Outcomes after extended totally extraperitoneal (eTEP) repair for ventral hernia with or without posterior rectus sheath closure: systematic review.

PURPOSE: To evaluate perioperative and long-term outcomes of extended totally extraperitoneal repair (eTEP) repair for midline ventral hernias, comparing procedures performed with versus without posterior rectus sheath (PRS) closure.

METHODS

A systematic review was performed according to Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. After PROSPERO registration (CRD420251083420), a search was performed in MEDLINE, Embase, and Web of Science databases for studies published up to April 2025. Articles were excluded if patients underwent concomitant transversus abdominal muscle release.

RESULTS

Five-hundred-fifty-five and 557 patients underwent eTEP without and with PRS closure, respectively. Patient and hernia characteristics were comparable between groups, with most defects appearing to fall within the W1-W2 range according to the European Hernia Society classification. The comparison between the non-closure and closure group showed statistically significant differences in the intraoperative peritoneal tears (2.2% versus 0.5% in the non-closure and closure group, respectively, p = 0.0189), impossibility to close the peritoneum (0.7% versus 0 in the non-closure and closure group, respectively, p = 0.0447), and conversion to open surgery (0.7% versus 0 in the non-closure and closure group, respectively, p = 0.0447). No differences in postoperative interparietal hernias occurred between the two groups.

CONCLUSION

Evidence comparing PRS non-closure and closure during eTEP repair remains limited and heterogeneous. Both approaches appear safe and effective, showing comparable intra- and postoperative outcomes; importantly, PRS closure is not associated with an increased risk of interparietal hernias. Current data do not justify a standardized recommendation, and the choice should be individualized based on defect characteristics and surgeon experience.