The TESAR Technique: Totally Endoscopic Sublay Anterior Repair

TESAR (Totally Endoscopic Sublay Anterior Repair) is a minimally invasive technique I developed to repair ventral hernias by placing mesh in the retromuscular (sublay) plane through small anterior ports, without laparotomy. It combines the durability of open sublay repair with reduced surgical trauma, suiting selected midline defects.

What is the TESAR technique?

TESAR stands for Totally Endoscopic Sublay Anterior Repair. It is a minimally invasive method for reinforcing the abdominal wall in patients with ventral or incisional hernias of the midline.

The defining feature is where the mesh is placed. TESAR positions the prosthesis in the retromuscular, or sublay, plane behind the rectus muscles and in front of the posterior rectus sheath.

This plane has long been considered a sound location for mesh in open surgery, following the principles described by Rives and Stoppa. TESAR aims to reach that same plane using endoscopic instruments through small incisions on the anterior abdominal wall.

I designed the technique to reproduce the mechanical logic of open sublay repair while avoiding the long midline incision that open surgery requires.

Why place mesh in the sublay plane?

The retromuscular position allows the mesh to be held in place by intra-abdominal pressure itself, rather than relying only on sutures or tacks. The wall works with the prosthesis instead of against it.

In this plane the mesh sits away from the bowel, separated by the posterior sheath and peritoneum. This reduces direct contact between the prosthesis and the viscera.

The sublay plane also offers a wide surface for tissue ingrowth, which contributes to durable incorporation of the mesh over time.

Who is a candidate for TESAR?

TESAR is not suitable for every hernia. Careful selection is essential, and I assess each patient individually with clinical examination and cross-sectional imaging, usually a CT scan.

In general terms, the technique is considered for the following situations.

Large or complex hernias, defects with substantial loss of domain, and situations requiring component separation usually fall outside the scope of TESAR. For these I consider other open or minimally invasive strategies.

Previous extensive abdominal surgery, significant adhesions, or emergency presentations may also make the technique less appropriate. These decisions are taken case by case.

The main technical steps of TESAR

The procedure is performed under general anaesthesia. What follows is a simplified account of the sequence; the operative reality demands precise anatomical orientation throughout.

Access and creation of the retromuscular space

I begin by establishing endoscopic access to the retromuscular plane through small anterior incisions. A working space is created behind the rectus muscle using controlled dissection and insufflation.

Developing this space carefully is the foundation of the whole operation. The plane must be extended sufficiently to accommodate the mesh with adequate overlap of the defect.

Reduction of the hernia and closure of the defect

The hernia contents are reduced and the sac managed as required. The fascial defect is then closed, restoring the midline and re-establishing the linea alba.

Closing the defect rather than simply bridging it is an important principle. It restores the functional continuity of the abdominal wall and reduces the risk of bulging.

Mesh placement and fixation

A flat mesh is introduced and positioned in the retromuscular plane, overlapping the closed defect on all sides. The overlap distributes forces across a broad area.

Because the plane itself contains the mesh, fixation can be minimal. This helps limit the fixation-related discomfort sometimes associated with tack-heavy techniques.

Closure

The working space is deflated and the small port incisions are closed. There is no long midline wound to heal.

What are the advantages of TESAR?

The potential benefits follow logically from the design, though I always frame them as expected tendencies rather than guarantees.

For suitable patients, these features may translate into a smoother early recovery compared with open sublay repair, while retaining the sound anatomical positioning of the mesh.

I want to be clear that these advantages apply to selected cases. The technique is a tool among others, not a universal solution.

What are the limits and risks?

Every operation carries risk, and endoscopic abdominal wall repair is no exception. Honesty about limits is part of proper informed consent.

TESAR is technically demanding. Creating and working within the retromuscular plane requires experience with advanced endoscopic dissection, and the learning curve is real.

The technique is limited by defect size and anatomy. Large hernias, loss of domain, and dense scarring reduce its applicability. In such cases forcing a minimally invasive approach would not serve the patient.

General surgical risks apply: seroma, haematoma, infection, recurrence, and complications of general anaesthesia. Conversion to an open procedure remains possible if the operative findings require it.

Long-term comparative data for newer minimally invasive retromuscular techniques continue to accumulate. I therefore present TESAR as a considered option within a wider surgical landscape, not as an established standard for all hernias.

How does TESAR compare with other repairs?

Open sublay repair remains a well-validated approach, particularly for larger and more complex defects. Its main drawback is the incision required to reach the plane.

Intraperitoneal onlay mesh (IPOM) techniques place the mesh inside the abdomen. They are minimally invasive but keep the prosthesis in contact with the viscera and may rely on more fixation.

TESAR sits between these worlds: it seeks the sublay plane of open surgery through a minimally invasive route. The best choice for an individual depends on hernia characteristics, patient factors, and surgeon experience.

I discuss these alternatives openly with each patient so that the decision is shared and grounded in their specific situation.

If you are considering treatment for a ventral or incisional hernia and would like to understand whether the TESAR technique or another approach is appropriate for you, I am available for a consultation. During that meeting I review your imaging, examine you, and explain the realistic options, including their limits. There is no single right answer for every abdominal wall, and my aim is to help you reach an informed decision at your own pace.

Frequently asked questions

Is TESAR suitable for large incisional hernias?
Generally no. TESAR is best suited to small and medium midline defects that can be closed and covered without excessive tension. Large hernias, significant loss of domain, or defects requiring component separation usually call for other open or minimally invasive strategies. I assess suitability individually using clinical examination and a CT scan before recommending any approach.
How is TESAR different from IPOM repair?
In IPOM the mesh is placed inside the abdominal cavity, in contact with the bowel, and often needs substantial fixation. TESAR places the mesh in the retromuscular sublay plane, outside the peritoneum and separated from the viscera. Both are minimally invasive, but they position the prosthesis in different planes, which affects fixation needs and mesh-bowel contact.
Will I have a large scar after TESAR?
No. TESAR is performed through small anterior port incisions rather than a long midline laparotomy. This means the visible wounds are small. The extent of any scarring still depends on your anatomy, healing, and whether the operation needs to be converted to an open procedure, which remains a possibility in some cases.
What are the main risks of the TESAR technique?
As with any hernia surgery, risks include seroma, haematoma, infection, recurrence, and complications related to general anaesthesia. The technique is also demanding to perform and has a genuine learning curve. Conversion to open surgery may be necessary if the operative findings require it. I discuss these risks fully during consultation before any decision is made.
Does closing the defect matter, or is covering it enough?
Closing the fascial defect matters. In TESAR I reconstruct the midline rather than simply bridging the gap with mesh. Restoring the linea alba re-establishes the functional continuity of the abdominal wall and reduces the risk of bulging. The mesh then reinforces this repair from within the retromuscular plane, working with the wall rather than replacing it.

Published on: 2026-08-13 · Content by Dr. Federico Fiori

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