Cranial Access in Preperitoneal Pretransversalis eTEP (PeTEP) for Primary Midline Hernias: Technical Description of a Novel Approach

Minimally invasive abdominal wall surgery continues to evolve, and the cranial approach to the PeTEP (preperitoneal/pretransversalis enhanced-view totally extraperitoneal) technique represents a meaningful addition to our armamentarium. In this report, we present a 62-year-old obese male (BMI 34.3) with a combined umbilical and epigastric hernia (EHS M2-M3 W1) managed using the cranial PeTEP approach. The procedure is detailed step-by-step to highlight technical nuances. The operation was completed without complications in 150 minutes, and the patient was discharged within 24 hours with no postoperative pain. Follow-up at 1 week, 1 month, 3 months and 6 months showed no adverse events or recurrence. Based on this experience, the cranial PeTEP approach appears to be a safe, effective, and reproducible option for primary midline hernia repair in appropriately selected patients, enabling wide preperitoneal mesh placement without entering the retromuscular space. Larger studies with longer follow-up are warranted to further validate these findings.