This laparoscopic clinical photograph illustrates an intraoperative view of a posterior layer closure during a ventral hernia repair (VHR). The surgical site shows the approximation of the posterior rectus sheath and peritoneum. The defect has been closed using 3-0 dark-colored multifilament suture material, visible as fine strands across the midline of the repair. The surrounding anatomical environment includes dissected retrorectus and preperitoneal spaces characterized by reddish, vascularized tissue and moist, glistening serosal surfaces. A surgical laparoscopic grasper is visible on the left side of the frame, assisting in tissue manipulation. This image demonstrates a critical step in the enhanced-view totally extraperitoneal (eTEP) technique, where the posterior layer is reconstituted to create a barrier between the abdominal contents and the subsequent mesh reinforcement. The suture technique aims for a tension-free, airtight closure to prevent internal herniation or contact between the mesh and the viscera.

This composite of six laparoscopic images (A-F) illustrates the sequential steps of the Transabdominal Sublay (TAS) procedure for ventral hernia repair. Image A shows initial laparoscopic adhesiolysis using graspers to clear the surgical field. In Image B, the peritoneum and posterior rectus sheath are incised to access the retromuscular plane. Image C demonstrates further blunt dissection of the retromuscular space to create sufficient room for mesh placement. Image D visualizes the closure of the primary hernia defect using a continuous suture technique with a surgical needle. In Image E, a synthetic polypropylene mesh with a characteristic woven texture is introduced and positioned within the dissected sublay space, ensuring adequate overlap of the defect margins. Finally, Image F shows the securing of the mesh and the closure of the peritoneal flap to exclude the mesh from the intraperitoneal cavity. This clinical series serves as an educational guide for surgeons on the laparoscopic transperitoneal approach to extraperitoneal space reinforcement.

This endoscopic clinical photograph captures an intraoperative view during an Enhanced-View Totally Extraperitoneal (eTEP) ventral hernia repair. The image highlights a central hernia defect within the abdominal wall, demarcated by a blue circular annotation. Within this circle, the hernia sac appears as a translucent, reddish-pink tissue layer. A laparoscopic surgical instrument, a Maryland-style or blunt dissector, is seen performing active dissection at the inferior margin of the defect. Green lines illustrate the cut edges of the posterior rectus sheath, which appears as a more opaque, whitish-fibrous structure compared to the thin peritoneal sac. This visual demonstrates the surgical technique of preserving the hernia sac in continuity with the posterior rectus sheath to facilitate a tension-free closure of the posterior layer in cases with large defects or significant midline separation.