Laparoscopic Totally Extraperitoneal Repair

Overview

Laparoscopic totally extraperitoneal (TEP) inguinal hernia repair is an effective minimally invasive method for treating hernias that avoids entry into the abdomen. Its indications have developed and broadened over time to encompass almost the whole spectrum of groin hernias. A detailed description of the procedure is presented focusing on seven key steps. Moreover, pre- and intra-operative considerations, pearls and pitfalls are highlighted in order to maximize efficiency and safety when performing this procedure. The attached figures and accompanying narrated videos complement this manuscript by providing an audiovisual adjunct and to clarify technical and anatomical descriptions.

Operative technique

• TEP requires the placement of 3 trocars in the lower midline, one Hasson and two 5 mm trocars. A 15 mm curvilinear infra umbilical incision is made and carried down sharply to the level of the fascia. The anterior rectus sheath is incised transversely off the midline to expose the rectus abdominis muscle. Avoiding the linea alba is important to avoid inadvertent entry into the peritoneal cavity.
• The rectus abdominis muscle is swept laterally exposing the posterior rectus sheath. The surgeon’s index finger is inserted into the preperitoneal space and is swept from side to side to develop the space and accommodate placement of the 5 mm trocars.
• The two 5 mm trocars are placed guided by the index finger to prevent their placement in the intra-peritoneal position. The Hasson cannula is then placed into the space under vision with the help of S-type retractors and the pre-peritoneal space is insufflated with CO2 to 10 mmHg.
• Minimally invasive hernia surgery allows the surgeon to avoid scar tissue from an earlier hernia repair, so it might be a good choice for people whose hernias recur after open hernia surgery. It also might be a good choice for people with hernias on both sides of the body (bilateral).

Special consideration: TEP after TEP or TAPP

• TEP after TEP or TAPP is a challenging procedure requiring proficient knowledge in anatomy and meticulous dissection and can be performed if an open anterior approach has also failed (18). The challenges arise from adhesions, leading to obscuring of normal anatomical landmarks and loss of working space with difficulty in developing the spaces of Retzius and Bogros. The key features of a TEP after TEP or TAPP are as follows:
• Development of the working space should be done in a plane between the old mesh and the anterior abdominal wall to keep the peritoneum intact.
• Identification of the epigastric vessels will lead to the identification of the hernia. Hernias do not normally have adhesions, and subsequently the presence of dense adhesions means that there is probably no hernia.
• Ligation of the epigastric vessels or their branches is done routinely to achieve adequate hemostasis because bleeding will compromise the exposure.
• Dissection of the hernia sac is done sharply without electrocautery whereas in primary hernias most dissection is blunt with traction and counter traction.
• External palpation and pulling of the testicle will aid in the identification of the cord structures.
• Although the working space is limited and may only allow placement of a smaller sized mesh, every attempt must be made to place a large mesh. Failing to place a large mesh increases recurrence rates and in that case, an anterior approach is preferred.

Conclusions

Modus operandi, mastery of the anatomy, and meticulous direction are the 3 M’s that need to be remembered in order to perform TEP with reproducibility, safety, efficiency and good outcomes. Mastery of the anatomy of the versatile pre-peritoneal space allowed surgeons to become facile in operations such as prostatectomies and retroperitoneal node dissections.