Bilateral Laparoscopic Inguinal Hernia Repair with Mesh Using the Totally Extraperitoneal (TEP) Technique

Case Overview

Inguinal hernia repair is one of the most frequently performed surgical procedures worldwide.¹ This common condition, characterized by the protrusion of abdominal contents through a weakness in the inguinal canal, affects a significant portion of the population, with a lifetime risk of 27% for men and 3% for women.²

Inguinal hernia repair has undergone significant evolution over time. The Bassini repair, introduced in the late 19th century, marked the beginning of modern hernia surgery.³ Subsequent advancements led to the development of tension-free repairs using prosthetic mesh, pioneered by Lichtenstein in the 1980s.⁴ These open techniques have been the gold standard for many years, offering low recurrence rates and relatively straightforward execution.

In recent decades, minimally-invasive approaches have gained considerable traction in the field of hernia repair. Laparoscopic techniques, first introduced in the early 1990s, have shown promise in reducing postoperative pain, facilitating faster recovery, and improving cosmetic outcomes.⁵ Among these approaches, two main techniques have emerged: the transabdominal preperitoneal (TAPP) repair and the totally extraperitoneal (TEP) repair.^6,7

The TEP technique, which is the focus of this video, has garnered particular interest due to its potential advantages. Unlike the TAPP approach, TEP avoids entry into the peritoneal cavity, potentially reducing the risk of visceral injuries and postoperative adhesions.8 However, the TEP procedure is technically challenging and requires a thorough understanding of the complex anatomy of the preperitoneal space.^9,10

Despite its potential benefits, the adoption of laparoscopic techniques, including TEP, has been gradual. Factors such as longer operative time and the need for general anesthesia have contributed to ongoing debates about the optimal approach for inguinal hernia repair.¹¹

Assessing a patient for inguinal hernia repair via TEP requires consideration of multiple factors. The patient's history should be examined for conditions that may increase complication risks, such as chronic cough, constipation, and prostate issues. Prior to surgery, modifiable risk factors like obesity, smoking, and poor glycemic control should be addressed.

This video is a comprehensive step-by-step demonstration of laparoscopic inguinal hernia repair using the TEP method. It features a middle-aged male with bilateral inguinal hernias who has experienced left groin pain for several years. This case is significant as it showcases the efficiency of laparoscopic techniques in addressing bilateral hernias, which are relatively common, through a single surgical procedure.

Prior to the procedure, a thorough patient assessment is conducted. General anesthesia is administered. The surgical site and scrotum are prepped and draped in a sterile manner. A Foley catheter is inserted to minimize the risk of bladder injury during the procedure. The patient's arms are tucked to allow close access to the abdominal wall, with padding applied to the elbows to prevent ulnar nerve injury. Sequential compression devices are applied to the legs for added safety.

The procedure begins with an infraumbilical incision, either up-and-down or curvilinear, depending on the belly button shape. Local anesthetic is applied to the midline to minimize discomfort. A 10-mm, 30-degree laparoscope is utilized throughout the procedure.

The initial dissection is made down to the anterior rectus sheath. A transverse incision is made in the anterior rectus sheath, lateral to the midline, to expose the underlying rectus abdominis muscle. Care is taken to avoid the linea alba, as this precaution is essential to prevent inadvertent penetration of the peritoneal cavity. The retrorectus space is identified by retracting the rectus muscle and moving downward. A middle finger of size 8 glove, assisted by an irrigator and suction device, is used to dissect the initial TEP plane. Then, approximately 240 mL of saline solution is injected, and the preperitoneal space is insufflated with CO₂ to a pressure of 10 mmHg to further develop and expand this space.

A 5-mm pediatric trocar is inserted 1 cm above the pubic bone, with care taken to protect the bladder. Another 5-mm trocar is placed at the level of the anterior superior iliac spine, guided by a needle finder. In total, TEP typically requires a placement of three trocars in the lower midline.

Anatomical variations can present significant challenges during laparoscopic inguinal hernia repair. Difficulties such as a narrow pelvis, prior lower abdominal surgery, or limited preperitoneal space can complicate dissection and safe mesh placement. One important example is a reduced umbilicus–pubic tubercle distance, which is associated with greater instrument angulation during totally extraperitoneal TEP repair, making dissection and visualization more technically demanding. In such cases, the extended-view totally extraperitoneal (eTEP) approach can provide a broader operative field and facilitate safer dissection. When anatomical challenges prevent safe creation of the preperitoneal space, conversion to a transabdominal preperitoneal (TAPP) approach or to an open anterior mesh repair remains a viable and recommended strategy. Thorough preoperative assessment and flexible intraoperative decision-making are essential to optimize outcomes in patients with challenging groin anatomy.^14-17

The pubic tubercle is identified and cleared using cautery. It serves as an important landmark to orient the surgeon, especially in complex cases. The bladder is posterior to the pubic symphysis and care must be made not to injure it when dissecting posterior to the pubic symphysis. Abnormal scarring in this region may suggest a potential direct hernia. The epigastric vessels are visualized, and redundant transversalis fascia, indicative of a direct inguinal hernia, is observed.

The femoral space is identified by locating the bone and Cooper's ligament. Dissection is performed laterally, with care taken to avoid the external iliac vein. Any fat in the femoral space is carefully removed, leaving lymphatic tissue intact.

The direct space (Hesselbach’s triangle) is identified immediately superior to the femoral space and separated by the medial aspect of the iliopubic tract. A lateral to medial dissection technique is employed, with the epigastric vessels held up by one hand while the other hand dissects laterally towards the internal ring.

In the TEP approach, the space of Bogros is created using gentle horizontal dissection while elevating the epigastric blood vessels. This space is extended outward to the anterior superior iliac spine (ASIS), ensuring there's enough room to place an appropriately sized mesh.

The surgeon then identifies the indirect space by locating either the spermatic cord (in male patients) or the round ligament (in female patients). These structures are found passing through the internal ring, which is positioned to the outside of the epigastric vessels. An indirect hernia sac, if present, can usually be seen overlying these cord structures or the round ligament. The presence of an indirect hernia is suggested if the surgeon cannot readily identify the vas deferens (in men) or the round ligament (in women) immediately adjacent to the epigastric vessels.

In the case presented, a large direct hernia is identified on the right side, with a suspected additional hernia on the left side. The direct space is cleared, revealing Cooper's ligament, which is crucial in identifying smaller direct hernias. Any fat or fascia within the hernia defects is carefully dissected and removed.

After thorough dissection and preparation of both sides, a preshaped, heavyweight mesh is placed. For direct hernias, the mesh is positioned to provide the necessary coverage. It is secured with fixation devices in key areas to ensure it lays flat and does not shift.

Following desufflation, the anterior fascia is closed with absorbable sutures to restore normal anatomy. The skin is closed, ensuring no risk of incisional hernia. Local anesthetic is added to minimize postoperative pain.
The bilateral laparoscopic inguinal hernia repair with mesh using the TEP technique, as demonstrated in this video, offers several advantages over traditional open repair methods. This approach is associated with a low chronic pain rate, low recurrence rate, and short recovery time.^12,13

TEP approach for inguinal hernia repair, while minimally invasive and effective, carries specific risks related to anatomical landmarks and technical challenges. Among vascular complications, injury to the corona mortis—an aberrant vascular connection between the external iliac or inferior epigastric vessels and the obturator vessels seen in the space of Reitzius—as well as injury to epigastric vessels, can result in significant hemorrhage if not promptly recognized. Management includes laparoscopic clipping and use of energy devices for vessel ligation. Nerve injuries are another critical concern, particularly involving structures within the so-called triangle of pain, which contains the lateral femoral cutaneous nerve, femoral branch of the genitofemoral nerve, and femoral nerve. Injury or entrapment of these nerves, especially through improper tacking or mesh fixation, can result in chronic postoperative neuralgia. To avoid this, no fixation should be applied lateral to the triangle of Doom and inferior to the iliopubic tract; in cases of nerve injury, conservative pain management is first-line, with surgical neurectomy reserved for refractory cases.¹⁸

Pneumoperitoneum is typically caused by peritoneal tears during dissection. An increased pressure on the abdominal wall due to pneumoperitoneum can limit the working space and make dissection more challenging. Identifying and repairing peritoneal tears early helps ensure smoother surgical progress. For patients with prior surgical scars, extra care and attention are needed throughout the procedure. If safe dissection cannot be ensured, conversion to either transabdominal preperitoneal (TAPP) repair or an open approach can be considered. Other TEP-related complications include seroma formation (managed expectantly), bladder injury during medial dissection (requiring intraoperative recognition and repair), and recurrence due to inadequate mesh positioning or fixation. Ultimately, careful anatomical dissection, minimal use of fixation in high-risk zones, and readiness to manage intraoperative events are key to minimizing complications in TEP hernia repair.^{14 -18}

The detailed description of the procedure provides valuable insights for surgeons at various stages of their careers. For novice surgeons, it offers a step-by-step guide to the TEP technique, highlighting critical anatomical landmarks and potential pitfalls. Experienced surgeons may benefit from the nuanced discussions on tissue handling, dissection techniques, and mesh placement. The emphasis on patient selection, preoperative preparation, and postoperative care underscores the importance of a holistic approach to surgical management. This comprehensive perspective is crucial for achieving optimal patient outcomes and minimizing complications.

In conclusion, this video serves as a valuable resource for the surgical community. It not only demonstrates the technical aspects of the procedure but also highlights the importance of thorough anatomical knowledge. As minimally-invasive techniques continue to evolve, such detailed educational resources will play a crucial role in disseminating knowledge and improving surgical outcomes for patients with inguinal hernias.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.