Laparoscopic Total ExtraperitonealInguinal Hernia Repair
Bruce Ramshaw, MD, FACS
he laparoscopic approach for inguinal hernia repairwas ﬁrst reported by Ger, who performed a high liga-tion of the sac without mesh placement.
In the early1990s, a variety of trans-abdominal laparoscopic ap-proaches were reported, with the trans-abdominal pre-peritoneal (TAPP) approach and the intraperitoneal onlaymesh (IPOM) techniques being the most common. Be-cause of reports of high recurrence rates, the IPOM tech-nique quickly fell out of favor. In 1993 the laparoscopictotal extraperitoneal (TEP) approach was reported byMcKernan.
The TEP approach allows for mesh placementwithin the preperitoneal space, without entering the ab-dominal cavity. Another beneﬁt of this approach is theavoidance of the incision and closure of the peritoneumtypically required in the TAPP approach.I had the fortune of being a resident in Atlanta in 1993,allowing me to travel only a few miles to watch Barry Mc-Kernan perform several laparoscopic TEP hernia repairs. With the help of fellow residents and my attendings, weintegrated this technique into all general surgery practices atGeorgia Baptist Medical Center that year. Because it is anextremelydifﬁcultproceduretolearn,itwasadvantageoustohave over 10 surgeons helping each other learn the tech-nique. On completing residency, the laparoscopic TEP ap-proach became my procedure of choice for essentially allinguinal hernia repairs in my practice. Contraindications forperforming the TEP technique include age (prepubertal chil-dren) and the inability to tolerate general or regional anes-thesia. Relative contraindications include large scrotal her-nias, previous lower midline abdominal surgery, andprevious mesh placement in the preperitoneal space. I cur-rently use a TAPP approach without reperitonealization, us-ing mesh designed for intraabdominal placement, in thesepatients.The primary barrier to performing a successful laparo-scopic TEP inguinal hernia repair is the difﬁculty associatedwith learning the technique. Once mastered, the repair canbeperformedfaster,withbettervisualizationandwidermeshcoverage than the commonly performed open tension-freeinguinal hernia repairs, especially for bilateral and recurrenthernias. There are several barriers to learning the technique.First, access to the extraperitoneal space through a smallinfra-umbilical incision is not something a general surgeonhas typically done. The extraperitoneal dissection of thelower abdomen, exposing the myopectineal oriﬁce bilater-ally, can be a daunting task. Balloon dissectors can signiﬁ-cantly help a surgeon perform a safe, consistent extraperito-neal dissection, especially early in the learning curve.However, even with the balloon, accidental placement intothe subcutaneous tissue, within the rectus muscle and insidethe abdominal cavity has occurred. A laparoscopic viewthrough the balloon helps ensure that it has been placed inthe correct space. Usually, the pubis and Cooper’s ligamentare the ﬁrst structures visualized when the balloon is placedcorrectly. However, even when placed in the correct space,inﬂation of the balloon can injure the bowel or bladder, es-pecially in patients with previous lower abdominal surgery.Directing the balloon more laterally toward the side of thedefect and inﬂating it less than usual can minimize the like-lihood of injury in these patients, including those who haveundergone previous open prostatectomy. Another barrier is the variability of the initial presentationof the anatomy. Signiﬁcant preperitoneal fat, presence of anunreduced direct hernia, bleeding from the balloon dissec-tion, and previous lower abdominal surgery, can obscure theanatomy. Probably the most dangerous portion of the oper-ation is the lateral dissection, where dissecting too far poste-riorly can increase the risk of inadvertent iliac vessel injury.To minimize this dangerous complication, lateral dissectionshould be done near the anterior extraperitoneal plane, justposterior to the rectus muscle and inferior epigastric vessels. All structures posterior and lateral to the epigastric vesselsshould be carefully dissected posteriorly and medially toopen up the lateral extraperitoneal space.Probablythemostdifﬁcultdissection,eveninexperiencedhands, is the reduction of a chronic, large indirect sac that isoften adherent to the cord and surrounding structures. Re-duction of the indirect sac can add several minutes to theprocedure in experienced hands, and may necessitate con-version to an open approach for the surgeon early in thelearning curve. Another barrier to learning the operation isthe mesh manipulation. Manipulating and orienting a largemesh in a relatively small space can be challenging.
Division of General Surgery, University of Missouri Hospital & Clinics, OneHospital Drive, MC414 McHaney Hall, Columbia, MO. Address reprint requests to Bruce Ramshaw, MD FACS, Associate Professorof Surgery, Chief, Division of General Surgery, University of MissouriHospital & Clinics, One Hospital Drive, MC414 McHaney Hall, Colum-bia, MO 65212. E-mail: email@example.com
1524-153X/06/$-see front matter © 2006 Elsevier Inc. All rights reserved.doi:10.1053/j.optechgensurg.2006.04.007