Evolution of Endoscopic Anterior Component Separation to a Precostal Access with a New Cylindrical Balloon Trocar.

INTRODUCTION Endoscopic anterior component separation (ECS) techniques facilitate tension-free midline closure of wide ventral hernia defects. We describe a novel approach with a precostal incision and a new cylindrical ballon trocar. MATERIALS AND METHODS A single-center analysis of 19 patients undergoing ECS between January 1, 2014 and August 2, 2017 was performed with regard to improvement of technique. We currently start with a lateral precostal incision. This access in a low-fat and stable area allows for easy identification of the external oblique muscle with the ribs functioning as dorsal abutment for entering the correct plane between external and internal oblique muscles. Then a trocar is inserted with a cylindrical ballon, thus providing sufficient pneumatic widening of the dissection plane. A second 5-mm port is inserted under direct vision below the 12th rib. From there a unidirectional incision of the external oblique aponeurosis is performed from subcostal to the inguinal ligament. If necessary, the cephalad muscular parts of the external oblique can be transected over several centimeters in both directions starting from the precostal incision. RESULTS We documented no procedure-related complications apart from two hematomas that required no interventions. Four procedures were carried out on one side and the remaining ones bilaterally. In one case, a conversion to conventional open component separation was required due to extensive scarring after open cholecystectomy. There were no notable abdominal bulgings or lateral hernias during a structured postoperative follow-up period of 1 year postoperatively. DISCUSSION The technique described offers advantages in terms of determination of the correct entry point for ECS, regardless of abdominal wall conditions and the precostal access allows for unidirectional dissection toward the inguinal ligament with only two trocars in total. The cylindrical shape of the ballon trocar provides adequate widening of the working space and ensures good overview for safe dissection.