Laparoscopic total extraperitoneal (TEP) treatment of inguinal hernia: step by step

Laparoscopic inguinal hernia repair is a method of tension-free mesh repair based on a preperitoneal approach. The laparoscopic approach provides the mechanical benefit of placing a large piece of mesh behind the defect using the natural forces of the abdominal wall to disperse intra-abdominal pressure so as to keep the mesh in place. It also offers other advantages such as quicker recovery and less postoperative pain , better visualization of the groin anatomy, and the option of fixing all inguinal hernia defects in one intervention.

We have several options for laparoscopic hernia repair. The most popular techniques are totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) approaches. The main difference between these techniques is the way of gaining access to the preperitoneal space. In the TAPP approach the preperitoneal space is accessed after initially entering the peritoneal cavity, whereas in the TEP approach, the dissection begins in the preperitoneal space using a balloon dissector.

This video focuses on the main steps to perform a Laparoscopic total extraperitoneal inguinal hernia repair (TEP).

The patient is placed in the supine position with both arms placed alongside the body.  The surgeon and the assistant stand on the opposite side of the hernia. We use 3 trocars to perform this surgery: one subumbilical 12 mm trocar for the endoscope, and two 5 mm trocars in the midline, one between the umbilicus and the pubic symphysis, and the other just above the pubic symphysis.

After disinfection and sterile draping, a small transverse incision for the first trocar is made just below the umbilicus on the contralateral side of the hernia; in this case, on the right . The anterior rectus sheath is opened transversely in order to clearly visualize the medial edge of the rectus muscle, which is then retracted laterally until visualization of the posterior rectus sheath. This space between the rectus muscle and the posterior rectus sheath is enlarged with a dissection balloon up to the retropubic space of Retzius . Then, a 12 mm trocar is inserted and insufflation with CO2 is started until 12 mmHg is reached.

Under direct vision with a 30º angled endoscope, we place the other two 5 mm trocars in the midline. During this step and the further dissection, it is paramount to be careful not to damage the epigastric vessels .

Then we start a blunt dissection , with traction and countertraction maneuvers, with a lateral and external direction, and as close as possible to the anterior abdominal wall between the hernia sac below and the epigastric vessels above. The correct preperitoneal dissection plane is easily found due to its angel hair appearance .

We identify the spermatic cord . The cord elements (the vas deferens and the spermatic vessels ) and all the surrounding preperitoneal fat are swept laterally away from the hernia sac. Progressively we proceed with the dissection toward the internal ring and the tip of the hernia sac. The hernia sac becomes smaller and we continue this dissection until the vas is visible . It can adhere to the tip of the sac and in this case it needs to be gently dissected away from the sac.

It is important to identify and reduce cord lipomas (which may appear small and unimportant until reduced). Often they are lateral to the cord’s elements and they should not be confused with lymph nodes. Most lipomas do not need to be removed, but they should be placed above the mesh to help prevent mesh rolling upward.

After all hernias are reduced, it is time to place the mesh . We usually use a ProGrip™ laparoscopic self-fixating mesh, but there are other types of mesh that can be used. Mesh size should be at least 15x10 cm . First, the mesh is rolled up and introduced blindly into the 12 mm trocar. Then it can be pushed down the trocar with the scope under direct vision. The mesh is placed, without a wrinkle, covering Hesselbach’s triangle , the internal inguinal ring , and the femoral space . It must overpass the Cooper’s ligament in 2-3 cm parietalizing the cord structures. It is imperative that the peritoneum is dissected at least 4 cm off the cord structures to prevent the peritoneum from encroaching below the mesh, which can cause hernia recurrence . It is also important to ensure that the lateroinferior corner of the mesh lies deep against the wall and does not roll up during space deflation .