# Hybrid approach for ventral hernia associated with rectus diastasis: endoscopic single-port diastasis plication with open preperitoneal hernia repair. ENDOP technique in 10 steps

## TL;DR

A new hybrid surgical technique called ENDOP is introduced to repair ventral hernias and rectus diastasis through a single incision, offering improved outcomes with minimal complications.

## Contribution

The ENDOP technique is the first hybrid approach combining endoscopic plication and open mesh repair for ventral hernia and rectus diastasis.

## Key findings

- The ENDOP technique was safely applied in 11 patients with no intraoperative complications and minimal postoperative issues.
- The procedure allows simultaneous correction of two pathologies through one incision, improving functional and aesthetic outcomes.
- Mean follow-up of 13 months showed effective bulging control and preservation of the retromuscular plane for future repairs.

## Abstract

Rectus Diastasis (RD) associated with ventral hernia disrupts the fascia, complicating repair. The European Hernia Society (EHS) recommends linea alba plication with mesh repair. At our center, we usually repair only the hernia in asymptomatic low-to-moderate RD to minimize complications, opting for plication when quality of life or aesthetic concerns arise. We employ the ENDOP technique, a hybrid single-incision approach combining onlay ENDoscopic plication with sublay OPen mesh repair. To our knowledge, no prior technique has addressed both conditions using different abdominal wall layers. This study aims to demonstrate the procedure in 10 steps.

The technique is detailed step by step using the case of a 43-year-old female with primary umbilical hernia and moderate RD (T2D2H1), illustrated by a video showing the 10 steps.

Eleven patients underwent ventral hernia repair with ENDOP. Seventy-three percent were female, with a mean age of 55.4 years and BMI of 28.6. Mean hernia defect size was 1.64 cm and mean maximal transverse diastasis 5 cm. All but two patients were treated as same-day cases. No intraoperative complications occurred. One patient developed hematoma and three developed postoperative seroma (Clavien–Dindo I), none requiring intervention. Mean follow-up was 13 months.

The ENDOP technique allows simultaneous correction of two pathologies through one incision, fulfilling the principles of minimally invasive surgery. The ENDOP technique is reproducible and safe. It avoids peritoneal access and allows optimal preperitoneal mesh placement, preserving the retromuscular plane for potential future repair and providing effective bulging control, thereby improving both functional and aesthetic outcomes.

The ENDOP technique may represent a valid option for managing this combined pathology.

The online version contains supplementary material available at 10.1007/s00464-025-12540-4.