What is the TESAR technique?

TESAR (Totally Endoscopic Sublay Anterior Repair) is an extraperitoneal endoscopic technique for ventral and incisional hernias and for rectus diastasis: anterior access, mesh placed in the retromuscular position, no entry into the abdominal cavity.

Who developed the TESAR technique?

It was developed and described by Dr. Federico Fiori, who published the first description in 2019 in the Journal of Laparoendoscopic & Advanced Surgical Techniques.

How does TESAR differ from other anterior endoscopic techniques?

Other anterior techniques usually place the mesh above the aponeurosis (onlay). TESAR keeps the anterior access but positions the mesh behind the rectus muscle (sublay).

Is TESAR also used for rectus diastasis?

Yes: it is indicated for rectus diastasis, isolated or associated with a midline hernia, when the goal includes reconstruction of the linea alba.

Does the mesh come into contact with the bowel?

No. The operation is extraperitoneal: the mesh is placed behind the rectus muscle and does not come into contact with the viscera.

Is TESAR always the best technique?

No. It is one tool among others. Very large defects, tissue loss, or a significant excess of skin and fat call for different solutions, to be planned during the assessment.

How long is the hospital stay?

In the published series of the first 120 operations the median stay was three days, with a range from two to ten. The time needed to return to daily and sporting activities is defined case by case, according to the defect treated and the reconstructive steps performed.

What is the risk of recurrence?

In the published follow-up — a median of 31 months, with 22 patients beyond five years — no clinical recurrence was detected across the first 120 consecutive operations, which are those with follow-up verified by us.

The TESAR Technique for Ventral Hernias, Incisional Hernias and Rectus Diastasis

Name: TESAR technique: what it is and when it is used
Creator: Dr. Federico Fiori

TESAR — Totally Endoscopic Sublay Anterior Repair — repairs rectus diastasis and midline hernias, both primary and incisional, endoscopically, placing the mesh in the retromuscular plane. The access is anterior and the abdominal cavity is never opened: the wall is rebuilt by working between its own layers.

Acronym	Totally Endoscopic Sublay Anterior Repair
Access	Anterior, endoscopic, extraperitoneal
Mesh position	Retromuscular (sublay)
Indications	Midline ventral and incisional hernias, rectus diastasis
First publication	J Laparoendosc Adv Surg Tech, 2019

If you are in a hurry, in plain words

TESAR repairs hernias of the midline of the belly and diastasis of the rectus muscles working only with a camera, through three small cuts above the pubic bone. No marks remain on the visible part of the abdomen.

The mesh is not placed inside the abdomen but behind the muscle: there the pressure of the belly holds it pressed against the wall and it does not touch the bowel. Above the mesh the two muscles are brought back together, reconstructing the midline.

It does not suit everyone. Very large defects, adhesions from previous surgery or genuinely excess skin call for different routes, because TESAR addresses the muscle layer but does not remove skin. Recovery takes patience: usually one or two nights in hospital, a few days before light activity, some weeks before real exertion.

What does TESAR stand for?

TESAR stands for Totally Endoscopic Sublay Anterior Repair: a fully endoscopic repair, with the mesh in the sublay position, through an anterior access. Each word of the acronym describes a specific technical choice: the operation is endoscopic, the mesh sits behind the muscle, and the access route is anterior.

After the first operations performed in 2018, I published it in 2019 in the Journal of Laparoendoscopic & Advanced Surgical Techniques. Since 2024 it has been included, alongside the other extraperitoneal endoscopic techniques, in the classification proposed in a systematic review published in Hernia.

How is the operation performed?

The operative sequence is as follows:

Preoperative marking of the midline and of the access points: the operation is planned before it starts.

a suprapubic access through small incisions;
endoscopic pre-aponeurotic dissection — above the aponeurosis — to create the working space;
incision of the medial edges of the anterior rectus sheaths;
placement of the synthetic mesh in the retromuscular position, behind the rectus muscle;
closure of the sheaths over the mesh, restoring the continuity of the midline.

All the work takes place outside the abdominal cavity: the operation is extraperitoneal. One technically relevant consequence follows — the mesh never comes into contact with the viscera.

Suprapubic accesses of the TESAR technique — Three small aligned suprapubic accesses: the working space is created from there, the wall is not opened.

Other steps are added to these, and they do not serve to close the defect but to give the wall back its ability to work:

the posterior plane can be plicated to increase the tension of the transverse muscles, which in diastasis have lost their load and are effectively re-tensioned;
where indicated, the oblique muscles are addressed to reduce the circumference of the abdominal core;
a transverse plication at the level of the umbilicus compensates, where necessary, for the vertical laxity of the fascia.

These are steps that concern function. Correcting shape, in this technique as in every minimally invasive technique, is not a primary aim: the improvement in shape is the consequence of properly restoring function.

How does it differ from other anterior approaches?

Historically, endoscopic techniques working through an anterior route place the mesh in the onlay position, that is, above the aponeurosis. Techniques that place the mesh retromuscularly, on the other hand, generally do so through a posterior route.

TESAR combines the two: an anterior route with a retromuscular mesh. That is the technical point that sets it apart, and the reason why, in the 2024 systematic review of extraperitoneal approaches, it is the only anterior technique classified with the mesh in the sublay position (Hernia 2024 — DOI 10.1007/s10029-024-03144-3).

Diagram of the TESAR technique: on the left the three suprapubic accesses and the anterior working corridor along the midline, on the right a cross-section of the wall with the mesh behind the rectus muscles and the midline sutured — Anterior access through three suprapubic entries, mesh behind the rectus muscle

Retromuscular space opened from an anterior route — The space behind the muscle, opened from an anterior route: this is where the mesh will sit.

What results has it produced over time?

The long-term outcomes of the first 120 consecutive operations were published in Hernia in 2026, with a median follow-up of 31 months and observations up to 81 months; 22 patients passed the five-year mark. Only patients whose follow-up we verified ourselves were included, through clinical examination or imaging: those who did not attend the check-up were excluded from the analysis, even though they had reported no problem. The series comprises 83 cases of diastasis with umbilical hernia, 39 incisional hernias and 15 other primary ventral hernias; 45.8% of the patients had already had abdominal surgery.

There were no intraoperative complications. Overall postoperative morbidity was 6.7%: six seromas (5%), none of which required a further operation, and two haematomas (1.6%), one of which required revision. There were no surgical site infections and no clinical recurrence was detected during the observation period. Median hospital stay was three days.

In functional terms the EuraHS-QoL score — the instrument that measures quality of life specific to abdominal wall surgery — went from a median of 57 before surgery to 0 at twelve months, across the 104 patients assessed. A lower score means a better condition: at one year patients reported the absence of the complaints they had before. The pain domain went from 17 to 0, the activity restriction domain from 26 to 0, the cosmetic domain from 14 to 0; the Carolinas Comfort Scale from 35.5 to 0. (Hernia 2026;30:305 — DOI 10.1007/s10029-026-03808-2 · PMID 42536212)

Managing the dead space

The most frequent complication of every technique involving subcutaneous undermining is seroma, the collection of fluid in the space created during the operation. Since 26 April 2023 the technique includes a specific modification to prevent it: a progressive-tension suture anchoring the subcutaneous tissue to the fascia along the midline, abolishing that space and distributing tension. The effect was measured by comparing patients operated on before and after its introduction: clinically relevant seromas went from six out of seventy-five to none out of forty-five.

Which conditions is it indicated for?

midline ventral hernias, including umbilical and epigastric hernias;
incisional hernias on a midline scar;
rectus diastasis, isolated or associated with a hernia defect;
situations in which reconstruction of the linea alba is part of the goal, not a side effect.

When is it not the right choice?

A technique is only as useful as its stated limits. TESAR is not the right answer when:

the excess of skin and fatty tissue is such that it requires surgical remodelling of the soft tissues, which has to be planned together with the repair: in these cases no minimally invasive technique is indicated;
the defect is very wide or involves a loss of domain that requires component separation techniques;
particular local or general conditions make another approach preferable, whether minimally invasive or open, for instance in the presence of comorbidities;
the clinical assessment concludes that no operation is needed: this too is an indication, and it must be stated as clearly as the others.

How does it fit into the morpho-functional approach?

TESAR is a technical tool. It is useful when the problem in front of us coincides with what this technique solves well: a midline defect in which the structure has to be rebuilt and the mesh has to go behind the muscle. When the picture is different — because the morphological component carries more weight and cannot be handled with a minimally invasive procedure, or because the defect is of another nature — the right choice has to be a different one.

It is the same logic described on the page about the morpho-functional approach: first the right question, then the technique.

Where has it been published and discussed?

Selected publications

Totally Endoscopic Sublay Anterior Repair for Ventral and Incisional Hernias. Journal of Laparoendoscopic & Advanced Surgical Techniques, 2019. PMID 30807248 · DOI 10.1089/lap.2018.0807 First description of the TESAR technique.
Surgical treatment of diastasis recti: the importance of an overall view of the problem. Hernia, 2021. DOI 10.1007/s10029-020-02252-0 Functional and morphological outcomes assessed with the EuraHS-QoL tool.
Laparoendoscopic extraperitoneal surgical techniques for ventral hernias and diastasis recti repair: a systematic review. Hernia, 2024. PMID 39312025 · DOI 10.1007/s10029-024-03144-3 Classification of anterior and posterior extraperitoneal approaches.
Totally Endoscopic Sublay Anterior Repair (TESAR) for diastasis recti, primary and incisional ventral hernias: long-term clinical outcomes and quality of life. Hernia 2026;30(1):305, 2026. PMID 42536212 · PMCID PMC13427856 · DOI 10.1007/s10029-026-03808-2 Long-term clinical outcomes and quality of life after TESAR, observational study.

Partial list, being updated. Every reference can be verified through PubMed or DOI.

Lectures and teaching

Speaker at the congresses of the European Hernia Society (EHS)
Speaker at the congresses of the Italian Association of Hospital Surgeons (ACOI)
Live surgery and teaching for the SIC-ISHAWS National School of abdominal wall surgery
Lectures at national and international courses and congresses on abdominal wall and minimally invasive surgery
Public-education meetings for patients and health professionals

For healthcare professionals

Two 1 cm suprapubic accesses and one 0.5 cm access, optics in the median trocar and two lateral working ports. Preaponeurotic dissection developed cranially under direct endoscopic vision as far as the xiphoid, with detachment of the umbilicus from the fascia and careful haemostasis. Reduction of the hernia sac, partially excised where indicated. Complete exposure of the linea alba to identify the hernia margins and the extent of the diastasis: a critical step also for morphological correction in slim patients with visible protrusion.

Incision of the medial edges of both anterior rectus sheaths and bilateral opening of the retrorectus space until a continuous retromuscular space is obtained. Posterior lamina preserved where possible, and safely plicable where re-loading the transverse muscles to recover function is indicated. Wide mesh in the retromuscular position, with minimal or selective fixation depending on the type of mesh and tissue quality: fibrin glue or cyanoacrylate, with a possible single loose cranial stitch to prevent translation. Closure of the anterior sheaths on the midline, restoring the linea alba and the midline tension vectors and isolating the mesh from the preaponeurotic compartment. Where indicated: plication of the external obliques to increase muscle tension and reduce core circumference; transverse fascial plication at umbilical level for craniocaudal laxity and the periumbilical muscular dome. One or two suction drains, at the surgeon's discretion. The technical steps are the same for every type of defect.

Dead space management: preaponeurotic undermining creates a potential space that is the main cause of seroma. Since 26 April 2023 the technique includes a progressive-tension quilting suture between subcutaneous tissue and fascia along the midline, extendable along the lateral border of the recti after wide dissections; the analysis is exploratory, before and after the refinement, with the date of introduction stated.

Series: 120 consecutive operations — 83 cases of diastasis with umbilical hernia, 39 incisional hernias, 15 other primary ventral hernias; 96 women and 24 men; median age 42 years (23-82); median BMI 23.0 kg/m² (17.1-34.0); 45.8% with previous abdominal surgery.
Operation: median duration 183 minutes (118-420); polypropylene mesh in 80.8% and poly-4-hydroxybutyrate in 19.2%; associated TAR in 6.7%.
Outcomes: no intraoperative complications; postoperative morbidity 6.7% (seroma 5%, haematoma 1.6%); no surgical site infection; no clinical recurrence; clinically relevant seromas 6/75 before the quilting suture and 0/45 after; median stay 3 days (2-10); median follow-up 31 months (12-81), beyond 60 months in 18.3%.
Quality of life (n=104): EuraHS-QoL total from 57 to 0 at twelve months; pain 17→0; restriction 26→0; cosmetic 14→0; Carolinas Comfort Scale 35.5→0. Positive correlation between BMI and operative time (r=0.309; p<0.001); association between BMI class and complications (χ²=10.5; p=0.004).
Source: Fiori F, Ferrara F, Corbellini C, Gallitiello L, Lo Conte D, Stella M. Totally Endoscopic Sublay Anterior Repair (TESAR) for diastasis recti, primary and incisional ventral hernias: long-term clinical outcomes and quality of life. Hernia 2026;30(1):305 — DOI 10.1007/s10029-026-03808-2 · PMID 42536212 · PMCID PMC13427856.
Comparison between mesh planes: Timmermans L, de Goede B, van Dijk SM et al. Meta-analysis of sublay versus onlay mesh repair in incisional hernia surgery. Am J Surg 2014;207:980-988 — DOI 10.1016/j.amjsurg.2013.08.030.

Glossary of minimally invasive abdominal wall acronyms

MILA: minimally invasive lipoabdominoplasty

Frequently asked questions about the TESAR technique

What is the TESAR technique?: TESAR (Totally Endoscopic Sublay Anterior Repair) is an extraperitoneal endoscopic technique for ventral and incisional hernias and for rectus diastasis: anterior access, mesh placed in the retromuscular position, no entry into the abdominal cavity.
Who developed the TESAR technique?: It was developed and described by Dr. Federico Fiori, who published the first description in 2019 in the Journal of Laparoendoscopic & Advanced Surgical Techniques.
How does TESAR differ from other anterior endoscopic techniques?: Other anterior techniques usually place the mesh above the aponeurosis (onlay). TESAR keeps the anterior access but positions the mesh behind the rectus muscle (sublay).
Is TESAR also used for rectus diastasis?: Yes: it is indicated for rectus diastasis, isolated or associated with a midline hernia, when the goal includes reconstruction of the linea alba.
Does the mesh come into contact with the bowel?: No. The operation is extraperitoneal: the mesh is placed behind the rectus muscle and does not come into contact with the viscera.
Is TESAR always the best technique?: No. It is one tool among others. Very large defects, tissue loss, or a significant excess of skin and fat call for different solutions, to be planned during the assessment.
How long is the hospital stay?: In the published series of the first 120 operations the median stay was three days, with a range from two to ten. The time needed to return to daily and sporting activities is defined case by case, according to the defect treated and the reconstructive steps performed.
What is the risk of recurrence?: In the published follow-up — a median of 31 months, with 22 patients beyond five years — no clinical recurrence was detected across the first 120 consecutive operations, which are those with follow-up verified by us.

Last updated: 2026-08-20 · Content by Dr. Federico Fiori