Inguinal hernia repair: Total Extraperitoneal approach (TEP)

This is live video recorded during a surgical course demonstrating the total extra-peritoneal (TEP) approach to repair of a right indirect inguinal hernia. Access to the pubis is gained on the midline. After taking down the adhesions, the authors visualize the pelvic bone. Moving laterally, they see the bladder and hernia, then the spermatic cord comes into view. The indirect hernia appears at 1 o’clock, the epigastric vessels serving as the landmark. The authors continue with reduction of the hernia sac.

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Inguinal hernia repair: Total Extraperitoneal approach (TEP)

Authors

B Dallemagne, S Perretta, J Marescaux

Abstract

This is live video recorded during a surgical course demonstrating the total extra-peritoneal (TEP) approach to repair of a right indirect inguinal hernia.

Access to the pubis is gained on the midline. After taking down the adhesions, the authors visualize the pelvic bone. Moving laterally, they see the bladder and hernia, then the spermatic cord comes into view. The indirect hernia appears at 1 o’clock, the epigastric vessels serving as the landmark. The authors continue with reduction of the hernia sac.

Keywords

inguinal, hernia, extraperitoneal, TEP, hernia

Media type

Surgical video

Duration

06'00''

Publication

2007-02

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E-publication

WeBSurg.com, Feb 2007;7(02).
URL: http://www.websurg.com/doi-vd01en2051.htm

Inguinal hernia repair: Total Extraperitoneal approach (TEP)

1. Dissection of pre-peritoneal space 00'16''

One technique is to create a pneumoperitoneum and go straight ahead. So I’m coming with the optical trocar, and I’ll try to follow the line of my posterior sheath. We’re using a 12mm Hg insufflation and I will ask the anesthesiologist to put a slight Trendelenburg to have an access to the pubis on the midline first. But usually it’s quite clear. The pubis is there. You see I’ve contact there. There are some adhesions there that I will try to take down with my 1st trocar. I’ll take down these adhesions on the midline. I’m trying to see the pubic bone before doing anything else. I’ll move progressively laterally reflecting all these adhesions. The bladder is there.

2. Identification of spermatic cord and indirect hernia sac 01'45''

This is the hernia over there. That increases a little bit my view. I think you have a better muscle relaxation also because the operative field is bigger. This is a lipoma apparently. The cord is there. We always say it’s very important to reduce the lipoma as the patient feels as if he still has the hernia. Usually you can leave it like this. Sometimes if there is a big hole, you can use suture or the Endoloop. What is that structure at 1 o’clock? An indirect hernia, outside of the epigastric vessels. I try to reduce the sac a little bit more.

3. Reduction of hernia sac 03'15''

This is the psoas muscle and you see these nerve fibers which are called the triangle of pain because if you put some staples there, you’ll be getting into trouble. I retract a little bit the sac. It usually comes without bleeding. That is also a classical point of peritoneal opening here. I clear this side a little bit more because for this approach, a posterior repair, it’s important to go down here next to the obturator hole, because the prosthesis has to go down. Because in most of the cases, I don’t fix the mesh. So I have to go quite deep in order to properly place the mesh. You see I’m on the abdominal wall there. You see the psoas very well with different fibers. Now I’m clear with dissection. You see this field is quite large and I’ll put my mesh in all this area.

4. Placement of mesh 04'40''

Through the 10mm port, I’ll introduce the mesh. I’m going on the psoas laterally. If it doesn’t fit the way I like, I’ll fix it. I’m just checking that everything is going well, and you see the peritoneum coming and covering the mesh. So as soon as the patient is awake, he will put a pressure on the mesh, and the mesh won’t move. You see the mesh is well placed there. We’re almost 15cm above the umbilicus, and we’re going back and that’s over.