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Anatomical Considerations and Tips for Laparoscopic and Robotic-Assisted Enhanced-View Totally Extraperitoneal Rives-Stoppa Repair for Midline Hernia
腹腔镜和机器人辅助增强视野完全腹膜外 Rives-Stoppa 中线疝修补术的解剖学考虑因素和技巧

Jorge Daes, MD, FACS, Igor Belyansky, MD, FACS
Jorge Daes，医学博士，全科医学硕士；Igor Belyansky，医学博士，全科医学硕士

The enhanced-view totally extraperitoneal (eTEP) approach was developed to facilitate
开发增强视野完全腹膜外（eTEP）方法是为了方便
extraperitoneal repair of complex inguinal hernias. It soon became evident that the technique could be used to approach other hernias, initially Spigelian and low abdominal defects (M5), and later, with the crossover described by Belyansky, ventral, incisional, and lumbar hernias.
腹膜外修复复杂的腹股沟疝。 很快，人们发现这种技术也可用于其他疝气的治疗，最初是 Spigelian 和低腹部缺损（M5），后来通过 Belyansky 所描述的交叉术， 腹股沟疝、切口疝和腰椎疝。
The "eTEP access concept" is a set of operative maneuvers and strategies to enhance the usable extraperitoneal space for minimally invasive hernia repair and other procedures. These maneuvers include retromuscular access and development of a large extraperitoneal space and division of the natural boundaries of the extraperitoneal space, such as the arcuate line and the medial aspect of the posterior rectus sheath (PRS) bilaterally, when necessary. When additional myofascial medialization is necessary, or when repairing a lateral hernia, division of the posterior lamella of the internal oblique and transversus abdominis muscle contributions is performed. Most of these maneuvers are initiated medial to the semilunar lines. However, the eTEP approach can be used to access the extraperitoneal space just lateral to the semilunar lines. Such an approach can be used to repair lateral lumbar hernias (L4), for example, or to perform posterior triple neurectomy.
eTEP 通路概念 "是一套手术操作和策略，用于提高腹膜外空间的可用性，以进行微创疝修补术和其他手术。 这些操作包括再肌层进入和开发大的腹膜外空间，以及必要时分割腹膜外空间的自然边界，如双侧弓形线和后直肠鞘（PRS）的内侧。当需要进行额外的肌筋膜内侧化或修复外侧疝气时，可进行腹内斜肌和腹横肌后壁的分割。这些手术大多在半月线内侧进行。不过，eTEP 方法可用于进入半月线外侧的腹膜外间隙。例如，这种方法可用于修复外侧腰疝（L4）或进行后三叉神经切除术。
The eTEP approach fulfills all modern principles for the repair of ventral hernias. In the hands of welltrained hernia surgeons, the approach is safe and effective,
eTEP 方法符合修复腹股沟疝的所有现代原则。 在训练有素的疝气外科医生手中，这种方法既安全又有效、
and improves the patient's quality of life, as has been demonstrated in more than 30 publications in the last 2 years. However, the eTEP approach is a complex operation that requires in-depth knowledge of the anatomy of the extraperitoneal space and natural boundaries. Formal training is necessary and ideally, includes working closely with an experienced mentor and practicing with a cadaver model before performing the procedure in a clinical setting. The technical aspects of eTEP ventral hernia repair are well described elsewhere. The purpose of this article is to present strategies that facilitate the procedure, especially for midline hernias in the umbilical and periumbilical areas and for surgeons early in their experience.
并提高患者的生活质量，过去两年中已有 30 多篇论文证明了这一点。 然而，eTEP 方法是一项复杂的手术，需要深入了解腹膜外间隙的解剖结构和自然边界。正规的培训是必要的，理想的培训包括与经验丰富的导师密切合作，并在临床环境中实施手术前使用尸体模型进行练习。关于 eTEP 腹股沟疝修补术的技术方面，其他地方已有详细描述。本文的目的是介绍促进手术的策略，尤其是针对脐部和脐周的中线疝以及经验尚浅的外科医生。

TECHNICAL CONSIDERATIONS TO ASSURE REPRODUCIBILITY OF eTEP RIVES VENTRAL HERNIA REPAIR
确保 eTEP RIVES 上腹部疝气修复的可复制性的技术考虑因素

It has been recommended that surgeons learning the technique first use the eTEP approach to repair small midline hernias associated with diastasis recti. These hernias, however, can be challenging to address, especially in patients with a small abdomen and pre-existing scars. We offer maneuvers to facilitate this procedure and other eTEP hernia repairs in a reproducible fashion.
建议学习该技术的外科医生首先使用 eTEP 方法修复与直肠膨出相关的小中线疝。然而，这些疝气的修复可能具有挑战性，尤其是对于腹部较小并已存在疤痕的患者。我们提供了一些操作方法，以便以可重复的方式进行这种手术和其他 eTEP 疝修补术。

CREATING THE eTEP RIVES SPACE IN STAGES
分阶段创建 eTEP RIVES 空间

In stage 1 , the ipsilateral retrorectus space is developed; in stage 2 , the crossover is performed; and in stage 3 , the contralateral retrorectus space is developed. Stage 2 can be further subdivided into for the medial division of the ipsilateral PRS, 2B for the medial division of the contralateral PRS from above, and 2C for contralateral PRS division from below (Fig. 1).
在第 1 阶段，同侧直肌后间隙发育；在第 2 阶段，进行交叉；在第 3 阶段，对侧直肌后间隙发育。第 2 阶段可进一步细分为同侧 PRS 内侧分割 、对侧 PRS 内侧自上而下分割 2B、对侧 PRS 自下而上分割 2C（图 1）。

OPTIMIZING THE INITIAL RETRORECTUS SPACE
优化初始直肠后间隙

Imaging studies, especially CT, can be very helpful in evaluating and planning the repair of ventral hernias. CT imaging provides information on the location and size of defects and the dimensions of the retromuscular
影像学检查，尤其是 CT，对评估和规划腹股沟疝的修复非常有帮助。CT 成像可提供有关缺损位置和大小以及后肌层尺寸的信息。

Abbreviations and Acronyms
缩略语

eTEP enhanced view totally extraperitoneal PRS posterior rectus sheath
eTEP 完全腹膜外增强视图 PRS 后直肌鞘
spaces. We frequently use CT in patients with incisional defects and recurrent hernias. For primary ventral hernias, CT images are not typically obtained. Alternatively, a portable ultrasonic device may be used immediately before surgery to delineate the relevant anatomy. Identification of this anatomy is especially helpful for surgeons during the initial learning curve. The xiphoid process, subcostal margins, linea semilunaris, width of the linea alba, and the defect are marked with indelible ink (Fig. 2). The semilunar line may be more lateral than expected, especially in patients with large defects.
空间。我们经常对切口缺损和复发性疝气患者使用 CT。对于原发性腹股沟疝，通常不需要获取 CT 图像。或者，可以在手术前立即使用便携式超声波设备来划定相关解剖结构。这种解剖结构的识别对外科医生的初期学习尤其有帮助。剑突、肋骨下缘、半月线、白线宽度和缺损都要用不褪色墨水标记出来（图 2）。半月线的外侧可能会比预期的更宽，尤其是在缺损较大的患者中。
An often-overlooked anatomic fact is that the rectus abdominis muscle inserts a few centimeters above the costal margin, allowing access into the retrorectus space from this area (Fig. 3). The initial incision can be made above the costal margin. This is a transverse skin incision and a small incision of the anterior rectus fascia, followed by blunt finger dissection of the muscle to feel the posterior sheath, which is thin at this level. Care is taken to bluntly dissect the plane between the muscle and the sheath caudally. The balloon dissector is introduced to further dissect the space (Fig. 4). Alternatively, a regular trocar may be introduced, and blunt dissection performed.
一个经常被忽视的解剖事实是，腹直肌插入肋缘上方几厘米处，可从该区域进入腹直肌后间隙 （图 3）。初始切口可在肋缘上方 。这是一个 横向皮肤切口和一个直肌前筋膜小切口，然后用手指钝性剥离肌肉，摸到后鞘，后鞘在这一水平很薄。注意在尾部钝性剥离肌肉和鞘之间的平面。引入球囊剥离器进一步剥离空间（图 4）。或者也可以导入普通套管，进行钝性剥离。
The advantages of this high out-of-cavity approach are:
这种高腔外方法的优势在于
  1. A larger surgical space is obtained.
    获得更大的手术空间。
  2. The semilunar line is identified without the need for preoperative ultrasonography, therefore optimizing the ports' lateral placement (Fig. 4 shows the marking of the semilunar line guided by the inflated balloon).
    无需进行术前超声波检查即可确定半月线，从而优化端口的侧向放置（图 4 显示了充气球囊引导下的半月线标记）。
  3. The precostal port may be used as a vantage point to visualize the space caudally, which facilitates a high crossover and orientation and division of the medial aspect of the PRS further down.
    可将肋骨前端口作为观察尾部空间的有利位置，这有利于高位交叉和定位，并进一步向下分割 PRS 的内侧。
  4. The precostal port can also be used as an excellent suturing port for midline defects and diastasis recti.
    肋前孔还可用作中线缺损和直肠膨出的绝佳缝合孔。
Once the space is insufflated, the camera's optical axis is aligned with the retrorectus space.
一旦空间充气完毕，摄像头的光轴就会对准后直肌空间。
For most other eTEP access we prefer to use a Kii Fios First Entry port (Applied Medical) because it enables us to place the trocar under camera visualization with the help of pneumo-insufflation. The port is typically inserted off the costal margin about from the linea alba and about 3 to below the tip of the
对于大多数其他 eTEP 通道，我们更喜欢使用 Kii Fios First Entry 端口（应用医疗公司），因为它能让我们在摄像头可视情况下借助气动充气放置套管。通常在距白线约 处的肋缘外侧插入套管口，并将套管口插入白线顶端下方约 3 到 处。
Figure 1. Stages in execution of enhanced-view totally extraperitoneal Rives procedure.
图 1.完全腹膜外 Rives 手术的各个阶段。
Figure 2. The relevant anatomy should ideally be marked with indelible ink under ultrasonic guidance immediately before surgery. (Reprinted courtesy of the artist, Joe Chovan.)
图 2.最好在手术前立即在超声波引导下用不褪色墨水标记相关解剖结构。(转载由艺术家 Joe Chovan 提供）。
Figure 3. CT images. The straight vertical line in the upper axial image indicates the level of the rectus muscle, which corresponds to the lower sagittal image, showing the extension of the rectus muscle several above the costal margin. Note the retrorectus space available for access at this precostal area.
图 3.CT 图像。上部轴位图像中的垂直直线表示直肌水平，与下部矢状位图像相对应，显示直肌延伸至肋缘上方数 。注意肋骨前区域有直肌后方空间可供进入。
xiphoid process. The subcutaneous tissue, anterior rectus sheath, and rectus muscle are penetrated under vision with alternating, partially rotating movements and careful progressive advancement of the trocar while is vented. The trocar's angle relative to the surface is gradually reduced, and the assembly is introduced further, flush with the posterior sheath. The camera and assembly are then removed, and the camera is reintroduced to continue blunt dissection with the tip of the camera in conjunction with pneumo- dissection. Although this technique is reproducible, it may have a longer learning curve than the balloon-assisted dissection described above and we recommend its use after the surgeon has gained
剑突。通过交替、部分旋转的动作，在视野下穿透皮下组织、直肌前鞘和直肌，并小心地逐步推进套管，同时排出 。套管相对于表面的角度逐渐减小，组件被进一步导入，与后鞘齐平。然后移除照相机和组件，重新导入照相机，继续用照相机尖端进行钝性剥离，同时进行气腹剥离。虽然这种技术具有可重复性，但其学习曲线可能比上述球囊辅助剥离术更长，因此我们建议外科医生在掌握了这种技术后再使用。
Figure 4. A patient with midline ventral and left inguinal hernias. The left retrorectus space has been distended with the balloon dissector introduced through a precostal port. The left semilunar line is easily identified and is being marked with indelible ink.
图 4.中线腹股沟疝和左腹股沟疝患者。左腹股沟后间隙已用球囊剥离器从肋骨前孔导入膨胀。左侧半月线很容易辨认，正在用不褪色墨水做标记。
experience. Figure 5 shows the relevant anatomy once the retrorectus space has been developed (Stage 1).
经验。图 5 显示了直肠后间隙形成后的相关解剖结构（第一阶段）。
Many port configurations are available for the eTEP access approach, depending on the location and size of the defect, previous surgical procedures and scars, body habitus, surgeon preference, and technology used, among other factors. The lateral port set-up is the most common port configuration used in conjunction with the robotic platform. The upper port set-up is the second most commonly used, especially for the laparoscopic approach,
根据缺损的位置和大小、先前的手术过程和疤痕、体型、外科医生的偏好以及所使用的技术等因素，eTEP 入路有多种端口配置可供选择。外侧端口设置是与机器人平台结合使用的最常见端口配置。其次是上端口设置，尤其是腹腔镜方法、
Figure 5. Relevant anatomy after development of the left retrorectus space. The inset shows Stage 1 completed. (Reprinted courtesy of the artist, Joe Chovan.)
图 5.左后直肌间隙发育后的相关解剖结构。插图显示第一阶段已经完成。(转载由艺术家乔-乔万（Joe Chovan）提供）。
and we use the lower port set-up least often. The crossover should be initiated away from the level of the hernia sac. Figure 6 demonstrates the suggested camera and working port positions to start the upper crossover when the ventral hernia sac is in the periumbilical or supraumbilical region.
而我们使用下端口设置的频率最低。交叉手术应在远离疝囊的位置开始。图 6 展示了当腹侧疝囊位于脐周或脐上区域时，开始上交叉手术时建议使用的摄像头和工作孔位置。

OPTIMIZING THE CROSSOVER
优化分频器

The crossover is initiated by dividing the medial aspect of the ipsilateral posterior rectus sheath contributions to the linea alba. For midline hernias, this step is usually performed by using lateral ports, with the first release incision typically made in the upper midline. Full muscle relaxation is ensured. The medial limit of the retrorectus space is dissected free from adhesions. The division of the medial aspect of the PRS is undertaken 0.5 to lateral to the linea alba. Note that the posterior sheath curves upward to join the anterior sheath at this level. Once the incision is made in the PRS, it is important to stay superficial to the falciform ligament and just posterior to the linea alba, which still has undisturbed contributions from the anterior rectus sheath. Staying in the proper plane prevents inadvertent pneumoperitoneum (caused by straying posteriorly) and damage to the linea alba (caused by straying anteriorly). The grasper in the left hand should push the posterior sheath downward to facilitate this maneuver (Fig. 6). The division is performed by
将同侧后直肌鞘的内侧与白线分开，即可开始交叉。对于中线疝，这一步骤通常使用侧切口进行，第一个松解切口通常在中线上部。确保肌肉完全松弛。剥离直肠后间隙的内侧界限，清除粘连。在白线外侧 0.5 到 处进行 PRS 内侧分割。注意后鞘向上弯曲，在此水平与前鞘相连。一旦在 PRS 上做了切口，重要的是要保持在镰状韧带的浅表和白线的正后方，因为白线仍未受到前直肌鞘的干扰。保持在正确的平面上可防止腹腔积气（因偏向后方而造成）和损伤白线（因偏向前方而造成）。左手的抓取器应将后鞘向下推，以方便这一操作（图 6）。分割方法如下
Figure 6. Port set-up for the initial crossover (Stage 2A). Note the grasper in the left hand pushing down on the posterior sheath while the hook in the right divides the medial aspect of the posterior sheath below the linea alba. An additional camera and ports are possible. (Reprinted courtesy of the artist, Joe Chovan.)
图 6.初始交叉的端口设置（第 2A 阶段）。注意左手的抓钩向下按压后鞘，右手的钩子在白线下方分割后鞘内侧 。可能需要额外的摄像头和端口。(转载由艺术家 Joe Chovan 提供）。
using a hook, scissors, ultrasonic device, or ligasure device. We prefer using the back of the hook and low voltage (Fig. 7). Alternatively, robotic surgeons use scissors as a monopolar instrument.
使用钩子、剪刀、超声波装置或结扎装置。我们更倾向于使用钩背和低电压（图 7）。另外，机器人外科医生也使用剪刀作为单极器械。

STRATEGIES FOR DIVISION OF THE CONTRALATERAL MEDIAL ASPECT OF THE POSTERIOR RECTUS SHEATH
后直肌鞘对侧内侧的分割策略

There are 2 main options for dividing the medial aspect of the contralateral PRS. The first option is to perform the division early, before dealing with the hernia sac. This method has the advantage of expanding the space early in the procedure, which protects the surgical field from accidental pneumoperitoneum. Also, it allows placement of an additional port high in the contralateral retrorectus space (upper port configuration) for better orientation and further caudad division of the medial aspects of both posterior sheaths. This early division of the contralateral PRS is more commonly used during laparoscopic repairs.
分割对侧 PRS 内侧有两种主要方案。第一种方案是在处理疝囊之前尽早进行分割。这种方法的优点是在手术早期扩大空间，从而保护手术视野，避免意外腹腔积气。此外，还可以在对侧直肠后间隙（上端口配置）的高处放置一个额外的端口，以便更好地定位和进一步分割两个后鞘膜的内侧。在腹腔镜修复术中，这种早期分割对侧PRS的方法更为常用。
Once the preperitoneal space has been developed, selecting the place for the initial division of the medial aspect of the contralateral PRS and subsequent division caudad and cephalad in a straight line may be a challenge. Incising too far lateral during division of the contralateral PRS leads to creation of a larger rent, making posterior closure more difficult. Incising the contralateral PRS too far medial carries a risk of injury to the linea alba, with the associated risk of postoperative midline hernia. Several
腹膜前间隙形成后，选择对侧 PRS 内侧的初始分割位置以及随后在尾部和头侧直线分割可能是一个挑战。在分割对侧 PRS 时过多地向外侧切开会导致产生较大的隙缝，使后方闭合更加困难。将对侧PRS向内侧切开太远会有损伤白线的风险，同时也会带来术后中线疝的风险。几种方法
Figure 7. A more advanced stage of the division of the medial aspect of the posterior rectus sheath (Stage 2A). Dissection takes place above the falciform ligament. (Reprinted courtesy of the artist, Joe Chovan.)
图 7.后直肌鞘内侧分割的晚期阶段（第 2A 阶段）。解剖在镰状韧带上方进行。(转载由艺术家乔-乔万（Joe Chovan）提供）。
maneuvers can assist in this stage. One is the preoperative marking of the diastasis borders, placing needles at the upper and lower limits of the planned division of the contralateral PRS. The needles serve as intraoperative markers orienting the surgeon to the limits of the division (Fig. 8). Identification of the rectus muscle fibers through the transparent posterior fascia or by use of monopolar cautery to elicit muscle fasciculations can also guide the proper division of the PRS.
在这一阶段，有两种方法可以提供帮助。其一是术前标记裂隙边界，在计划分割对侧 PRS 的上下限放置针头。这些针头可作为术中标记，帮助外科医生确定分割界限的方向（图 8）。通过透明的后筋膜识别直肌肌纤维，或使用单极烧灼法引起肌肉筋膜收缩，也可以指导正确分割 PRS。
Alternatively, after division of the ipsilateral PRS, the hernia sac together with the falciform and umbilical ligaments may be dissected free of their attachments to the underside of the linea alba. The contralateral arcuate line is identified, and the contralateral medial aspect of the PRS is divided in a caudad-to-cephalad direction starting at the arcuate line. This maneuver can be used in robotic- or laparoscopic-assisted eTEP access repair of midline hernias. The robotic platform facilitates this
或者，在分割同侧 PRS 后，可将疝囊连同镰状韧带和脐韧带从其与白线下方的连接处剥离。确定对侧弧形线，然后从弧形线开始，从尾部到头部方向分割 PRS 的对侧内侧。 这种方法可用于机器人或腹腔镜辅助的 eTEP 入路中线疝修补术。机器人平台有助于
Figure 8. Division of the contralateral medial posterior sheath (Stage 2B) is guided by 2 needles placed at the planned limits of the division at this phase (insert). (Reprinted courtesy of the artist, Joe Chovan.)
图 8.对侧内侧后鞘（第 2B 阶段）的分割由放置在该阶段计划分割界限处的 2 根针引导（插入）。(转载由艺术家 Joe Chovan 提供）。
maneuver without creating accidental pneumoperitoneum or compromising the space (Fig. 9).
在不造成意外腹腔积气或影响空间的情况下进行操作（图 9）。

ACCESSING AND DEVELOPING BOTH RETRORECTUS SPACES AT THE OUTSET
从一开始就进入并开发两个后直肌空间

Developing both retrorectus spaces at the outset of the procedure facilitates part of Stage 1 and Stage 3, and protects against early accidental pneumoperitoneum (Fig. 10). However, this option still requires proper division of the medial aspect of the ipsilateral PRS, dissection of the preperitoneal space, and careful placement of the initial incision in the contralateral posterior sheath (Fig. 11).
在手术一开始就开发两个直肠后间隙有利于第一阶段和第三阶段的部分工作，并防止早期意外腹腔积气（图 10）。不过，这种方法仍需要适当分割同侧 PRS 的内侧、解剖腹膜前间隙，并将初始切口小心放置在对侧后鞘中（图 11）。

MANEUVERS TO FACILITATE CLOSURE OF THE ANTERIOR DEFECT AND DIASTASIS RECTI
帮助闭合前部缺损和直肠膨出的手法

Closure of the anterior sheath is more comfortable with robotic assistance and with ports in the lateral configuration. Some strategies can facilitate the laparoscopic approach. For example, when using an upper port configuration, we prefer to have the suturing hand working through the port most medial to the hernia defect (left
在机器人的协助下，前鞘的闭合更舒适，端口也是侧向配置。一些策略可以促进腹腔镜方法。例如，在使用上端口配置时，我们倾向于让缝合手通过疝气缺损最内侧的端口（左侧）进行缝合。
Figure 9. Division of the contralateral medial posterior rectus sheath is undertaken from the arcuate line cephalad (Stage 2C). A left-hand grasper is spread to guide the scissors in the right hand to divide the sheath properly in this robotic procedure. (Reprinted courtesy of the artist, Joe Chovan.)
图 9.从头侧弧线开始分割对侧内侧后直肌鞘（第 2C 阶段）。在这种机器人手术中，使用左手的抓钳引导右手的剪刀正确分割鞘。(转载由艺术家 Joe Chovan 提供）。
upper quadrant); therefore, the laparoscopic needle driver is parallel to the longitudinal axis of the hernia defect. The assistant provides visualization by using a 30 -degree laparoscope through a contralateral medial port (right upper quadrant). The use of an angled scope enables the surgical team to align and center the target anatomy during this step. The surgeon's nondominant hand works through a port just lateral to the suturing hand and typically holds a grasper to aid in needle manipulation (Fig. 12).
上象限）；因此，腹腔镜针驱动装置与疝气缺损的纵轴平行。助手通过对侧内侧端口（右上象限）使用 30 度腹腔镜进行观察。在此步骤中，使用倾斜的腹腔镜可使手术团队对准目标解剖结构并使其居中。外科医生的非惯用手通过缝合手外侧的端口进行操作，通常会握住一个抓手来帮助操作针头（图 12）。
Alternatively, the surgeon's nondominant hand can be used to push down on the abdominal wall from outside to help with limitations of laparoscopy and to bring the abdominal wall down to ease passage of the needle, which is controlled with a nonarticulating laparoscopic needle driver in the dominant hand (Fig. 13).
另外，外科医生的非惯用手可以从外部向下按压腹壁，以帮助解决腹腔镜手术的限制，并使腹壁向下，以方便穿刺针的通过，穿刺针由惯用手的非关节型腹腔镜穿刺针驱动装置控制（图13）。
Suturing can be performed with the surgeon seated on a stool and the operating table elevated and rotated so that the defect and diastasis are as frontal as possible (Fig. 13).
缝合时，外科医生可以坐在凳子上，将手术台抬高并旋转，使缺损和裂口尽可能位于正面（图 13）。
Additional helpful strategies include using as many ports as necessary to facilitate ergonomics, using barbed sutures, suturing from distal toward the surgeon, holding the needle upside down (backhanding the needle), and lowering the pressure when necessary.
其他有用的策略包括：根据需要使用尽可能多的 端口，以方便人体工程学设计；使用带倒刺的缝合线；从远端朝向外科医生缝合；倒持针头（反手持针）；必要时降低 压力。

CONCLUSIONS 结 论

The eTEP approach for hernia repair is a welcome development with tangible advantages. The method requires proper training, ideally including cadaver dissection and a mentor.
用于疝气修补的 eTEP 方法具有切实的优势，是一项值得欢迎的发展。这种方法需要适当的培训，最好包括尸体解剖和导师。
The maneuvers and strategies described may aid in the safe adoption of this procedure by the surgical community.
所描述的操作和策略可能有助于外科界安全地采用这种手术。

Author Contributions 作者供稿

Study conception and design: Daes
研究构思与设计：设计
Acquisition of data: Daes, Belyansky
数据采集：泽斯、别良斯基
Analysis and interpretation of data: Daes, Belyansky
分析和解释数据：泽斯、别良斯基
Figure 10. Both retrorectus spaces have been developed, and crossover takes place in the ipsilateral medial posterior sheath. (Reprinted courtesy of the artist, Joe Chovan.)
图 10两个直肠后间隙都已发育，交叉发生在同侧内侧后鞘。(转载由艺术家 Joe Chovan 提供）。
Figure 11. Both retrorectus spaces have been developed at the outset. Stage 2B is executed. Note the small excoriations in the linea alba produced while attempting to find the proper area for the contralateral division of the medial aspect of the PRS. Once the proper area is found, Stage 3 is greatly facilitated.
图 11.两个后直肌空间在一开始都已开发。执行第二阶段 B。注意在试图找到 PRS 内侧对侧分割的适当区域时在白线上产生的小割伤。一旦找到合适的区域，第 3 阶段就会变得非常容易。
Figure 12. Upper port configuration for the laparoscopic repair of a midline hernia. The surgeon's suturing hand works through the most medial port in relation to the hernia defect (left upper quadrant); therefore the laparoscopic needle driver is parallel to the longitudinal axis of the hernia defect. The surgeon's nondominant hand is lateral and the camera operator is medial to the suturing port.
图 12.腹腔镜修补中线疝气的上端口配置。外科医生的缝合手通过相对于疝气缺损（左上象限）最内侧的端口进行缝合；因此腹腔镜针驱动装置与疝气缺损的纵轴平行。外科医生的非支配手位于外侧，摄像师位于缝合口的内侧。
Figure 13. Suturing of the anterior fascia can be performed by the seated surgeon during the laparoscopic eTEP approach. The surgeon's nondominant hand manipulates the wall to facilitate suturing. (Reprinted courtesy of the artist, Joe Chovan.)
图 13.在腹腔镜 eTEP 方法中，坐着的外科医生可以缝合前筋膜。外科医生的非惯用手操作腹壁以方便缝合。(转载由艺术家 Joe Chovan 提供）。
Drafting of manuscript: Daes
手稿起草：代斯
Critical revision: Belyansky
严格修订：别良斯基
Acknowledgment: We thank Rebecca Tollefson, DVM, from Edanz Group (https://en-author-services.edanz.com/ ac) for editing a draft of this manuscript.
致谢：我们感谢 Edanz Group ( https://en-author-services.edanz.com/ ac) 的兽医 Rebecca Tollefson 编辑了本手稿的草稿。

REFERENCES 参考文献

  1. Daes J. The enhanced view-totally extraperitoneal technique for repair of inguinal hernia. Surg Endosc 2012;26:1187-1188.
    Daes J. 腹股沟疝修补的增强视野--完全腹膜外技术。Surg Endosc 2012;26:1187-1188.
  2. Belyansky I, Daes J, Radu VG, et al. A novel approach using the enhanced-view totally extraperitoneal (eTEP) technique for laparoscopic retromuscular hernia repair. Surg Endosc 2018;32: .
    Belyansky I, Daes J, Radu VG, et al. 使用增强视野完全腹膜外（eTEP）技术进行腹腔镜回肠疝修补的新方法。Surg Endosc 2018; 32: 。
  3. Daes J. Abordaje extraperitoneal de vista extendida (eTEP) para la reparación de hernias. Cir Esp 2020;98:249-250.
    Daes J. 用于疝气修补的腹膜外扩展视角方法（eTEP）。Cir Esp 2020;98:249-250.
  4. Daes J. eTEP repair of a lumbar hernia. International Hernia Collaboration (IHC). Available at, https://www.facebook.com/ jorge.daes/videos/10202854061713213/?l=1=734626961354422 8903&tn=R. Accessed March 16, 2021.
    Daes J. 腰疝的 eTEP 修补术。国际疝气合作组织（IHC）。网址：https://www.facebook.com/ jorge.daes/videos/10202854061713213/?l=1=734626961354422 8903&tn=R。访问日期：2021 年 3 月 16 日。
  5. Daes J, Telem D. The principled approach to ventral hernia repair. Rev Colomb Cir 2019;34:25-28.
    Daes J, Telem D. 腹股沟疝修补的原则性方法。Rev Colomb Cir 2019;34:25-28.
  6. Quezada N, Grimoldi M, Besser N, et al. Enhanced-view totally extraperitoneal (eTEP) approach for the treatment of abdominal wall hernias: mid-term results. Surg Endosc 2021 Feb 2. Available at: https://doi.org/10.1007/s00464-021-08330-3. Epub ahead of print.
    Quezada N, Grimoldi M, Besser N, et al. Enhanced-view totally extraperitoneal (eTEP) approach for the treatment of abdominal wall hernias: mid-term results.Surg Endosc 2021 Feb 2. Available at: https://doi.org/10.1007/s00464-021-08330-3.Epub ahead of print.
  7. Belyansky I, Reza Zahiri H, Sanford Z, et al. Early operative outcomes of endoscopic (eTEP access) robotic-assisted retromuscular abdominal wall hernia repair. Hernia 2018;22: .
    Belyansky I, Reza Zahiri H, Sanford Z, et al. 内镜（eTEP通道）机器人辅助腹壁疝修补术的早期手术效果。Hernia 2018; 22: 。
  8. Köhler G, Kaltenböck R, Pfandner R, et al. Precostal top-down extended totally extraperitoneal ventral hernia plasty (eTEP): simplification of a complex technical approach. Hernia 2020;24: .
    Köhler G, Kaltenböck R, Pfandner R, et al. 肋前自上而下完全腹膜外腹股沟疝成形术 (eTEP)：简化复杂的技术方法。Hernia 2020; 24: 。
  1. Disclosure Information: Nothing to disclose.
    披露信息：无信息披露。
    Disclosures outside the scope of this work: Dr Daes receives honoraria for organizing hands-on courses and lectures from and Covidien. Belyansky is a paid consultant to Intuitive and Bard and receives payment for lecture from Intuitive and Gore.
    本工作范围之外的披露：Daes 博士从 和 Covidien 获得组织实践课程和讲座的酬金。 Belyansky 是 Intuitive 和 Bard 的有偿顾问，并从 Intuitive 和 Gore 领取讲课费。
    Received March 22, 2021; Revised May 8, 2021; Accepted May 10, 2021. From the Department of Minimally Invasive Surgery, Clinica Portoazul, Barranquilla, Colombia (Daes), and the Abdominal Wall Reconstruction Program, Anne Arundel Medical Center Luminis Health, Annapolis, MD (Belyansky).
    2021年3月22日收到；2021年5月8日修订；2021年5月10日接受。来自哥伦比亚巴兰基亚 Portoazul 诊所微创外科部（Daes）和马里兰州安纳波利斯 Anne Arundel 医疗中心 Luminis Health 的腹壁重建项目（Belyansky）。
    Correspondence address: Jorge Daes, MD, FACS, Carrera 50 no 79-223
    通讯地址Jorge Daes, MD, FACS, Carrera 50 no 79-223
    PH B, Barranquilla, Colombia, 850020 email: jorgedaez@gmail.com
    哥伦比亚巴兰基亚 PH B 邮编：850020 电子邮件：jorgedaez@gmail.com