The concomitance of midline hernias and DRAM is commonly seen, and both should be repaired in the same session as mostly recommended. Kohler et al. demonstrated that midline ventral hernias with diastasis have a significantly higher recurrence rate than hernias without DRAM [2]. The use of absorbable sutures and non-use of meshes have been reported as the other technical factors for recurrence [2]. Several open, laparoscopic, hybrid, or endoscopic techniques have been previously described for midline hernias associated with DRAM [3,4,5]. Some of the patients with DRAM have excess skin and, therefore, would need a dermolipectomy. Claus et al. described the subcutaneous onlay laparoscopic approach (SCOLA) for repairing ventral hernia and the plication of DRAM, particularly for the patients who do not need skin resection to avoid unaesthetic results of the midline incisions [6]. A similar REPA technique (preaponeurotic endoscopic repair) was described earlier by Muas, DMJ [7,8]. According to Claus et al., the SCOLA technique has some modifications concerning the REPA, such as the absence of relaxation incisions and the placement of a larger screen in a pre-aponeurotic position [6].
There were some differences from the previously described SCOLA technique in this particular case. The insufflation pressure was set to lower pressure as 6-8 mmHg, which was adequate for a good view and to open the dissected space. We also selected the Ligasure device for initial dissection to get less smoke and clear vision, and excellent hemostasis. However, it takes more time than using a monopolar hook or scissors. It is evident that using a monopolar hook or scissor is faster but generates more smoke in the narrow space at the beginning of the procedure. In this particular case, the self-gripping polyester mesh was used, which was positioned easily and required less suture to additional fixation. A medium-weight polypropylene mesh can be used and fixed with sutures, glue, or tackers.
Seroma is the most frequent postoperative complication of the SCOLA procedure [6]. The early postoperative period was uneventful, and the patient was discharged on the second postoperative day. The drains were kept in place for eight days after surgery and removed after the drainage decreased to under 20 ml per day. There were no complications, including seroma and surgical site infection in the first and third months of the postoperative period.