Background: The enhanced-view totally extraperitoneal (eTEP) approach has broadened the applicability of retrorectus abdominal wall reconstruction (AWR). However, medium-to-large midline ventral and incisional hernias (VIH) often preclude primary fascial closure, requiring transversus abdominis release (TAR). Reliable preoperative predictors of TAR are essential for surgical planning.
Methods: Seventy-nine consecutive patients with midline VIH underwent laparoscopic eTEP-AWR between April 2020 and August 2025. TAR was performed when posterior sheath approximation was impossible despite adequate retrorectus dissection. Preoperative CT parameters included hernia width, rectus-to-defect ratio (RDR), and component separation index (CSI). Reproducibility was tested in 20 random cases by two blinded observers using intraclass correlation coefficients (ICC) and Bland-Altman analysis. Univariable and multivariable logistic regressions identified independent predictors, and diagnostic accuracy was assessed for RDR cutoffs of 2.0 and 2.35.
Results: TAR was required in 45 patients (57%). The TAR group had greater hernia width (6 vs. 4 cm, p < 0.0001), lower RDR (1.64 vs. 2.67, p < 0.0001), and higher CSI (0.12 vs. 0.09, p = 0.0004). Reproducibility was excellent (ICC = 0.94 for RDR; 0.91 for CSI). Multivariable analysis identified hernia width > 5 cm (OR 6.64, p = 0.0021) and RDR < 2.35 (OR 6.51, p = 0.0043) as independent predictors. No significant interaction with hernia type was found for RDR < 2.35 (p = 0.84) or hernia width > 5 cm (p = 0.39).
Conclusions: Preoperative CT assessment of hernia width and RDR predicts the need for TAR in laparoscopic eTEP-AWR. RDR < 2.35 provided superior diagnostic accuracy and may optimize surgical planning and patient counseling.
Keywords: Abdominal wall reconstruction; Computed tomography; Predictive factors; Transversus abdominis release; Ventral hernia; eTEP.
© 2026. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.