Laparoscopic Inguinal Hernia Repair—TEP Technique
Pradeep K. Chowbey
The inguinal hernia repair has been a controversialarea in the surgical practice from time it has beenconceived. The history of inguinal hernia repair overseveral decades implies how innovations are adoptedinto surgical practice through combination of scientificand subjective processes. The techniques of laparoscopichernia repair have evolved in parallel with experience
and technology. In the laparoscopic procedure, tensionfree repair is achieved by placement of a prostheticmesh to cover the entire groin area including the sitesof direct, indirect and femoral hernia. The laparoscopicapproach is based on the principle of tension free repair,which has been well established by open operation byNyhus and Stoppa. The greater availability of space inthe extraperitoneal approach facilitates the insertion ofa much bigger mesh.
Patient selection
TEP groin hernia repair is an advanced laparoscopicprocedure. It requires greater skills of laparoscopicdissection and manipulation as the working spaceavailable is limited. It has a long learning curve andmust be done only after acquiring experience in basiclaparoscopic procedures and when the learning curveis over. Today, we are well past the learning curveand have performed well over thousand laparoscopicgroin hernia repairs. Except for strangulated hernia, atpresent there are no absolute contraindications for thisprocedure. Relative contraindications include patientsunfit for anesthesia, obese and pregnant patients andpatients with a history of lower abdominal surgery.
Preoperative preparation
A thorough history of the presenting complaints and othercomorbid conditions should be taken. Specific measuresshould be taken if the patient is on drugs like Aspirin andwarfarin, oral hypoglycemic agents etc. Besides routinehematological investigations, other specific investigationslike X-Ray chest, ECG, coagulation profile, pulmonaryfunction test etc should be done for patients with historyof cardiac / pulmonary pathology.A written consent should be taken explaining theprobable complications and possibility of conversion toopen surgery.
Following preanesthetic check up and clearance forsurgery, the patient is kept fasting overnight. The patientis prepared adequately.
Surgical Technique
The procedure is done under general anesthesia (regionalanesthesia if the patient is unfit for general anesthesia).The patient is catheterized or asked to empty the bladdersbefore surgery and prophylactic antibiotic is given at thetime of induction of anesthesia. After induction, complete
reduction of the contents of the hernial sac is ensured.
Extraperitoneal access
A 10mm infraumbilical transverse incision is made.The anterior rectus sheath is exposed and transverseincision is then made on the anterior rectus sheath to oneside of the midline to avoid inadvertent opening of theperitoneum [Fig.1]. The margins of incised sheath areheld in stay sutures using vicryl 1-0 [Fig.2]. The rectusmuscle is retracted laterally from the midline and by finger dissection a space is created between the rectus muscle and the posterior rectus sheath.
Fig. 1: Transverse infraumbilical incision with incision in anterior rectus sheath
Fig. 2: Stay sutures over incised anterior rectus sheath
Balloon dissection of theextraperitoneal space
A self made balloon is then inserted in this preperitonealspace. The balloon trocar used by us is an indigenouslymade trocar where we tie two finger stalls of a size 8latex surgical glove on the tip of the 5 mm laparoscopicsuction cannula [Fig. 3]. The balloon trocar is theinflated with 100-150ml of saline. It not only creates aninitial working space but also brings about hemostasis
by balloon tamponade. The balloon is then deflated andthe cannula is removed.
A 10 mm Hassan’s cannula (blunt tip cannula)mounted with a conical sleeve is then introduced into thepreperitoneal space through the infraumbilical incision[Fig. 4]. The conical sleeve snuggly fits into the incisionand is secured with stay sutures. The insufflation tubingis attached to the Hasson’s Cannula and insufflation isbegun with pressure setting at 12 mm Hg.A 10 mm 30° telescope is used. The camera is introducedthrough the sub umbilical port and preperitoneal space isvisualized. The other two working ports are placed in thepreperitoneal space. First, a 5 mm port is placed about 2-3cm above the pubic symphysis in the midline and second,a 5/10 mm port is placed in the midline midway betweenthe two placed ports (subumbilical and suprapubic)[Fig. 5 & 6].
Fig. 3: Indigenous balloon trocar
Fig. 4: Hassan’s cannula introduced in sub umbilical port
Dissection of the extraperitoneal space
The surgeon stands on the side opposite to the operatingside / or side where hernia is present. Dissection in extraperitoneal space begins by dividing the loose areolartissue in the midline using sharp and blunt dissection.The first landmark / reference point i.e. the pubic boneis identified which appears as white glistening structurein the midline. The pubic bone is visualized and baredof all connective tissue creating a shelf extending about2-3 cm in the retropubic space, which acts as a shelf toplace the mesh [Fig.7].
The dissection is then traced laterally towards theside of the hernia. In case of direct hernia, the hernial sacis visualized as a weakness in the Hasselbach’s trianglemedial to the inferior epigastric vessels. On the otherhand, in the indirect hernia, the inferior epigastric vesselsare seen before the hernial sac, which is encounteredlaterally. Once the adhesions are lysed or hernial sac isreduced as in direct hernia, the anatomical landmarkswhich now become visible are Cooper’s ligament,iliopubic tract, femoral canal and the inferior epigastricvessels [Fig. 8, 9].
Fig. 5: Port placement for TEPFig. 6: Preperitoneal space
Fig. 7: Preperitoneal spaceFig. 8: Left direct hernial defect seen after dissection
Fig. 9: Right direct hernial defect
The spermatic cord lies immediately inferior andlateral to the inferior epigastric vessels. The adhesionsall around the cord are lysed with caution as the externaliliac vessels lie just below the cord structures. Theperitoneal extension (sac) is seen as a white glisteningstructure lying anterolateral to the cord [Fig.10]. Thesac is completely dissected off the cord structures andreduced. In cases of complete hernia, attempt should notbe made to completely reduce the sac as excessive tractionand dissection causes severe postoperative pain andedema. The sac should be transected and ligated using acatgut endoloop or by intracorporeal sutures, leaving thedistal sac open in situ [Fig.11].
Fig. 10: Right indirect hernial sac with cord structures Fig. 11: Dissected and ligated right indirect hernial sac
The peritoneal sac with reflection is completelyreduced. The vas deferens is seen lying separately on themedial side and gonadal vessels are seen on the lateralside forming a triangle. This triangle, known a “triangleof doom”, is bounded medially by the vas deferenslaterally by gonadal vessels with its apex at the internalinguinal ring and the base is formed by the peritoneum.No dissection should be carried within this triangle as itcontains the external iliac vessels.
Dissection is continued lateral to the cord structuresto create adequate space for the placement of mesh.The lateral space contains loose aerolar tissue, which iscompletely divided using sharp and blunt dissection. Thepsoas muscle is seen lying on the floor on which lateralcutaneous nerve of thigh and genito femoral nerve can beseen transversing. The anterior superior iliac spine marksthe lateral boundary of the dissection.
After creating the lateral space adequately the mesh isintroduced through the 10mm subumbilical port [Fig.12].The mesh is placed over the space created so that it coversthe sites of direct, indirect, femoral and obturator hernias[Fig.13]. The mesh is the secured in place with the helpof fixation devices like helical fasteners, staples anchorsetc. depending upon the preference of the surgeon. Afteradequately spreading the mesh, which extends from themidline medially, to lying over the psoas muscle on thelateral side, preperitoneal space is deflated.In cases of bilateral hernias the similar procedure canbe done on both the sides through the same three ports
made for unilateral repair.
Fig. 12: Rolled prolene meshFig. 13: Prolene mesh being placed for repair