a curvilinear configuration. Rectus muscle atrophy was more pronounced on the right side across the entire group (p < 0.05) but was reversed in the last 15 patients. Rehabilitation improved contour and muscle recovery. The mathematical formula demonstrated high diagnostic accuracy, achieving 100% sensitivity and 95% specificity.
Postoperative bulging after eTEP repair is infrequent under non-stressed conditions but more prevalent during stress maneuvers. Structured rehabilitation reduced bulging and improved rectus muscle recovery. Changes in X2 and muscle length challenge traditional hypotheses regarding bulging mechanisms. This study underscores the importance of standardized imaging protocols, mathematical criteria for bulging identification, and structured recovery protocols.
强化视野完全腹膜外（eTEP）里夫斯手术因符合腹壁重建的现代原则，在腹疝修补术中越来越受欢迎。作为一项正在进行的质量改进计划的一部分，本研究解决了与腹部轮廓变化、腹直肌行为和康复相关的未解决问题。
45例患有腹直肌分离的小腹疝患者接受了标准化的eTEP修复。后15例患者术后进行了结构化核心训练和电刺激，而前30例接受常规护理。使用椭圆9工具分析的CT扫描提供了腹部轮廓、偏心率（c/a）、半月线距离（X2）和腹直肌宽度。对29例患者在术前和术后测量了腹直肌面积，并在17例患者的亚组中评估了瓦尔萨尔瓦动作时的膨出情况。测试了一个用于膨出的数学公式的敏感性和特异性。
在无压力的CT扫描中，11.1%出现术后膨出，在瓦尔萨尔瓦动作时的CT扫描中，23.5%出现术后膨出。后15例患者在无压力条件下未出现膨出（0%对16.7%，p = 0.067），并且偏心率有显著改善（p = 0.035）。术后，腹直肌外侧边界之间的距离（X2）减小，而宽度增加，表明呈曲线形态。在整个组中，右侧腹直肌萎缩更明显（p < 0.05），但在后15例患者中得到了逆转。康复改善了轮廓和肌肉恢复。该数学公式显示出较高的诊断准确性，敏感性达到100%，特异性达到95%。
eTEP修复术后在无压力条件下术后膨出不常见，但在应激动作时更普遍。结构化康复减少了膨出并改善了腹直肌恢复。X2和肌肉长度的变化挑战了关于膨出机制的传统假设。本研究强调了标准化成像方案、用于膨出识别的数学标准和结构化恢复方案的重要性。
