The eTEP Technique (extended Totally Extraperitoneal)

eTEP (extended Totally Extraperitoneal) is a laparoscopic approach to anterior abdominal wall defects that extends the extraperitoneal access of inguinal TEP to the whole retromuscular space: the mesh stays outside the peritoneal cavity, in contact only with the tissues of the wall.

eTEP was born from extending the inguinal TEP to the ventral wall and answers a precise need of minimally invasive wall surgery: obtaining a wide retromuscular plane for the mesh without entering the peritoneal cavity. The approach was described and codified by Igor Belyansky starting from 2012, with results published in 2018.

The principle: staying outside the peritoneum

In intraperitoneal approaches (IPOM, TAPP for the groin) the mesh or the operative field shares space with the viscera, with the risk of adhesions and the need for composite meshes or traumatic fixation. In eTEP the dissection develops between the rectus muscle and its posterior sheath — the same plane as the Rives-Stoppa technique — reached laparoscopically.

Access and dissection

Access is usually from above (hypochondrium), with the scope pointing downwards: an "inverted" view compared with inguinal TEP, called the enhanced view. The retromuscular space of one side is developed, the linea alba is divided to cross to the opposite side (crossover) when a bilateral pocket is needed, and below the dissection communicates with the preperitoneal space of the pelvis. The mesh is then laid out to widely cover the defect, with an overlap of at least 5 cm in every direction, and the defect is closed by suture before mesh placement.

Indications

• Primary and incisional midline defects (M2–M4 zones of the EHS classification)
• Midline incisional hernias of moderate width, even with contained loss of domain
• Defects associated with rectus diastasis when a minimally invasive approach is preferred
• Patients in whom a mesh in contact with the viscera is to be avoided

Advantages and limits

The reported advantages are fewer intraperitoneal adhesions, no traumatic mesh fixation, contained post-operative pain and a short stay, in line with enhanced recovery pathways. The limits are the learning curve, initially long operative times, difficulty in very lateral defects and the caution required in contaminated fields. In very wide defects the retromuscular pocket can be completed with a posterior component separation (TAR).

eTEP and the other approaches

Compared with TAPP for the groin, eTEP does not require opening and then closing the peritoneum; compared with IPOM, it places the mesh outside the abdominal cavity. The same dissection can be performed with robotic assistance, which facilitates suturing in deep spaces. The choice of approach remains part of the wider decision on the mesh placement plane.

The same family of extraperitoneal techniques includes TESAR (Totally Endoscopic Sublay Anterior Repair), developed by Dr. Fiori and published in 2019: the same retromuscular mesh position, but with an anterior endoscopic access through small suprapubic ports. The dedicated page on the hub reports technique, indications and long-term results.