Dr. Brijendra Singh discusses the evolving role of Preperitoneal eTEP in ventral hernia repair at WALS 2025, presenting an advanced minimally invasive approach designed to address abdominal wall defects while keeping the prosthetic mesh outside the peritoneal cavity. The technique builds on the principles of extraperitoneal surgery and modern abdominal wall reconstruction, offering surgeons another option for appropriately selected patients with ventral and incisional hernias.

Ventral hernia repair has undergone substantial changes with the development of minimally invasive surgery. Traditional open repair remains an important option for many patients, while laparoscopic and robotic techniques have introduced alternative methods of accessing and reconstructing the abdominal wall. One of the major developments has been the transition toward retromuscular and preperitoneal mesh placement, which aims to position the prosthesis in a tissue plane separated from the abdominal viscera. eTEP represents one of the advanced minimally invasive methods used to achieve this objective.

The term Extended Totally Extraperitoneal reflects the expansion of the extraperitoneal concept beyond its original applications. In ventral hernia surgery, the surgeon develops a working space within the abdominal wall and extends the dissection across the midline or toward the required anatomical region. This allows access to the hernia defect and creation of an adequately sized space for mesh placement without making the peritoneal cavity the principal operative workspace.

A central principle of the technique is avoiding unnecessary intraperitoneal mesh placement. When mesh is placed inside the peritoneal cavity, it may come into contact with abdominal organs, particularly the bowel. Modern extraperitoneal approaches seek to position the prosthesis in a tissue plane between the abdominal wall layers, thereby separating the mesh from the visceral contents. This is an important consideration in the development of contemporary ventral hernia repair techniques.

The surgical procedure requires careful development of the retrorectus and preperitoneal spaces. The surgeon must identify the appropriate tissue planes and extend the dissection sufficiently to accommodate the planned mesh with adequate overlap around the defect. Anatomical landmarks guide the creation of the working space, while preservation of the abdominal wall's neurovascular structures is important during lateral dissection. The technical steps can differ depending on whether the defect is upper midline, lower midline, lateral, recurrent, or associated with previous abdominal surgery.

Another important component is closure of the hernia defect. Modern abdominal wall reconstruction increasingly emphasizes restoration of the abdominal wall anatomy rather than relying exclusively on a bridging mesh repair. In suitable cases, laparoscopic closure of the fascial defect can be combined with mesh reinforcement. This may help reconstruct the linea alba and restore abdominal wall continuity while the mesh provides additional reinforcement.

For larger or more complex ventral hernias, eTEP can be adapted to include additional abdominal wall reconstruction techniques. The literature describes combining eTEP with transversus abdominis release (TAR) in selected large defects, allowing development of a larger retromuscular plane and facilitating medial advancement of the abdominal wall. Such procedures require advanced expertise because the dissection becomes more extensive and the anatomy more complex.

The potential benefits of this approach include the use of small laparoscopic access incisions, extraperitoneal mesh placement, and the ability to perform anatomical abdominal wall reconstruction through a minimally invasive approach. Published studies have reported encouraging early and mid-term outcomes, although the available evidence varies according to technique, patient selection, hernia characteristics, and follow-up duration. More comparative and long-term studies are needed before definitive conclusions can be made about the relative benefits of different ventral hernia repair approaches.

An important aspect of Dr. Brijendra Singh's WALS 2025 presentation is the technical learning curve associated with eTEP. Unlike conventional intraperitoneal laparoscopy, the surgeon must become familiar with operating within the abdominal wall planes. Recognition of the correct tissue plane, management of peritoneal breaches, control of bleeding, maintenance of orientation, and safe lateral dissection are all important skills. Structured training and supervised experience can be valuable when surgeons begin adopting advanced extraperitoneal hernia techniques.

The technique may also be relevant to patients with diastasis recti associated with midline ventral hernias. Recent early clinical experience with preperitoneal eTEP has explored simultaneous management of small-to-medium primary midline hernias and diastasis while preserving the retrorectus space. Such applications demonstrate the versatility of extraperitoneal abdominal wall surgery, although evidence remains limited and longer follow-up is required.

The broader field of ventral hernia surgery now includes multiple minimally invasive options. An Indian Delphi consensus identified several techniques—including eTEP and other extraperitoneal approaches—as valid minimally invasive options, while emphasizing that procedure selection depends on factors such as hernia size, location, previous operations, and patient characteristics. This reinforces the importance of individualized surgical planning rather than applying one technique universally.

The WALS 2025 session by Dr. Brijendra Singh is therefore an important educational resource for surgeons interested in advanced hernia surgery and minimally invasive abdominal wall reconstruction. It demonstrates how modern laparoscopic techniques can be used to develop extraperitoneal working spaces, reconstruct abdominal wall defects, and position mesh in an anatomical plane outside the peritoneal cavity.

For general surgeons, laparoscopic surgeons, hernia specialists, robotic surgeons, and doctors undergoing advanced minimal access surgery training, the topic provides valuable insight into contemporary ventral hernia management. Understanding the principles of eTEP, patient selection, port placement, anatomical dissection, defect closure, mesh positioning, and management of complex defects is essential for surgeons seeking to develop expertise in advanced abdominal wall procedures.

Overall, Preperitoneal eTEP illustrates the continuing evolution of minimally invasive ventral hernia repair. Its emphasis on extraperitoneal access, anatomical mesh placement, defect closure, and abdominal wall reconstruction represents an important area of contemporary hernia surgery. Through his WALS 2025 presentation, Dr. Brijendra Singh highlights the technical possibilities of this approach while contributing to ongoing surgical education and discussion surrounding advanced minimally invasive abdominal wall repair.