The Iskandar Complex Hernia Center Releases Video of an ETEP Repair of a Complex Hernia

Waxahachie, Texas -

The Iskandar Complex Hernia Center, a medical center in Waxahachie, TX that offers complex hernia surgery and advanced abdominal procedures, has released a new video where the clinic’s chief physician Dr. Iskandar, MD, FACS, performs an enhanced totally extraperitoneal (eTEP) left subcostal complex hernia surgery.

The newly posted video, produced for physicians and surgeons to view, walks through a robotic eTEP access Rives-Stoppa with a left Transversus Abdominis Release (TAR) for a recurrent left subcostal hernia. The patient in the video presented to the doctor with a bulge on his left side after a Whipple which was repaired previously with a robotic intraperitoneal only mesh (IPOM).

The eTEP procedure involves accessing the retro-rectus spaces along with the preperitoneal spaces of Retzius and Bogros and performing a rives stop repair. eTEP technique for ventral hernias was developed by Dr. Belyansky et al based on the work of Dr Daes et al in inguinal hernias.

In the video, the doctor accesses the left retro rectus space below the patient’s incision and initiates dissection with the camera. Once he is able to place the first trocar, he starts the dissection using a hook into the space of Retzius and develops the space for placement of three suprapubic trocars. The doctor then demonstrates a dissection of the right space of Bogros in the preperitoneal plane.

Then, in the eTEP Repair of Hernia video, the robot is docked, and the dissection is initiated. First, the right retro muscular space is dissected which leads the doctor to spot a defect in the peritoneum that was created. The doctor mentions in the video that the defect does not interfere with continuing the surgery and that it will be repaired towards the end of the procedure. Then, the left retro muscular space is dissected as the balloon tip trocar that was used for access is visible.

The doctor then continues the dissection towards the semilunar line heading superiorly. He then showcases the division of the posterior rectus sheath at its insertion on the linea alba where an inverted “V” of the two posterior sheaths and the preperitoneal bridge in between is seen. The neurovascular bundles are visible on the right side. As the scar is reached, it becomes obvious that there is more scarring, and the planes are not easily developed. The doctor mentions in the video that the planes are fused and it would be hard to dissect them. The doctor tries to stay high up on the rectus muscle, doesn’t manage to get a good plane to dissect there, and decides to go around on each side.

Eventually, the doctor goes more medially and decides to dissect more in the preperitoneal space and gets more progress done there. The doctor then proceeds to reduce the hernia which mostly looks like preperitoneal fat and continues the preperitoneal dissection in the subxiphoid space. The doctor mentions that the goal is to get as much superior mesh overlap and as much lateral mesh overlap as possible with the limiting step being the left lateral overlap.

The doctor then transitions into a pre-transversalis plane to allow dissection, especially more laterally to get the lateral coverage that he needs. He heads laterally, dividing the posterior lamina of the internal oblique and fibers of the transabdominis muscle. He then points out that while doing a partial TAR he noticed a defect in the posterior layer which was also repaired at a later stage.

The video then shows the end of the dissection where the defect is measured to be about 6 centimeters by 8 centimeters wide. The doctor says that he has a minimum of 8 centimeters superior overlap and lateral mesh overlap, which is satisfactory for his needs. The doctor then proceeds with the closure of the peritoneal defects. He then closes the fascia with a number one symmetric STRATAFIX suture. The video is then sped up 3x while incorporating some bites into the hernia sac to obliterate the dead space.

Dr. Iskandar, MD, FACS, is a board-certified general surgeon with fellowship training in minimally invasive bariatric surgery who specializes in complex hernia repair and abdominal reconstruction. The doctor’s previous surgical video where he performed a recurring right inguinal hernia repair is also available to be studied.

The Iskandar Complex Hernia Center is receiving hernia and complex hernia repair referrals. The center can be contacted at the phone number (469) 800-9832 or at the email address info@iskandar.


For more information about The Iskandar Complex Hernia Center, contact the company here:

The Iskandar Complex Hernia Center
Mazen Iskandar
The Iskandar Complex Hernia Center
2460 I-35E Suite 215-B
Waxahachie, TX 75165