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Table of Contents
Year : 2022  |  Volume : 5  |  Issue : 4  |  Page : 165-178

Endoscopic and endoscopically assisted mini or less open sublay mesh repair (EMILOS and MILOS) of abdominal wall hernias: Update and 10-year experience of a single insitution

1 Department of Abdominal Wall Surgery, Helios Mariahilf Hospital Hamburg, Hamburg, Germany
2 Surgical Clinic Marienhospital Stuttgart, Stuttgart, Germany

Date of Submission10-Nov-2022
Date of Decision15-Nov-2022
Date of Acceptance16-Nov-2022
Date of Web Publication24-Dec-2022

Correspondence Address:
Wolfgang Reinpold
Department of Abdominal Wall Surgery, Helios Mariahilf Hospital Hamburg, Stader Strasse 203c, 21075 Hamburg
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_61_22

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Introduction: Abdominal wall hernia and incisional hernia repair are among the most frequent operations in general surgery. However, despite the use of mesh and other recent improvements, the open mesh techniques and laparoscopic IPOM repair have specific disadvantages and risks. Materials and Methods: To minimize complications of the existing open and laparoscopic techniques we developed the endoscopic Mini- or Less Open Sublay (EMILOS) and endoscopically assisted Mini- or Less Open Sublay (MILOS) concept. We report on our large series of minimally invasive sublay repair of and ventral incisional hernias. The operation is performed transhernially with light-holding laparoscopic instruments either under direct, or endoscopic visualization, while the abdominal wall is circumferentially elevated with retractors. An endoscopic light tube was developed to facilitate this approach (Endotorch,TM Wolf Company). Each MILOS operation can be converted to standard total extraperitoneal gas endoscopy (EMILOS repair) once an extraperitoneal space of at least 8 cm has been created. The technique allows minimal invasive repair of ventral hernias with concomitant rectus diastasis. In large eventrations E/MILOS m. transversus abdominis release (TAR) can be performed. All MILOS operations were prospectively documented in the German Hernia registry Herniamed. Technical modifications and improvements from the inception of the E/MILOS concept including variants of the EMILOS technique are addressed. Results: The total and surgical complication rates of 1745 E/MILOS incisional hernia operations were 4.6% and 3.1%, respectively. The reoperation rate was 1.7%. Haemorrhage, seroma, enterotomy, infection and bowel obstruction were detected in 1.0, 0.9, 0.2, 0.3 and 0.4 percent of the cases, respectively. The recurrence rate after one year was 1.2%. Chronic pain at rest, at activities and chronic pain requiring therapy was reported in 3.8, 7.4 and 3.6 percent, respectively. Conclusion: The MILOS technique allows minimally invasive transhernial repair of incisional hernias using large retromuscular / preperitoneal meshes with low morbidity. The technique is reproducible, cost effective, easy to standardize and combines the advantages of open sublay and the laparoscopic IPOM repair.

Keywords: Endoscopic retromuscular hernia repair, endoscopic ventral hernia repair, incisional hernia, minimally invasive sublay repair, primary abdominal wall hernia, recurrent abdominal wall hernia, sublay technique, total extraperitoneal preperitoneal repair

How to cite this article:
Reinpold W, Berger C, Bittner R. Endoscopic and endoscopically assisted mini or less open sublay mesh repair (EMILOS and MILOS) of abdominal wall hernias: Update and 10-year experience of a single insitution. Int J Abdom Wall Hernia Surg 2022;5:165-78

How to cite this URL:
Reinpold W, Berger C, Bittner R. Endoscopic and endoscopically assisted mini or less open sublay mesh repair (EMILOS and MILOS) of abdominal wall hernias: Update and 10-year experience of a single insitution. Int J Abdom Wall Hernia Surg [serial online] 2022 [cited 2023 Jun 9];5:165-78. Available from: http://www.herniasurgeryjournal.org/text.asp?2022/5/4/165/365096

  Introduction Top

Primary abdominal wall and incisional hernia repair figure among the most frequent operations in surgery. The main cause seems to be genetically determined insufficient cross-links between the collagen molecules. The risk of incarceration is about one percent per incisional hernia and year. Since the advent of synthetic mesh recurrence rates could be reduced from 25%-60% to below 15%.[1] The open sublay mesh implantati based on techniques of Jean Rives and René Stoppa and the laparoscopic intraperitoneal onlay mesh plasty (laparoscopic IPOM) are the internationally leading procedures for the treatment of incisional hernias.[1],[2],[3],[4]

In open sublay repair the alloplastic mesh is inserted via a large skin incision between the peritoneum/posterior rectus sheath and the abdominal wall. Today the sublay mesh position is considered most advantageous because direct contact of alloplastic material with bowel and other viscera is omitted. The disadvantage of the procedure is the major access trauma which is related with higher infection rates and more acute and chronic pain. Despite the advantages of keyhole skin incisions the pain level after laparoscopic IPOM repair is not low. A further concern is the implantation of a non-absorbable foreign body into the abdominal cavity, which is a risk factor for adhesion formation to the bowel and injuries to the viscera. In addition, traumatic mesh fixation to the pain-sensitive peritoneum and abdominal wall with many staples, clips, tacks or sutures are mandatory.[1],[2],[3],[4] Expensive implants with adhesion barriers on the area facing the bowel have to be used. Re-operations have shown that all IPOM prostheses can lead to massive adhesions and do not provide a safe protection of the viscera. The above-mentioned concerns and risks of the traditional techniques have led surgeons around the world to look for new minimal invasive ways of ventral hernia repair.[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14]


It is a trial of the German Hernia Registry Herniamed, which has ethical approval by the Ethical Board of Tübingen University. The trial is registered: ClinicalTrials.gov. Identifier: NCT03133000.

  The E/MILOS Concept (MILOS and EMILOS Operation) Top

For the further reduction of complications and pain in abdominal wall hernia repair we developed new minimally invasive concepts – firstly a transhernial mini or less open sublay repair (MILOS) using endoscopic instruments and secondly a hybrid technique, which starts like MILOS with open transhernial access, reduction of the hernia sack and limited incision of the posterior rectus sheath, but then after provisional closure of the skin the operation continues endoscopically with capno- preperitoneum (EMILOS).

The E/MILOS repair allows the transhernial retrorectus / preperitoneal insertion of large standard meshes via a small incision and anatomical reconstruction of the abdominal wall. Using the E/MILOS technique the abdominal cavity is neither burdened with alloplastic mesh material nor foreign body mesh fixation devices. The E/MILOS operation with minimal invasive transhernial access avoids major trauma to the abdominal wall.[8],[10],[12],[13],[14] We performed the first EMILOS operation in single port technique in March 2009. At that time we denominated this new technique “Endoscopic total extraperitoneal transhernial single port sublay mesh repair of abdominal wall hernias.” The term EMILOS was coined in 2016 (see below).

  MILOS and EMILOS Repair Top

The MILOS repair consists of two operation phases. EMILOS repair adds phase three:

MILOS phase 1: Mini open dissection with standard open repair instruments.

MILOS phase 2: Transhernial dissection with light-armed laparoscopic instruments under direct view [Figure 1] or with gasless endoscopy (MILOS using endoscopic instruments).
Figure 1: Transhernial dissection of the preperitoneal / retromuscular plane using the Endotorch TM

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Phase 3: Endoscopic dissection with capno preperitoneum (EMILOS): After mini open transhernial dissection of a preperitoneal / retrorectus space of about 8 cm diameter (phase 1 and 2) the operation may be continued in two variations: 1. Variation: Transhernial insertion of a port system and CO2 insufflation (W. Reinpold). Proceeding of the operation endoscopically with standard laparoscopic instruments and a 30° MIS optic in transhernial position [Figure 2]. 2. Variation: With finger guidance insertion of an optic trocar into the retrorectus space below of the costal margin or like in TEP creating a retrosymphysic space (Retzius) by balloon dissection and suprasymphysic insertion of the optic trocar (R. Bittner). Closure of skin, creating capno-preperitoneum and endoscopically continuing the operation.
Figure 2: a: EMILOS operation of midline hernia: transhernial insertion of 10 mm camera port with capped wound protector (Alexis TM, Applied Medical) and two 5 mm working ports. b. EMILOS operation with single port

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  E/MILOS Definitions Top

Incision length and mesh size definitions of E/MILOS operations: in all E/MILOS operations the skin incision has a maximum length of one fourth of the largest mesh diameter. Incisions of 2 to <6 cm are called “mini open,” and incisions of 6 to 12 cm “less open.” Hernia operations with incisions longer than 12 cm are not E/MILOS operations.

MILOS and EMILOS repair: The MILOS operation can be performed mini open with light-armed laparoscopic instruments either under direct vision [Figure 1] or endoscopically assisted with gasless endoscopy, mechanical elevation of the region of the linea alba, introducing the endoscope in the retrorectus space and videooptic continuing the dissection.

EMILOS repair: After transhernial mini-open dissection of an retrorectus space of at least 8 cm diameter, transhernial insertion of an optic port device, and CO2 insufflation, the procedure can be continued endoscopically as total extra-peritoneal ventral hernia repair (VTEP) using either standard trocars [Figure 2a] or as it described above as second variation. Working port positions can be adopted according to the individual hernia defect size and location. In our first attempts to perform an EMILOS operation in 2009 a transhernial single port [Figure 2b] was utilized[8],[12],[13] which was technically demanding due to the narrow parallel alignment of laparoscopic instruments and MIS optic. Therefore, in recent years we changed our technique to the use of standard ports which allow better angulation.[10]

Today, at our institution almost all primary and incisional abdominal wall hernias are operated on with the MILOS / EMILOS technique, however, small hernias with a hernia defect diameter smaller than 1.5 cm are treated with a suture repair and extremely large hernias with an open sublay approach and open TAR. E/MILOS instruments are shown in [Figure 3].
Figure 3: Set of E/MILOS instruments

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  Indications for MILOS and EMILOS Repair Top

The MILOS technique is mainly used in operations with a maximum mesh size of 15 cm diameter. If larger meshes are implanted, we perform an EMILOS repair.

The E/MILOS technique allows the extraperitoneal dissection of the whole rectus compartment and both lateral compartments. If necessary, very large synthetic meshes can be implanted minimal invasively. Posterior component separation (TAR) can be performed using the E/MILOS technique. Thus, a sublay repair of the complete abdominal wall is possible.

  The Surgical Steps of the E/MILOS Repair of Midline Hernias Top

MILOS repair

  • Step 1: The MILOS operation starts with a small skin incision directly above the center of the main hernia defect [Figure 4].

  • Step 2: Identification and mobilization of the hernia sac [Figure 5]. If necessary, incision of the hernia sac and liberation of incarcerated viscera.

  • Step 3: Small incision of the peritoneum for diagnostic laparoscopy if adhesions or other intraabdominal pathologies are suspected.

  • Step 4: Excessive parts of the hernia sac which later may pose a risk of bowel obstruction are excised. Before performing this step consider that parts of the hernia sac may later be necessary for the tension free closure of the abdominal cavity!

  • Step 5: The border of the hernia defect (hernia ring) is circumferentially exposed and elevated with sharp clamps [Figure 6] and [Figure 7].

  • Step 6: The neck of the hernia sac and adjacent peritoneum is circumferentially detached from the fascial edge of the hernia defect and abdominal wall with a radius of at least 2 cm [Figure 8]. In hernia defects with a diameter of less than 3 cm, the fascial edge of the hernia ring must be minimally incised at 3h and 9h, to allow the mini open transhernial preperitoneal dissection.

  • Step 7: The posterior rectus sheath is incised on both sides about 1 cm lateral to the medial border of the rectus muscle [Figure 9]. Retromuscular dissection starts with a blunt tipped curved clamp: The rectus muscle is mobilized from the posterior rectus sheath on both sides [Figure 10]. Now the mini open dissection with light armed laparoscopic instruments starts [Figure 1], [Figure 11]. The sharp clamps are removed. The abdominal wall around the hernia defect is now exposed with narrow rectangular retractors of different size [Figure 1]. The transhernial preperitoneal / retromuscular dissection around the hernia gap is performed with light armed laparoscopic instruments either under direct visualization or by using an endoscope which allows to demonstrate the situs to the trainees. For these purposes a laparoscopic instrument armed with a 10-mm light tube is used which was specifically designed by our working group and Wolf company (Endotorch, Wolf TM, [Figure 1] and [Figure 11]).[12],[13] The Endotorch is a modified 20 cm long and 10 mm diameter laparoscope, however, instead of a telescopic rod lens system it has a central canal for the insertion of any 5 mm laparoscopic instrument [Figure 1] and [Figure 11]. The Endotorch gives maximum light at the tip of the light holding laparoscopic instrument, thus automatically pointing to the center of the surgeon’s dissection field [Figure 1]. This allows precise wide range tissue manipulation via mini-incisions within the extraperitoneal space. It may also be used for gasless laparoscopy and adhesiolysis. The circumferential dissection range in relation to the skin incision and recommended size of the rectangular retractors are given in [Table 1]. MILOS operations via 2 cm incisions are prefereably performed with 3 mm laparoscopic instruments and a 5 mm 30° laparoscope. Scar tissue formation, especially after previous operation(s) with mesh implantation, may reduce the maximum dissection range and warrant larger incisions.[12],[13] Via a 3 to 4 cm incision the Endotorch TM allows circumferential dissection of the extraperitoneal plane with a radius of at least 15 cm from the fascial border of the hernia gap.

  • Step 8: In the midline, the peritoneum is separated from the linea alba [Figure 12]. The right and left posterior rectus sheath are extensively mobilized from the rectus muscle with laparoscopic instruments [Figure 10].

  • Step 9: Transhernial longitudinal incision of the posterior rectus sheath on both sides parallel to the linea alba is performed in all quadrants corresponding to the size of the hernia defect and planned alloplastic mesh insertion [Figure 13]a and b.

  • Step 10: The posterior rectus sheath is closed only if this is possible with low tension. In most of our E/MILOS operations, the cut edges of both rectus sheaths are not adapted [Figure 14]. In all E/MILOS operations the peritoneum is closed meticulously thus preventing any contact between alloplastic material and the intestines [Figure 14]. Parts of the hernia sac may be very useful for complete tension free closure of the peritoneum. If the posterior rectus sheath is not adapted, the mesh is placed in the right and left retrorectus position and dorsal to the linea alba in the preperitoneal plane [Figure 14].

  • Step 11: Transhernial extraperitoneal implantation of standard large pore synthetic mesh, preferably polypropylene or polyvinylidenfluoride (PVDF). The mesh should posteriorly overlap the hernia defect by at least 5 cm in all directions. Prior to mesh insertion we change gloves and perform skin disinfection.
Figure 4: Mini open incision above the center of the main hernia defect

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Figure 5: Identification and mini open dissection of the hernia sac

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Figure 6: Complete mobilization of the hernia sac and circumferential identification of the hernia ring

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Figure 7: Circumferential dissection the fascial hernia ring

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Figure 8: Circumferential mini-open detachment of the peritoneum from the abdominal wall with radius of 1- 2cm

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Figure 9: The posterior rectus sheath is medially incised

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Figure 10: Dissection of the posterior rectus sheath

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Figure 11: Endotorch TM with laparoscopic grasper

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Table 1: MILOS dissection range (cm) in relation to skin incision / minimal hernia defect size and recommended blade size of rectangular retractor pairs

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Figure 12: The linea alba and posterior rectus sheath are pulled upwards, the posterior rectus sheath downwards

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Figure 13: a: The posterior rectus sheath is incised longitudinally in all 4 quadrants. b: The posterior rectus sheath is incised longitudinally in all 4 quadrants

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Figure 14: Large standard mesh in retromuscular / preperitoneal plane. The posterior rectus sheath (PRS) is only closed if this is possible with low tension. The peritoneum between the cut edges of the PRS and the hernia defect are meticulously closed

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The mesh is double rolled and inserted transhernially with two long curved clamps without skin contact [Figure 15] and then unfolded with light-armed laparoscopic instruments. The implantation of very large meshes is possible. [Figure 16] shows an implanted large sublay mesh in the lower abdomen. In most cases, due to large mesh overlap, and complete anterior closure of the hernia defect, there is no need for mesh fixation. The intraabdominal pressure prevents mesh dislocation and supports rapid mesh integration into the abdominal wall. In the case of subxiphoidal or suprapubic hernia defects, the mesh is secured with absorbable sutures to the paraxiphoidal fascia or Cooper´s ligaments. In very large hernia defects when even after bilateral TAR maneuver a complete hernia defect closure is not possible, we perform a mesh bridging in sandwich technique: a second standard large pore mesh with 5 cm overlap is inserted in the sublay plane anterior to the first sublay mesh. The second mesh is fixated with a running 0 non absorbable suture to the fascial edge of the hernia gap. It is important that the fixating suture spares the first large mesh. Central sutures to the first large mesh may result in central mesh rupture, recurrence and ileus. When bridging a hernia defect the mesh - defect size ratio should be at least 16: 1. [Table 2] shows the size of the meshes implanted. One suction Redon drain (8 Charr.) is inserted into the extraperitoneal space.
Figure 15: Transhernial insertion of a large double rolled standard alloplastic mesh

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Figure 16: EMILOS midline incisional hernia repair: endoscopic mesh insertion

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Table 2: Size of mesh in incisional hernia operations (E/MILOS-OP; n = 1,745)

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  • Step 12. Additional hernia defects are closed transhernially. Satellite hernia defects and the main hernia gap are anatomically closed anterior to the mesh with a running non-absorbable or long term absorbable 0 suture in small-bite-small-stitch technique [Figure 17]a and b. Anatomical reconstruction of the abdominal wall is always the primary goal.

  • Step 13: Management of subcutaneous tissue and skin: Large hernia sacs are removed, meticulous subcutaneous electrocoagulation is performed and a subcutaneous 8 Char. Redon drainage is inserted. If necessary, contracted scar tissue is mobilized and resected, and the umbilicus is reconstructed. The skin is closed with a running subcutaneous and intracutaneous suture. [[Figure 18]a and b] shows two patients with small scars and corresponding mesh size after MILOS repair of incisional hernias.
Figure 17: a: EMILOS repair: satellite hernia defects are endoscopically closed. b: EMILOS repair: satellite hernia defects are endoscopically closed

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Figure 18: a: Young woman with 3 cm incisional hernia after umbilical hernia suture repair. MILOS operation with 3 mm instruments, 5 mm endoscope and 2cm incision. Implantation of a 15x15cm PP mesh. b: MILOS operation of the 4. Recurrence of an incisional hernia after open prostatectomy

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EMILOS repair

After transhernial mini-open dissection of an extra peritoneal space of at least 8 cm diameter and after closure of the skin incision either by a flexible plastic sheet port or by suture the operation is continued endoscopically with capno preperitoneum [Figure 1] and [Figure 19]. In analogy to TEP repair of the groin EMILOS is an endoscopic total extra peritoneal ventral hernia repair (VTEP).
Figure 19: EMILOS repair with transhernial flexible plastic sheet port (Alexis TM)

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  • EMILOS Step 1: If necessary gas tight closure of the peritoneum to prevent CO2 leakage into the abdominal cavity,

  • EMILOS Step 2: Transhernial insertion of an optic port device that fits gas tight into the skin incision to allow CO2 insufflation without ambient leakage [Figure 1] and [Figure 19]. In skin incisions of up to 4 cm standard blunt tip ports for TEP groin hernia repair may be used (e.g., Blunt tip port, Applied Medical, [Figure 20]). In incisions larger than 4 cm we use flexible plastic sheet ports (e.g., Alexis, Applied Medical, [Figure 1] and [Figure 19]). The port devices may be blocked at the level of the hernia defect or skin. The latter is recommended in larger hernia defects because it allows to keep the skin incision smaller than hernia defect diameter. To prevent subcutaneous emphysema the CO2 pressure should be limited to 10 mmHg.

  • EMILOS Step 3: Optic port and working port placement. Our standard is the use of a transhernial 10 mm, 30° MIS laparoscope and two retromuscular 5 mm working ports at the horizontal level of the main hernia defect [Figure 1] This allows 360° circumferential endoscopic dissection. The position of the optic and working ports may be adopted to the specific location and size of the hernia defect(s).

In patients with high cosmetic expectations, e.g., young women with smaller hernia defects combined with postpartum diastasis recti, E/MILOS operations can be performed via a small transhernial skin incision (2 cm) with 3 mm laparoscopic instruments [Figure 18], [Figure 21]a and b and 5 mm Optic.
Figure 20: EMILOS repair: Transhernial insertion of blunt tip port in incisions of up to 4 cm

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Figure 21: a: Set of 3 mm EMILOS instruments. b: EMILOS ventral hernia repair with 3 mm instruments

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Our first EMILOS operations in 2009 were performed in transhernial single port technique [Figure 2b] which is technically demanding due to the narrow parallel alignment of laparoscopic instruments and MIS optic port.[8] The use of standard ports allows better angulation. [Figure 22]a and b shows the cranial and caudad view of an EMILOS midline incisional hernia repair.
Figure 22: a: Cranial endoscopic view of an EMILOS midline incisional hernia repair. b: Caudal endoscopic view of an EMILOS midline incisional hernia repair

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The E/MILOS technique allows: a) exposure of the entire extraperitoneal rectus compartment from the retroxiphoid to the retropubic region, b) additional mini-open or endoscopic assisted posterior component separation/m. transversus abdominis release (TAR), c) dissection of the complete lateral compartment and d) closure of diastasis recti.

Based on the MILOS and single port EMILOS technique which is described by W. Reinpold, for the first time a standardized EMILOS technique without using a single-port device for the surgical treatment of midline ventral hernias and concomitant diastasis recti was published by Schwarz, Reinpold and Bittner in 2016[10] [Figure 23][Figure 24][Figure 25][Figure 26][Figure 27]. The initial steps of the EMILOS approach are identical to the E/MILOS technique: after transhernial mini open dissection and reduction of the hernia sac exposition of the posterior layer of the rectus sheath and bilateral incision like in MILOS repair. Then a balloon [Figure 23] is inserted to dilate the retropubic space (Retzius) like in TEP operation but for suprapubic implantation of the optic trocar [Figure 24]a and b. After provisional closure of the skin and insertion of the 5 mm working trocars the endoscopic dissection of the whole retrorectus space is carried out in bottom up direction in the sense of reversed TEP [Figure 25] and [Figure 26].[10] Alternatively the optic trocar can be inserted into the retrorectus space just below the costal margin followed by top down dissection. The posterior rectus sheath is closed by running suture if this is possible with low tension [Figure 27] and the mesh is implanted as described above. After implantation of the mesh the skin incision which was initially sutured is opened, the defect and skin are adequately closed.
Figure 23: Reversed TEP EMILOS operation: After initial MILOS dissection around the umbilicus, balloon dilation of the preperitoneal / retromuscular space in lower abdomen towards the space of Retzii

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Figure 24: a: Reversed TEP EMILOS operation: Under endoscopic view insertion of the suprapubic 10 mm optic port. b: Reversed TEP EMILOS operation: Under endoscopic view insertion of the suprapubic 10 mm optic port

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Figure 25: Reversed TEP EMILOS operation: After placement of the suprapubic 10 mm optic port and closure of the skin incision at the umbilicus, the operation continues endoscopically in bottom-up direction

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Figuure 26: Reversed TEP EMILOS operation: cranial view after extensive epigastric retrorectus dissection. Note the exposure of the xiphoid and costal margen

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Figure 27: Reversed TEP EMILOS Operation: Closure of posterior rectus sheath with low tension midline suture

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  E/MILOS Repair of Lateral Abdominal Wall Hernias Top

In primary and recurrent hernias of the lateral compartments the transhernial dissection is performed in the preperitoneal plane. In order to obtain sufficient medial mesh overlap the incision of the posterior rectus sheath may be necessary. For the protection of segmental nerves and blood vessels the longitudinal incision should be performed at least 2 cm medial to the lateral border of the rectus compartment (reversed TAR procedure).

  E/MILOS Operation of Ventral Hernias with Concomitant Diastasis Recti Top

The E/MILOS concept allows surgical repair of symptomatic diastasis recti (DR) with concomitant ventral hernias. Especially young women after childbirth often suffer from ventral hernias and concomitant symptomatic DR. The MILOS technique is used in operations with a maximum mesh size of 15 cm diameter. If larger meshes are implanted, we perform an EMILOS repair.[13]

  Treatment Algorithm Top

Mesh augmentation of diastasis recti (DS)

Many obese patients, mostly men elder than 45 years, present with umbilical or epigastric hernias with concomitant asymptomatic diastasis recti (DR). DR is considered asymptomatic if it does not cause neither pain, instability, nor functional deficits. Many of these patients are often not aware of their DR which is a risk factor for hernia recurrence.[15] In those patients we perform an E/MILOS repair with mesh augmentation of the fragile diastatic linea alba with circumferential mesh overlap of at least 5 cm. If the complete LA is fragile, mesh size is extended to 4 cm behind the xiphoid.

Mesh augmentation with plication of DR

In patients with a concomitant symptomatic RD i.e., patients with functional deficit of the abdominal wall, instability and/or pain mesh augmentation with additional plication of the linea alba is indicated. In obese patients an endoscopic posterior inverting suture of the LA is performed.

In slim and normal weight patients, especially women with postpartum DR we prefer an EMILOS repair with additional subcutaneous (=epifascial) skin mobilization and anterior inverting plication of the LA. In those patients a posterior inverting plication often leads to an ugly, symptomatic, and palpable vertical rim of the linea alba. The onlay dissection of the skin (Endoscopic mini or less open onlay dissection = E/MILOO) is performed via the same incisions and with the same instruments that are used for the transhernial retrorectus EMILOS dissection. In all E/MILOS operations the posterior rectus sheath is only closed if this is possible with low tension. To prevent an ugly cutaneous rim after RD suture repair, the subcutaneous tissue has to be detached from the linea alba and medial aspect of the anterior rectus sheath (2 to 5 cm on every side). The linea alba is anatomically reconstructed by an anterior inverting non-absorbable running suture (0). The mesh is transhernially implanted in the Sublay plane as described above. In women of childbearing age the mesh should not be larger than 20 cm × 15 cm. We do not recommend E/MILOS ventral hernia and RD repair if further pregnancies are planned. Using the endoscopic mini open approach, onlay mesh repair is also possible. However, we are strongly in favor of sublay mesh repair.

  E/MILOS TAR Options Top

In large hernias and non-midline primary or incisional ventral hernias the m. transversus abdominis release (TAR)[16] can be performed using the E/MILOS technique. In very large hernias we use the less open E/MILOS approach [Figure 28]. The operation steps of the minimal invasive E/MILOS TAR procedure are identical to the procedure published by Novitsky et al.[16]
Figure 28: Less open repair of large midline incisional hernia. If necessary E/MILOS TAR is performed

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  Results Top

From 2009 to March 2021 we carried out 1745 E/MILOS-operations for primary and incisional abdominal wall hernias. Data of all patients were prospectively documented in the German Hernia registery “Herniamed”: The results of our first 615 E/MILOS incisional hernia operations with one year questionnaire follow-up were published in 2018.[12] Propensity score matching of incisional hernia operations comparing the results of the E/MILOS operation with the laparoscopic intraperitoneal onlay mesh operation (IPOM) and open sublay repair from other German Hernia registry institutions was performed. Six hundred fifteen E/MILOS incisional hernia operations were included. Compared with laparoscopic IPOM incisional hernia operation, the E/MILOS repair is associated with significantly fewer postoperative surgical complications (P < 0.001), general complications (P < 0.004), recurrences (P < 0.001), and less chronic pain (P < 0.001). There were less infections after E/MILOS operations compared to laparoscopic IPOM repairs but the difference was not statistically significant. Matched pair analysis with open sublay repair revealed significantly fewer postoperative complications (P < 0.001), reoperations (P < 0.001), infections (P = 0.007), general complications (P < 0.001), recurrences (P = 0.017), and less chronic pain (P < 0.001). The average operating time of E/MILOS incisional hernia repair was 102 minutes, 7 and 20 minutes longer than open sublay (95 min.) and laparoscopic IPOM repair (82 min), respectively.[12] Mesh sizes are given in [Table 2].

Complication rates after E/MILOS incisional hernia repair are very low [Table 3] and [Table 4]. There were two enterotomies of the small bowel without spillage. The bowel lesions were closed with absorbable sutures. In these cases E/MILOS mesh repair was performed without complications. Three superficial wound infections healed without mesh infection.
Table 3: E/MILOS incisional hernia repair at Gross Sand Hospital (n = 1,745) vs. all incisional hernias documented in the German hernia Registry (99.516)

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Table 4: E/MILOS incisional hernia operations at Gross-Sand Hospital (n = 1,745) vs. All incisional hernias operations documented in Herniamed Register (n = 88.866) with complete one year follow-up

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The results of our primary umbilical and epigastric hernia E/MILOS operations were recently published[13]: All primary ventral hernia E/MILOS operations were prospectively documented in the German hernia registry “Herniamed.” Five hundred and twenty primary umbilical and 554 epigastric E/MILOS operations with complete 1-year questionnaire follow-up were included. Concomitant RD were treated in 18.3% and 14.1% of the umbilical and epigastric hernia cohort, respectively. Total perioperative complication rates and reoperation rates were 1.2% and 0.9% for both umbilical and epigastric hernias, respectively. Infection rates were 0.0% and 0.2% after umbilical and epigastric hernia operations, respectively. Recurrence rates 1 year after E/MILOS umbilical and epigastric hernia were 0.0% and 0.5%, respectively. One year rates of chronic pain at rest, chronic pain during physical activities, and chronic pain requiring treatment after umbilical and epigastric hernia repair were 1.5% and 2.7%, 2.1% and 4.2%, and 0.6% and 1.8%; respectively (Reinpold, Hernia 2019). Today we use the EMILOS technique in 65.5% of abdominal wall hernia operations. There is no difference in complication rates between the MILOS and EMILOS approach.

Postoperative consumption of analgesics was comparable low. The standard postoperative pain medication was Metamizol 4 × 1 g p.o. Additional opioids were necessary in only 9.5% of the cases. Even in the case of large incisional hernias a peridural analgesic catheter is dispensable.

We have performed 117 E/MILOS TAR operations with low morbidity: There was one infection (mesh preserved), two hematomas with reoperation, one small bowel injury with immediate suture repair (uneventful course), two recurrences at one year follow up. The chronic pain rate at one year follow up was 5.2%.

  Discussion Top

To further improve abdominal wall hernia surgery and overcome the obvious disadvantages of the currently most widely used open sublay and laparoscopic IPOM repair, we have successfully developed the E/MILOS technique which is the first technique that allows the minimally invasive sublay mesh repair of almost all primary and recurrent abdominal wall hernias, except for giant eventrations. But even in extremely large primary ventral and incisional hernias the principles of E/MILOS repair help to reduce the surgical trauma to the abdominal wall.

Advantages of the E/MILOS hybrid concept

Our experience with 1745 E/MILOS incisional hernia operations and about the same number of primary ventral hernia E/MILOS repairs showed the following advantages of this novel technique:

  1. The E/MILOS operation allows minimal invasive sublay repair of all ventral and incisional hernias except giant hernias.

  2. E/MILOS operations were associated with significantly less perioperative complications, reoperations, general complications, and less recurrences and chronic pain after one year compared to open sublay and laparoscopic IPOM repair.

  3. E/MILOS allows minimal invasive sublay repair of ventral hernias combined with rectus diastasis.

  4. Easy and safe dissection of the hernia sac and incarcerated viscera (bowel, omentum).

  5. Easy closure of hernia gaps and anatomical reconstruction of the abdominal wall. Protection of viable abdominal wall structures including nerves.

  6. Option of laparoscopy or mini laparotomy easy to perform.

  7. Mini skin incision allows skin and scar corrections with good cosmetic results.

  8. E/MILOS approach allows minimal invasive TAR.

  9. Allows minimally invasive insertion of large standard meshes in sublay plane without traumatic mesh fixation.

  10. In comparison with laparoscpic IPOM operations there is a saving of around 1.200,- € in material costs per operation.

  11. The E/MILOS repair combines the advantages and avoids disadvantages of laparoscopic IPOM repair and the open Rives Stoppa operation.

  Conclusion Top

The novel E/MILOS technique allows the minimally invasive endoscopically assisted extraperitoneal (retrorectus) repair of primary and incisional hernias with very low perioperative morbidity, recurrences and chronic pain after one year. The technique has the potential to revolutionize abdominal wall hernia repair if future studies of other working groups can reproduce our promising results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

Dr. Reinhard Bittner is an Editor-in-Chief, Dr. Wolfgang Reinpold is an Editorial Board member of International Journal of Abdominal Wall and Hernia Surgery. The article was subject to the journal’s standard procedures, with peer review handled independently of them and their research groups.

  References Top

Bittner R, Bingener-Casey J, Dietz U, Fabian M, Ferzli GS, Fortelny RH, et al. Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (international endohernia society [IEHS])—part 2. Surg Endosc 2014;28:353-79.  Back to cited text no. 1
Forbes SS, Eskicioglu C, McLeod RS, Okrainec A Meta-analysis of randomized controlled trials comparing open and laparoscopic ventral and incisional hernia repair with mesh. Br J Surg 2009;96:851-8.  Back to cited text no. 2
Kapischke M, Schulz T, Schipper T, Tensfeldt J, Caliebe A Laparoscopic versus open repair of incisional/ventral hernia: A meta-analysis. Am J Surg 2009;197:64-72. Epub 2008 Jul 9. Review.  Back to cited text no. 3
Bittner R, Bain K, Bansal VK, Berrevoet F, Bingener-Casey J, Chen D, et al. Update of guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (international endohernia society (IEHS))-part A. Surg Endosc 2019;33: 3069-139.  Back to cited text no. 4
Miserez M, Penninckx F Endoscopic totally preperitoneal ventral hernia repair. Surg Endosc 2002;16:1207-13.  Back to cited text no. 5
Schroeder AD, Debus ES, Schroeder M, Reinpold WM Laparoscopic transperitoneal sublay mesh repair: A new technique for the cure of ventral and incisional hernias. Surg Endosc 2013;27:648-54. doi: 10.1007/s00464-012-2508-9. Epub 2012 Sep 6.  Back to cited text no. 6
Abdalla RZ, Garcia RB, da Costa RI, Abdalla BM Treatment of mid-line abdominal wall hernias with the use of endo-stapler for mid-line closure. Arq Bras Cir Dig 2013;26:335-7.  Back to cited text no. 7
Reinpold W, Schroeder AD, Schroeder M, Berger C, Rohr M, Wehrenberg U Retroperitoneal anatomy of the iliohypogastric, ilioinguinal, genitofemoral, and lateral femoral cutaneous nerve: Consequences for prevention and treatment of chronic inguinodynia. Hernia 2015;19:539-48.  Back to cited text no. 8
Köckerling F, Botsinis MD, Rohde C, Reinpold W Endoscopic-assisted linea alba reconstruction plus mesh augmentation for treatment of umbilical and/or epigastric hernias and rectus abdominis diastasis - early results. Front Surg 2016;3:27.  Back to cited text no. 9
Schwarz J, Reinpold W, Bittner R Endoscopic mini/less open sublay technique (EMILOS)-a new technique for ventral hernia repair. Langenbecks Arch Surg 2017;402:173-80. doi: 10.1007/s00423-016-1522-0. Epub 2016 Oct 20.  Back to cited text no. 10
Belyansky I, Daes J, Radu VG, Balasubramanian R, Reza Zahiri H, Weltz AS, et al. A novel approach using the enhanced-view totally extraperitoneal (etep) technique for laparoscopic retromuscular hernia repair. Surg Endosc 2018;32:1525-32.  Back to cited text no. 11
Reinpold W, Schröder M, Berger C, Nehls J, Schröder A, Hukauf M, et al. Mini- or less-open sublay operation (MILOS): A new minimally invasive technique for the extraperitoneal mesh repair of incisional hernias. Ann Surg 2019;269: 748-55.  Back to cited text no. 12
Reinpold W, Schröder M, Berger C, Stoltenberg W, Köckerling F MILOS and EMILOS repair of primary umbilical and epigastric hernias. Hernia 2019;23:935-44.  Back to cited text no. 13
Köckerling F, Hoffmann H, Mayer F, Zarras K, Reinpold W, Fortelny R, et al. What are the trends in incisional hernia repair? Real-world data over 10 years from the herniamed registry. Hernia 2021;25:255-65.  Back to cited text no. 14
Köhler G, Luketina RR, Emmanuel K Sutured repair of primary small umbilical and epigastric hernias: Concomitant rectus diastasis is a significant risk factor for recurrence. World J Surg 2015;39:121-6; discussion 127.  Back to cited text no. 15
Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ Transversus abdominis muscle release: A novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg 2012;204:709-16.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24], [Figure 25], [Figure 26], [Figure 27], [Figure 28]

  [Table 1], [Table 2], [Table 3], [Table 4]


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