Laparoscopic repair has been shown to be superior to open hernia repair, with reduced intraoperative blood loss, postoperative pain, infection, seroma formation, duration of hospital stay, and intensive care unit (ICU) admissions.1 This leads to earlier recovery, improved quality of life, and significantly reduced overall hospital costs. The introduction of mesh materials has significantly lowered recurrence rates, with some studies reporting rates as low as 1–14%.2 The laparoscopic approach involves safe entry into the abdomen, followed by adhesiolysis, reduction of hernia contents and sac, and reinforcement of the fascial defect with a suitably sized mesh placed posterior to the fascia in the intraperitoneal space.3 It is a viable option for nearly all ventral hernias, particularly those with multiple defects, where a single mesh can cover all defects. The concurrent presence of diastasis of the rectus abdominis muscles (DMRA) with hernias, particularly without mesh reinforcement, can lead to repair failure and recurrence. DMRA is characterized by a midline separation exceeding 2.2 cm and is often mistaken for an abdominal wall hernia. Although typically asymptomatic, DMRA can be a cosmetic concern. Conventional laparoscopic techniques may not adequately address DMRA; however, novel approaches such as the SCOLA technique and the extended totally extraperitoneal (eTEP) technique, which combine ventral hernia repair with rectus abdominis muscle plication, offer promising alternatives.4 The extended totally extraperitoneal (eTEP) technique, first described in 2017, has recently gained popularity in abdominal wall hernia surgery.5 To address technical challenges of traditional totally extraperitoneal (TEP) ventral hernia repair—such as limited working space and poor ergonomics—Jorge Daes introduced a modification known as enhanced-view totally extraperitoneal (eTEP) repair.6 This approach accesses the preperitoneal space via the retro-rectus space by placing the camera port more cranially. Building on this technique, Igor Belyansky adapted eTEP for ventral hernia repair (eTEP-RS), incorporating the Rives-Stoppa method.7 This approach offers the advantage of completely excluding the mesh from the intraperitoneal cavity by placing it in a spacious retro-rectus space without penetrating fixation. The surgical technique begins by accessing the space between the rectus abdominis muscle and the posterior rectus sheath, connecting this space with the fatty preperitoneal space at the midline and the contralateral retro-rectus space. The hernia sac is identified and dissected within this created cavity. Finally, the posterior plane and linea alba are closed, and a mesh prosthesis is deployed along the entire dissected space.5 Claus CMP and colleagues introduced the subcutaneous onlay endoscopic method (SCOLA) in 2018.8 This technique was initially developed to treat ventral hernias associated with diastasis, thereby avoiding extensive skin incisions. A recent review by Coco D and Leanza S confirmed the efficacy and safety of SCOLA for the correction of rectus diastasis.9 By performing endoscopic dissection of the preaponeurotic subcutaneous space, the abdominal wall can be repaired by inserting an onlay prosthesis in patients without excessive skin or subcutaneous tissue. SCOLA is a safe and effective option for correcting diastasis recti and symptomatic midline hernias, yielding excellent cosmetic outcomes. However, seroma formation and abdominal wall numbness are common complications.10 Both SCOLA and eTEP-RS have been successfully implemented at our institution for ventral hernia repair. This study aims to compare these two techniques, focusing on early postoperative complications such as postoperative pain, seroma formation, and length of hospital stay. Intraoperative and postoperative complications, including recurrence and neurological issues, were also evaluated.

This prospective, cross-sectional, hospital-based observational study was conducted among 60 patients with ventral hernia having a defect size less than 10 cm, including recti diastasis as well as paraumbilical and paraepigastric hernias. The study was performed in the Department of General Surgery, M.G.M. Medical College and M.Y. Hospital and associated hospitals in Indore, Madhya Pradesh, India. The study duration was one year from the date of Ethics Committee approval, allowing for a comprehensive analysis of the outcomes of these surgical approaches in the specified patient population. Inclusion criteria: Patients aged 20 years and older of both sexes, with ventral hernias having defect sizes smaller than 10 cm, including recti diastasis, paraumbilical, and paraepigastric hernias, were included. Only patients providing written informed consent for SCOLA or eTEP-RS were enrolled. Exclusion criteria: Patients were excluded if they were on anticoagulant therapy; had chronic obstructive pulmonary disease (COPD), immunocompromised status (e.g., HIV), or late-diagnosed strangulated hernias with advanced bowel obstruction; or had recurrent ventral hernias, lateral hernias (other than paraumbilical and paraepigastric hernias), or loss of domain. Patients who refused consent for surgery or were lost to follow-up were also excluded. The 60 enrolled patients were divided into two groups of 30 each and underwent laparoscopic ventral hernia repair with either SCOLA or eTEP-RS. Patients were followed at regular intervals: postoperative days 1, 3, 5, 7, 14, 1 month, and 6 months. Patient outcomes and complications were meticulously documented, and all records were maintained for analysis. A comprehensive record analysis was performed at the end of the study period. Patient identities were kept strictly confidential. To minimize costs, only materials readily available in the hospital were used, ensuring no additional financial burden on patients. Statistical analysis: Data were analyzed using SPSS version 21 (IBM Corporation, Chicago, IL, USA). Results were tabulated and presented as frequencies and percentages, as appropriate. For all tests, a p-value <0.05 was considered statistically significant (95% confidence interval).

Table 1: Age-wise distribution of study subjects in the two groups Age group (years) Group eTEP-RS Frequency Group eTEP-RS Percent Group SCOLA Frequency Group SCOLA Percent 20–30 4 13.3 1 3.3 31–40 11 36.7 7 23.3 51–60 12 40.0 17 56.7 >60 3 10.0 5 16.7 Total 30 100.0 30 100.0 Mean ± SD 41.80 ± 8.81 44.03 ± 7.02 Chi-square = 4.05, p = 0.256 Table 1 shows the age distribution of participants in the eTEP-RS and SCOLA groups. Most participants in both groups were aged 51–60 years (40.0% in eTEP-RS and 56.7% in SCOLA). The next most common age group was 31–40 years, particularly in the eTEP-RS group (36.7% vs 23.3% in SCOLA). Very few participants were in the youngest (20–30 years) and oldest (>60 years) age groups. The mean age was slightly lower in the eTEP-RS group (41.80 ± 8.81 years) than in the SCOLA group (44.03 ± 7.02 years). The chi-square test yielded a p-value of 0.256, indicating no statistically significant difference in age distribution between the groups. Table 2: Distribution of complications in the study groups Complications eTEP-RS Freq eTEP-RS % SCOLA Freq SCOLA % p value Shoulder pain 3 10.0 2 6.7 0.654 Seroma 1 3.3 7 23.3 0.03* Urinary retention 1 3.3 1 3.3 1.00 Ileus 1 3.3 1 3.3 1.00 Hematoma 0 0.0 2 6.7 0.157 Surgical site infection 0 0.0 2 6.7 0.157 Pain 1 3.3 2 6.7 0.563 Major intraoperative injuries 0 0.0 0 0.0 NA Recurrence 0 0.0 0 0.0 NA Mesh complications 0 0.0 0 0.0 NA Chi-square = 5.88, p = 0.435; *Statistically significant Table 2 summarizes postoperative complications. No major intraoperative injuries, such as bowel, bladder, or vascular injury, were observed in either group. Shoulder pain occurred slightly more frequently in the eTEP-RS group (10%) than in the SCOLA group (6.7%). Seroma formation was significantly more common in the SCOLA group (23.3%) than in the eTEP-RS group (3.3%; p=0.03). Hematoma and surgical site infection occurred only in the SCOLA group (6.7% each). Other complications, including urinary retention, ileus, and pain, occurred at similar low frequencies in both groups. Overall, the chi-square value was 5.88 with a p-value of 0.435, indicating no statistically significant difference in overall complication rates between the groups. Table 3: Postoperative pain (VAS score) distribution in the study groups VAS score eTEP-RS Freq eTEP-RS % SCOLA Freq SCOLA % 2 4 13.3 7 23.3 3 25 83.3 21 70.0 4 1 3.3 2 6.7 Chi-square = 1.49, p = 0.472 Table 3 presents postoperative pain assessed using the Visual Analogue Scale (VAS). Most patients in both groups reported a VAS score of 3 (83.3% in eTEP-RS and 70.0% in SCOLA). Only a small proportion reported scores of 2 or 4. The difference in pain scores between groups was not statistically significant (chi-square 1.49, p=0.472). Table 4: Comparison of mean hospital stay between the two groups Group Mean (days) Std. Deviation t value p value eTEP-RS 2.37 0.56 3.556 0.001* SCOLA 3.13 1.04 *Statistically significant Table 4 demonstrates a statistically significant difference in the duration of hospital stay. The eTEP-RS group had a shorter mean stay (2.37 ± 0.56 days) compared with the SCOLA group (3.13 ± 1.04 days; t=3.556, p=0.001). This finding indicates faster recovery and discharge in the eTEP-RS group. Table 5: Comparison of mean time to return to normal activities Group Mean (days) Std. Deviation t value p value eTEP-RS 12.70 1.26 2.572 0.014* SCOLA 14.00 2.46 *Statistically significant Table 5 compares the time required for patients to return to normal daily activities. Patients in the eTEP-RS group returned earlier (mean 12.70 ± 1.26 days) than those in the SCOLA group (14.00 ± 2.46 days). The t-test (t=2.572, p=0.014) shows a statistically significant difference in favor of the eTEP-RS technique.

The eTEP-RS approach demonstrated advantages over SCOLA in terms of shorter hospital stays and faster recovery, though both techniques proved effective for ventral hernia repair. Participants were randomized into eTEP-RS and SCOLA groups, showing no significant differences in age or gender distribution (χ²=4.05, p=0.256). Most patients were aged 51–60 years (40.0% eTEP-RS, 56.7% SCOLA), followed by 31–40 years (36.7% eTEP-RS vs 23.3% SCOLA). Mean ages were 41.80±8.81 years (eTEP-RS) and 44.03±7.02 years (SCOLA). These findings align with prior studies: Dong CT et al11 reported a mean age of 45.7±11.9 years; Kumar J et al12 found 37.50±8.41 years among SCOLA patients; and Rayman S et al13 noted 60.4±13.8 years in eTEP-RS patients. No major intraoperative injuries (bowel, bladder, or vascular) occurred in either group. Shoulder pain was slightly more frequent in eTEP-RS (10.0% vs 6.7%). Seroma formation was significantly higher in SCOLA (23.3% vs 3.3%, p=0.03), with hematoma and surgical site infections occurring exclusively in SCOLA (6.7% each). Urinary retention, ileus, and pain occurred at similarly low rates across groups. Overall complication rates showed no significant difference (χ²=5.88, p=0.435). Andreuccetti J et al14 reported complications in 10.5% of eTEP-RS cases (asymptomatic seroma, postoperative ileus) with no recurrences, confirming its safety. Trujillo-Díaz JJ et al15 noted 19% complications in Rives-Stoppa repairs (71.4% of cases), including 9.5% clinical seromas (57.1% on ultrasound), but no hematomas, infections, or recurrences. Taşdelen HA et al16 found no significant differences in intraoperative complications (p=0.56), seroma formation (p=0.83), or recurrence (p=0.83) between eTEP-RS and IPOM-plus. Rayman S et al13 reported 6.5% recurrence in eTEP Rives-Stoppa patients. VAS scores showed most patients reporting mild pain (score 3: 83.3% eTEP-RS, 70.0% SCOLA), with minimal scores of 2 or 4 (χ²=1.49, p=0.472). Taşdelen HA et al16 found less pain on days 1 and 10 with eTEP-RS versus IPOM-plus. Deshpande GA et al17 reported SCOLA pain scores of 2.91±1.82 (day 1) and 1.95±1.13 (discharge). Surya Srikanth Saride NS et al18 and Deshpande GA et al17 both noted SCOLA superiority over IPOM-plus for pain control. Bui NH et al19 demonstrated reduced analgesic requirements with eTEP-RM versus IPOM. No prior studies directly compare eTEP-RS and SCOLA pain outcomes, warranting further investigation. Mean hospital stay was significantly shorter in eTEP-RS (2.37±0.56 days) versus SCOLA (3.13±1.04 days; t=3.556, p=0.001). Andreuccetti J et al14 reported 3.9 days (range 2–6) for eTEP-RS (longer than ours). Trujillo-Díaz JJ et al15 found 1.6 days (shorter than ours). Bui NH et al19 confirmed shorter stays with eTEP-RM versus IPOM. Taşdelen HA et al16 reported eTEP-RS superiority over IPOM-plus (1.48 vs 2.58 days) in 74 patients. Pereira-Rodrigues AK et al20 found onlay techniques had longer stays and drainage than Rives-Stoppa (52.7% of cases). Claus CMP et al8 noted seroma (27%) and wound infection (2%) in SCOLA patients. eTEP-RS patients resumed normal activities significantly faster (12.70±1.26 days) than SCOLA patients (14.00±2.46 days; t=2.572, p=0.014), approximately 1.3 days earlier. The benefits of eTEP-RS in postoperative recovery are highlighted by this finding. Longer-term follow-up is needed to assess recurrence rates and chronic complications, particularly neurological sequelae. Multicenter studies with larger cohorts and cost-effectiveness analyses would further validate these findings and guide clinical practice.

This study found that postoperative pain was similar between the eTEP-RS and SCOLA groups, and no major intraoperative injuries were observed in either group. However, the SCOLA group experienced significantly higher rates of seroma formation, hematoma, and surgical site infection. The eTEP-RS group had a significantly shorter mean hospital stay and quicker return to normal activities. These findings suggest that the eTEP-RS approach may offer advantages in terms of faster recovery and potentially fewer complications associated with prolonged hospitalization. Ultimately, the choice between SCOLA and eTEP-RS for ventral hernia repair should be guided by individual patient characteristics, surgeon expertise, and specific clinical scenarios, underscoring the importance of personalized treatment strategies in hernia surgery.

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