Subject: submission of manuscript entitled "integrating eTEP ventral hernia repair into bariatric surgery: technical insights and clinical outcomes from an institutional experience".

Abstract

<h4>Background</h4>Obesity is a well-established risk factor for ventral hernia, and concomitant repair during bariatric surgery offers the advantage of a single-stage solution. While the intraperitoneal onlay mesh (IPOM) technique has been the traditional approach, the enhanced-view totally extraperitoneal (eTEP) repair provides a biomechanically superior, retro-muscular alternative. However, its integration with bariatric surgery has not been previously described.<h4>Objective</h4>The primary objective of this study was to evaluate the feasibility and safety of integrating enhanced-view totally extraperitoneal (eTEP) ventral hernia repair into bariatric surgery and describing its technical nuances. Secondary objectives included reporting early hernia-related and metabolic outcomes.<h4>Methods</h4>A retrospective analysis was performed on 35 consecutive patients who underwent concomitant eTEP ventral hernia repair with bariatric procedures between July 2021 and January 2025. Of these, 23 underwent eTEP without transversus abdominis release (TAR) and 12 required TAR for posterior fascial closure. Bariatric procedures included laparoscopic sleeve gastrectomy (LSG), Roux-en-Y gastric bypass (RYGB), and one-anastomosis/mini-gastric bypass (OAGB-MGB). Perioperative outcomes, complications, and follow-up data were analyzed.<h4>Results</h4>Among 23 patients without TAR, 12 underwent LSG, 5 RYGB, and 6 MGB. Among the 12 TAR cases, 6 underwent LSG, 3 RYGB, and 3 MGB. The mean operative time was 157 ± 23 min, and the mean hospital stay was 3 ± 1 days. There were no intraoperative conversions or mesh-related infections. Two patients developed seroma managed conservatively. No hematomas, posterior rectus sheath ruptures, or recurrences were observed during a minimum follow-up of six months (mean 17 ± 3 months).<h4>Conclusions</h4>This study demonstrates that concomitant eTEP ventral hernia repair can be safely integrated with bariatric surgery when performed in a standardized, contamination-safe manner. The detailed technical framework presented here provides a reproducible roadmap for surgeons adopting this approach in complex obese patients.