The two 5 mm trocars are placed guided by the index finger to prevent their placement in the intra-peritoneal position. The surgeon’s index finger is inserted into the preperitoneal space and is swept from side to side to develop the space and accommodate placement of the 5 mm trocars. The rectus abdominis muscle is swept laterally exposing the posterior rectus sheath. Avoiding the linea alba is important to avoid inadvertent entry into the peritoneal cavity. The anterior rectus sheath is incised transversely off the midline to expose the rectus abdominis muscle. A 15 mm curvilinear infra umbilical incision is made and carried down sharply to the level of the fascia. TEP requires the placement of 3 trocars in the lower midline, one Hasson and two 5 mm trocars ( Figure 2) ( 6). Operative technique Initial trocar placement These hernias may not be readily identifiable by examining the peritoneal side. When the space of Retzius is developed in TEP, 3/4 (femoral, obturator and direct) hernias are explored on the contralateral side. TEP can be performed without the use of electrocautery which may translate into less post-operative pain. TEP also avoids the issue of peritoneal closure and the problems associated with that closure. TEP completely avoids entry to the abdomen which can be advantageous in patients with prior surgery.
Neither approach has been shown to be the better however several fundamental differences exist when comparing the two approaches. TEP and transabdominal pre-peritoneal (TAPP) are the two most commonly used approaches for minimally invasive inguinal hernia repair. (A,B) Anatomy of the preperitoneal space (C) anatomy of the fascial layer deep to transversals fascia or spermatic fascia. A thorough understanding of the anatomy of the preperitoneal space is crucial when considering performing TEP ( Figure 1A,B,C).įigure 1 Anatomical considerations. The indications and contraindications for TEP are summarized in Tables 1 and 2. Moreover, and with increased experience with the technique, the classic indications and applications have been extended to encompass the whole spectrum of groin hernias from the non-recurrent unilateral hernia to the more complex and recurrent cases. Decreased wound complications, faster recovery, and decreased incidence of chronic pain are some of the advantages that drove more surgeons to adopt these techniques ( 3- 5). Since the initial description of laparoscopic totally extraperitoneal (TEP) inguinal hernia repair by Ferzli and McKernan, abundant data have become available on laparoscopic inguinal hernia repairs and their outcomes compared to open approaches ( 1, 2). Received: 25 January 2019 Accepted: 05 March 2019 Published: 26 March 2019. Keywords: Totally extraperitoneal (TEP) inguinal hernia laparoscopic