Overview
Definition:
Totally Extraperitoneal (TEP) laparoscopic inguinal hernia repair is a minimally invasive surgical technique that involves dissecting the preperitoneal space and placing a mesh prosthesis to repair inguinal hernias without entering the peritoneal cavity.
Epidemiology:
Inguinal hernias are common, affecting an estimated 1-5% of the general population, with a male-to-female ratio of approximately 9:1
They are more prevalent in older individuals and those with risk factors like chronic cough, constipation, or heavy lifting
TEP is increasingly adopted worldwide due to its benefits.
Clinical Significance:
TEP offers advantages over open repair and transabdominal preperitoneal (TAPP) approaches, including reduced postoperative pain, faster recovery, lower recurrence rates, and decreased risk of visceral injury
It is a crucial skill for general surgeons preparing for DNB and NEET SS examinations.
Indications
Primary Indications:
Symptomatic primary inguinal hernias (direct and indirect) in both men and women
Bilateral inguinal hernias
Recurrent inguinal hernias following open repair where a suitable plane exists.
Contraindications:
Absolute: Uncorrected coagulopathy, inability to tolerate general anesthesia
Relative: Extensive adhesions in the preperitoneal space, strangulated hernias with compromised bowel, extensive previous lower abdominal surgery with adhesions into the preperitoneal space, suspected large incarcerated hernias with risk of peritoneal breach.
Patient Selection:
Patients should be medically fit for general anesthesia
Careful patient selection is vital to maximize outcomes and minimize complications
Preoperative assessment for risk factors is essential.
Preoperative Preparation
Patient Evaluation:
Detailed history including onset, duration, and nature of symptoms, previous surgeries, and comorbidities
Physical examination to confirm the presence and type of hernia
Imaging may be used in equivocal cases but is often not mandatory for typical hernias.
Anesthesia:
General anesthesia is typically required
Epidural or spinal anesthesia may be considered in select cases but are less common for TEP.
Informed Consent:
Thorough discussion with the patient regarding the procedure, potential risks, benefits, alternatives (open repair), and expected recovery
Emphasis on minimally invasive benefits and potential complications.
Prophylaxis:
Prophylactic antibiotics are generally administered intravenously before skin incision, typically a first-generation cephalosporin, unless contraindicated
Deep vein thrombosis (DVT) prophylaxis is administered based on patient risk factors, usually with low molecular weight heparin (LMWH).
Procedure Steps
Port Placement:
Typically, three ports are used: a primary umbilical port for the camera, and two working ports, one supraumbilical and one in the iliac fossa on the same side as the hernia
Alternatively, a single infraumbilical midline incision can be used for all ports in some techniques.
Preperitoneal Dissection:
A small incision is made inferomedially to the anterior superior iliac spine
A balloon dissector or blunt dissection is used to create a working space in the preperitoneal plane, separating the transversalis fascia from the peritoneum
Dissection extends superiorly to the umbilicus, medially to the pubic symphysis, and laterally to the anterior superior iliac spine.
Hernia Sac Management:
The peritoneum is carefully dissected off the spermatic cord structures
The hernia sac is identified, reduced into the abdominal cavity, or ligated and divided if too large
For recurrent hernias, scar tissue is meticulously cleared.
Mesh Placement:
A large, lightweight, multifilament polypropylene or composite mesh (e.g., dual mesh with an anti-adhesion barrier) is introduced into the preperitoneal space and positioned to cover the myopectineal orifice (MPO) completely
The mesh is secured using tackers, sutures, or fibrin glue, or left unsecured depending on surgeon preference and mesh type.
Closure:
Ports are removed, and small incisions are closed with absorbable sutures or steristrips
No drains are typically used
Pneumoperitoneum is released gradually.
Postoperative Care
Pain Management:
Multimodal analgesia is key, including parenteral analgesics (NSAIDs, opioids as needed), oral analgesics, and sometimes local anesthetic infiltration at port sites
Patients usually ambulate within hours of surgery.
Activity Restrictions:
Patients are advised to avoid strenuous activity, heavy lifting (>10 lbs), and vigorous exercise for 2-4 weeks, with gradual return to normal activities
The exact duration depends on the extent of dissection and patient recovery.
Diet:
Diet is usually advanced as tolerated, starting with clear liquids and progressing to a regular diet as bowel function returns.
Wound Care:
Port sites are kept clean and dry
Patients are advised to monitor for signs of infection
Suture removal is usually not required if absorbable sutures are used and incisions are closed with steristrips.
Discharge Criteria:
Ambulatory, tolerating oral intake, pain controlled with oral analgesics, able to void, and with no significant signs of complications
Patients are typically discharged the same day or the next morning.
Complications
Early Complications:
Hematoma formation in the preperitoneal space or scrotum
seroma
wound infection at port sites
bleeding from dissection or tacker sites
urinary retention
nerve injury (e.g., lateral femoral cutaneous nerve) causing pain or paresthesia
inadvertent peritoneal entry with possible bowel injury
bowel injury (rare)
vascular injury (rare).
Late Complications:
Chronic groin pain (persistent or new onset)
mesh infection
mesh migration or shrinkage
hernia recurrence
persistent paresthesia
adhesions
scrotal swelling
phantom testis syndrome (rare).
Prevention Strategies:
Meticulous dissection to avoid vascular and nerve injury
careful identification and reduction of hernia sac
judicious use of mesh fixation devices
adequate mesh coverage of the MPO
proper port placement to avoid injury
prompt diagnosis and management of complications
Adherence to surgical technique and patient selection criteria.
Key Points
Exam Focus:
Understanding the anatomical layers involved in TEP dissection (endoabdominal fascia, transversalis fascia, peritoneum)
Recognizing the boundaries of preperitoneal dissection
Knowledge of mesh types, fixation methods, and their indications
Differentiating TEP from TAPP and open repairs
Management of specific complications like cord lipomas or obturator hernias during TEP.
Clinical Pearls:
Adequate preperitoneal space creation is crucial for safe dissection and mesh placement
Careful identification of the peritoneum is paramount to avoid injury
Bilateral TEP can be performed safely in one session
The use of coated meshes may reduce chronic groin pain but increases cost.
Common Mistakes:
Inadequate dissection leading to poor mesh coverage or mesh folding
Injury to the spermatic cord structures
Missing indirect hernia component
Failure to secure the mesh adequately leading to migration
Over-dissection of the peritoneum leading to increased risk of injury
Incorrect port placement causing iatrogenic injury.