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458
S. Roll and J. Skinovsky
Fig. 43.12 ( a ) Right side—start closure of the peritoneal fl ap (running suture). ( b ) Right side—fi nal aspect of running
suture
erative complications was 2.8%, and the most
serious complication was injury of the bladder in
one case. The postoperative complications were
present in 235 (29.6%) patients. There were 10
(1.2%) relapses; 9 cases in the TAPP, and one in
the TEP group.
NOTE : In my experience, inguinoscrotal her-
nias show a signifi cantly higher rate of complications such as seromas, postoperative pain,
bleeding, injury to the deferens, and orchiditis.
Recommendation
TAPP TEP
Routine X
Prior Abdominal Surgery X
Bilateral Hernia X
Inguinoscrotal hernia X
Incarcerated hernia X
Hernia & Diagnosis X
Recurrent hernia X
Hernia and cholecystectomy X
Prior preperitoneal surgery X
Contraindication–general anesthesia X
TAPP is an effective and safe technique. It can be
performed in a standard way for all inguinal and
femoral hernias. It is simple to learn and easy to
teach.
References
1. Kavic M, Roll S. Laparoscopic transabdominal preperitoneal hernia repair (TAPP). In: Bendavid R,
Abrahamson J, Arregui M, Flament J, Phillips E,
editors. Abdominal wall hernias—principles and
management. New York: Springer; 2001.
p. 454–63.
2. Bittner R, Arregui ME, Bisgaard T, Dudai M, Ferzli
GS, Fitzgibbons RJ, et al. Surg Endosc. 2011;25(9):
2773–843.
3. Edwards CC, Bailey RW. Laparoscopic hernia repair:
the learning curve. Surg Laparosc Endosc Percutan
Tech. 2000;10(3):149–53. (Neumayer L, GiobbieHurder A, Jonasson O, Fitzgibbons R Jr, Dunlop D,
Gibbs J, et al. Open mesh versus laparoscopic mesh
repair of inguinal hernia. N Engl J Med. Apr 29
2004;350(18):1819-27.
4. Cavazzola LT, Rosen MJ. Surg Clin N Am. 2013;93:
1269–79.
5. Zacharoulis D, Fafoulakis F, Baloyiannis I, Sioka E,
Georgopoulou S, Pratsas C, Hantzi E, Tzovaras G.
Laparoscopic transabdominal preperitoneal repair of
inguinal hernia under spinal anesthesia: a pilot study.
Am J Surg. 2009;198(3):456–9.
6. Agresta F, Mazzarolo G, Balbi P, Bedin N. Inguinalscrotal hernias in young patients: is laparoscopic
repair a possible answer? Preliminary results of a
single-institution experience with a transabdominal
preperitoneal approach. Hernia. 2010;14(5):471–5.
7. McCormack K, Wake BL, Fraser C, et al.
Transabdominal pre-peritoneal (TAPP) versus totally
extraperitoneal (TEP) laparoscopic techniques for
inguinal hernia repair: a systematic review. Hernia.
2005;9(2):109–14.
8. Nikkolo C, Lepner U, Murrus M, Vaasna T, Seepter
H, Tikk T. Randomised clinical trial comparing lightweight mesh with heavyweight mesh for inguinal hernioplasty. Hernia. 2010;14(3):253–8.
43 Laparoscopic TAPP Inguinal Hernia Repair
459
9. Cobb WS, Kercher KW, Heniford BT. The argument
for lightweight polypropylene mesh in hernia repair.
Surg Innov. 2005;12(1):63–9.
10. Hatzitheofi lou C, Lakhoo M, Sofi anos C, Levy RD,
Velmahos G, Saadia R. Laparoscopic inguinal hernia
repair by an intraperitoneal onlay mesh technique
using expanded PTFE: a prospective study. Surg
Laparosc Endosc. 1997;7(6):451–5.
11. Kapiris S, Mavromatis T, Andrikopoulos S, et al.
Laparoscopic transabdominal preperitoneal hernia
repair (TAPP): stapling the mesh is not mandatory.
J Laparoendosc Adv Surg Tech A. 2009;19:419.
12. Drake RL, Vogl AW, Mitchell AWM. Gray’s Anatomy
for Students. Philadelphia: Churchill-Livingstone;
2004. p. 258–65.
13. Roll S, dePaula A, Miguel P, Carim J, Campos FG,
Hashiba K. Transabdominal laparoscopic hernioplasty using preperitonial mesh. In: Radcliffe R,
editor. Inguinal hernia advances or controversies?
Oxford: Oxford University Press; 1994. p. 261–4.
14. Spaw AT, Ennis BW, Spaw LP. Laparoscopic hernia
repair: the anatomic basis. J Laparoendosc Surg.
1991;1(5):269–77.
15. Bittner R, Leibl BJ, Jäger C, Kraft B, Ulrich M,
Schwarz J. TAPP—Stuttgart technique and result of a
large single center series. J Minim Access Surg.
2006;2(3):155–9.
16. Richards SK, Vipond MN, Earnshaw JJ. Review of
the management of recurrent inguinal hernia. Hernia.
2004;8(2):144–8.
17. Ross SW, Oommen B, Kim M, Walters A,
Augenstein V, Heniford BT. Tacks, staples, or
suture: method of peritoneal closure in laparoscopic
transabdominal preperitoneal inguinal hernia repair
effects early quality of life. Surg Endosc. 2015;
29(7):1686–93.
18. Bittner R, Schmedt C-G, Schwarz J, Kraft K, Leibl
BJ. Laparoscopic transperitoneal procedure for routine repair of groin hernia. Br J Surg. 2002;89(8):
1062–6.
Laparoscopic Total Extra-Peritoneal (TEP) Inguinal Hernia Repair
Tammy Kindel and Dmitry Oleynikov
44
Introduction to Total Extraperitoneal Inguinal Hernia Repair
Laparoscopic total extra-peritoneal (TEP) has
gained popularity over the past 15 years as an
acceptable alternative to the open Lichtenstein
repair for the surgical treatment of initial, unilateral inguinal hernias given the similar recurrence
risk and decreased post-operative pain, early
ambulation and return to work [ 1 , 2 ]. Initial
results of both TEP and TAPP compared to an
open, tension-free repair for inguinal hernias
were disappointing due to higher recurrence and
complication rates with a laparoscopic (10.1 and
39%) compared to open repair (4.9 and 33.4%) at
2 years [ 4 ]. However, further studies looking spe-
cifi cally at TEP have shown a similar recurrence
rate to the open, Lichtenstein repair [ 5 , 6 ]. A
recent meta-analysis using bias evaluation and
Electronic supplementary material: The online version
of this chapter (doi:
tains supplementary material, which is available to authorized users.
T. Kindel , M.D., Ph.D. (*) • D. Oleynikov , M.D.
Department of Surgery , University of Nebraska
Medical Center , 986245 Nebraska Medical Center ,
Omaha , NE 68198-6245 , USA
tammy.kindel@unmc.edu;
e-mail:
doleynik@unmc.edu
10.1007/978-3-319-27470-6_44 ) con-
trial sequence analysis of randomized controlled
trials found no difference in recurrent rates
between TEP and the open approach [ 6 ]. Early
post-operative pain as well as long-term moderate and severe chronic pain is reduced when a
TEP is performed compared to an open, tensionfree repair [ 7 – 9 ].
It is now believed that one of the primary reasons for inferior early results with TEP compared to open or TAPP repairs is due to the steep
learning curve required in TEP [ 10 , 11 ]. There is
an initial critical learning curve of approximately 30–50 cases with TEP due to the unfamiliar anatomic orientation encountered in the
pre-peritoneal space as well as limited working
space [ 12 , 13 ]. Even after 50 cases, while the
recurrence rate and number of intraoperative
complications are not signifi cantly affected, the
operative time, conversion rate, and post-operative complications may continue to improve up
to 250 cases [ 14 ]. Beyond operating with an
experienced laparoscopic inguinal hernia surgeon, novices may be able to shorten their learning curve with the use of simulation- based
training as well as using a Stoppa’s pre-peritoneal approach, if converting to open, to increase
anatomic familiarity [ 13 , 15 ]. Further, careful
patient selection may be advised for the surgeon
gaining experience with TEP including selection of young, thin male patients with a unilateral, non-scrotal hernia and without prior
abdominal surgery [ 16 ].
Y.W. Novitsky (ed.), Hernia Surgery, DOI 10.1007/978-3-319-27470-6_44
461© Springer International Publishing Switzerland 2016
462
T. Kindel and D. Oleynikov
Patient Selection for TEP Repair
Indications
As mentioned previously, TEP is an excellent
option for a recurrent inguinal hernia following
an open repair or for bilateral inguinal hernias.
Given surgeon preference, TEP is also an appropriate choice for an initial, unilateral inguinal
hernia as long as the patient can tolerate general
anesthesia and has no contraindications, as discussed below, with the added advantage of
exploring for an occult, contralateral inguinal
hernia [ 3 ].
Contraindications
Any patient who cannot tolerate general anesthesia and would be better served with local, sedation,
or a spinal anesthetic is not an appropriate candidate for TEP. Chronically incarcerated and scrotal
hernias have traditionally been a contra- indication
to laparoscopic repair. However, these hernias can
be repaired successfully by TEP in experienced
hands. Modifi cations from a traditional TEP
should include mandatory Foley catheter placement to allow for full development of the space of
Retzius as well as surgeon comfort with ligating
the epigastric vessels, if needed, as well as knowledge on how to incise the transversalis fascial sling
to aid in indirect hernia sac reduction [ 17 ].
For acute incarcerations, high suspicion of
ischemia is a contraindication for the TEP
approach. If there are no concerning signs of
bowel compromise, a TEP approach can be considered. Similarly to treatment of other chronically incarcerated hernias, the use of a relaxing
incision is often needed in the acute situation for
sac content reduction. For direct hernias, an anteriomedial incision can be directed toward the rectus, carefully avoiding injury to the epigastric
and iliac vessels. The relaxing incision for the
indirect space is performed in the transversalis
fascial sling and in the lacunar ligament and/or
anteriomedial iliopubic tract for femoral hernias
[ 18 ]. We advocate opening the sac in all cases of
acute incarceration or new obstruction to ensure
bowel viability and inspect the transition point if
present. The sac and peritoneum can then be
closed and the intra-peritoneal gas evacuated to
maintain pre-peritoneal visualization.
We also recommend an open approach over
TEP-IHR for patients who have had prior violation of the pre-peritoneal space such as occurs
after prostatectomy [ 19 ].
Technical Considerations of TEP-IHR
(a) Development of the pre-peritoneal space .
The patient is positioned on the operating
table supine with both arms tucked and
appropriately padded. A Foley catheter is
placed, if it is a known recurrent hernia or
large scrotal hernia; otherwise, the patient
can void just prior to entering the operating
room and avoid Foley catheter insertion. An
infra-umbilical, curvilinear incision is made
in the midline. This is extended to the anterior rectus sheath. The anterior rectus sheath
is divided just off the midline of the affected
side with refl ection of the rectus muscle
proper laterally. With this, the posterior
sheath is exposed and the initial blunt dissection can be performed with a fi nger sweeping
the rectus muscle laterally and anteriorly.
Care should be taken to enter the retro-rectus
space at the most medial aspect of the rectus
belly to prevent muscle bleeding. A curved S
or Army–Navy retractor can then be placed
within the pre-peritoneal space to aid in passage of a lubricated dissecting balloon. The
dissecting balloon should be inserted with
only gentle force in the direction of the pubis.
Once the pubis is reached, we place the balloon just inferior to the bone and insuffl ate
the dissecting balloon under camera visualization. The dissector is then removed with
the trocar left in place with an infl atable balloon tip and the pre-peritoneal space
insuffl ated with carbon dioxide to an insuffl ating pressure of 15 mmHg. A 45° 10-mm
laparoscope aids in enhancing the view of the
pre- peritoneal inguinal space. Two 5 mm trocars are then placed in the midline. The fi rst
is placed in the supra-pubic location and the
second just inferior to the trocar balloon.
44 Laparoscopic Total Extra-Peritoneal (TEP) Inguinal Hernia Repair
463
Fig. 44.1 Blunt dissection of the bladder and alveolar
tissue inferiorly to expose the pubis and Cooper’s
ligament
Fig. 44.2 Once Cooper’s ligament is exposed laterally
reaching the femoral vessels, any fi bro-fatty tissue
(b) Exposure of the pubic tubercle and Cooper’s
remaining superior to Cooper’s represents a direct hernia
ligament . Initial dissection is done with blunt
graspers to expose the pubic bone in the midline and Cooper’s ligament (Fig. 44.1 ). The
bladder should be gently dissected posteriorly off the pubic bone to avoid injury during
mesh placement. Caution should be made for
the crossing blood vessels over the pubic
bone to prevent signifi cant venous bleeding.
(c) Identifi cation of a Femoral and Direct Hernia .
If a hernia is identifi ed before reaching the
femoral vein while traveling laterally on
Cooper’s ligament, this represents a femoral
hernia. At times, lacunar’s ligament will need
to be divided medio-superiorly to allow for
femoral content reduction. If no femoral hernia is identifi ed, as shown in Fig. 44.2 , any
fi bro- fatty tissue remaining superior to
Cooper’s ligament lies within the direct space
and may represent a direct hernia. This tissue
should be cleared and the transversalis fascia
identifi ed. If a large direct hernia is found, the
pseudo- sac of the weak transversalis fascia
can be secured to Cooper’s ligament with a
tack to potentially reduce the occurrence of a
post- operative seroma.
(d) Identifi cation of an Indirect Hernia . The lat-
eral space is fully dissected to allow for future
mesh placement. Exposure of the abdominal
wall muscle may result in bleeding and care
should be taken to stay within the alveolar
space to minimize muscle and nerve injury
leaving pre-peritoneal fat on the anterior
abdominal wall. With completion of dissec-
tion both medial and lateral to the internal
ring, the cord contents are grasped and
retracted laterally. This allows for early iden-
tifi cation and protection of the vas deferens
and spermatic cord vessels, which will be
found medially (Fig. 44.3 ). The vas and ves-
sels are fully separated from the indirect her-
nia sac. Once the indirect hernia sac has been
isolated, both graspers are placed on the her-
nia sac and the contents fully reduced with the
medial hand applying counter traction to the
internal ring.
(e) Mesh placement. We prefer to use a light-
weight, macro-porous, permanent mesh sized
to cover the direct, indirect, and femoral
hernia spaces. After insertion through the
12 mm umbilical trocar, the mesh is unrolled
and positioned within the pre-peritoneal
space. The medial aspect of the mesh should
be positioned along the pubic bone at least
1 cm off the midline to the opposite side to
give adequate coverage of the direct space.
464
T. Kindel and D. Oleynikov
Fig. 44.3 The cord contents are retracted laterally with
identifi cation of the vas deferens and cord vessels
medially
Fig. 44.5 The mesh is positioned laterally to accommodate the spermatic cord at the medial aspect of the cut slit
in mesh with the two tails overlapping laterally and
secured to prevent an indirect recurrence. A slit is made in
the mesh before insertion for approximately half the distance of the long end of a 10 × 15 cm mesh with one-third
of the mesh below the slit and two-thirds above the slit.
For direct hernias only, a non-slitted mesh may be used
ensuring the peritoneal edge is below the inferior border
of the mesh
Fig. 44.4 The mesh is secured to Cooper’s ligament with
non-absorbable tacks
The mesh is then secured with non-absorbable
tacks to Cooper’s ligament and the rectus
muscle anteriorly (Fig. 44.4 ). The vas and ves-
sels are positioned within the slit, the mesh
rolled laterally so that it lies fl at without
bunching, and the lower fl ap secured overlying the upper fl ap slightly with a tack at least
1 cm above the anterior superior iliac spine
(Fig. 44.5 ). Care must be taken to avoid the
branches of the lateral femoral cutaneous
nerve and genito- femoral and femoral nerve.
(f) Occult bilateral inguinal hernias . Our group
performed a prospective study of patients
undergoing TEP repairs with a pre-operative
diagnosis of a unilateral hernia only [ 3 ]. 22%
of patients had an occult bilateral inguinal her-
nia. For this reason, we advocate routine
exploration of the contralateral side to evalu-
ate for an occult, contralateral inguinal hernia
and immediate repair when identifi ed. This is
done in a similar manner to the ipsilateral
(symptomatic) side; however, the space is
selectively dissected to include identifi cation
of cooper’s ligament for inspection of the
direct space, followed by identifi cation of the
internal ring and cord contents. The peritoneal
refl ection can be followed medial to lateral
and if found to enter the internal ring, an indi-
rect hernia is assumed and full dissection is
44 Laparoscopic Total Extra-Peritoneal (TEP) Inguinal Hernia Repair
465
Epigastrics
Internal ring
Peritoneal
reflection
Fig. 44.6 The contralateral side is inspected for an occult
inguinal hernia by exposing the direct and indirect space.
The cord contents are seen within the indirect space and
the peritoneal refl ection is noted to not enter the internal
ring; therefore, a contralateral indirect hernia is not
present
Vas deferens
then undertaken (Fig. 44.6 ). We have found
that such inspection of the contralateral side
does not signifi cantly increase the diffi culty of
a contralateral repair, if required later compared to unilateral TEP only.
Conclusions
TEP is an excellent option for the repair of not
only recurrent and bilateral inguinal hernias, but
also for initial unilateral inguinal hernias. The
long-learning curve and complicated, posterior
inguinal anatomy associated with TEP limit its
application for those surgeons who are not comfortable with dissection of the pre-peritoneal
space. However, we fi nd TEP to be our procedure
of choice due to the minimal post-operative complication profi le, the ability to intra-operatively
inspect the opposite inguinal region, and excellent long-term durable outcomes.
References
1. Heikkinen TJ, Haukipuro K, Koivukangas P, Hulkko
A. A prospective randomized outcome and cost comparison of totally extra-peritoneal endoscopic hernioplasty versus Lichtenstein operation among employed
patients. Surg Laprosc Endosc. 1998;8:338–44.
2. Pawanindra L, Kajla RK, Chander J, et al. Randomized
controlled study of laparoscopic total extra-peritoneal
versus open Lichtenstein inguinal hernia repair. Surg
Endosc. 2003;17:850–6.
3. Bochkarev V, Ringley C, Vitamvas M, Oleynikov
D. Bilateral laparoscopic inguinal hernia repair in
patients with occult contralateral inguinal defects.
Surg Endosc. 2007;21(5):734–6.
4. Neumayer L, Giobbie-Hurder A, Jonasson O, et al.
Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med. 2004;350:1819–27.
5. Pokorny H, Klingler A, Schmid T, et al. Recurrence
and complications after laparoscopic versus open
inguinal hernia repair: results of a prospective randomized multicenter trial. Hernia. 2008;12:385–9.
6. Koning GG, Wettersley J, van Laarhoven CJ, Keus
F. The totally extraperitoneal method versus
Lichtenstein’s technique for inguinal hernia repair: a
systematic review with meta-analyses and trial
sequential analyses of randomized clinical trials.
PLoS One. 2013;8:e52599.
7. Aigner F, Augustin F, Kaufmann C, Schlager A, Ulmer
H, Pratschke J, Schmid T. Prospective, randomizedcontrolled trial comparing postoperative pain after plug
and patch open repair with totally extraperitoneal
inguinal hernia repair. Hernia. 2014;18(2):237–42.
8. Eklund A, Montgomery A, Bergkvist L, Rudberg C,
et al. Chronic pain 5 years after randomized comparison of laparoscopic and Lichtenstein inguinal hernia
repair. Br J Surg. 2010;97(4):600–8.
9. Bracale U, Melillo P, Pignata G, et al. Which is the
best laparoscopic approach for inguinal hernia repair:
TEP or TAPP? A systematic review of the literature
with a network meta-analysis. Surg Endosc.
2012;26:3355–66.
10. Gass M, Banz VM, Rosella L, et al. TAPP or TEP?
Population-based analysis of prospective data on
4,552 patients undergoing endoscopic inguinal hernia
repair. World J Surg. 2012;36:2782–6.
11. Eker HH, Langeveld HR, Klitsie PJ, et al. Randomized
clinical trial of total extraperitoneal inguinal hernioplasty vs Lichtenstein repair: a long-term follow-up
study. Arch Surg. 2012;147:256–60.
12. DeTurris SV, Cacchione RN, Mungara A, et al.
Laparoscopic herniorrhaphy: beyond the learning
curve. J Am Coll Surg. 2002;194:65–73.
13. Pawanindra L, Kajla RK, Chander J, Ramteke
VK. Laparoscopic total extraperitoneal (TEP) inguinal hernia repair: overcoming the learning curve. Surg
Endosc. 2004;18:642–5.
14. Schouten N, Simmermacher RKJ, van Dalen T, et al.
Is there an end of the “learning curve” of endoscopic
totally extraperitoneal (TEP) hernia repair? Surg
Endosc. 2013;27:789–94.
15. Kurashima Y, Feldman LS, Kaneva PA, et al.
Simulation-based training improves the operative performance of totally extraperitoneal (TEP) laparoscopic
inguinal hernia repair: a prospective randomized controlled trial. Surg Endosc. 2014;28:783–8.
466
T. Kindel and D. Oleynikov
16. Schouten N, Elshof JWM, Simmermacher RKJ, et al.
Selecting patients during the “learning curve” of
endoscopic totally extraperitoneal (TEP) hernia
repair. Hernia. 2013;17:737–43.
17. Ferzli G, Kiel T. The role of the endoscopic extraperitoneal approach in large inguinal scrotal hernias. Surg
Endosc. 1997;11(3):299–302.
18. Ferzli G, Shapiro K, Chaudry G, Patel S. Laparoscopic
extraperitoneal approach to acutely incarcerated
inguinal hernia. Surg Endosc. 2004;18:228–31.
19. Dulucq JL, Wintringer P, Mahajna A. Totally extraperitoneal (TEP) hernia repair after radical prostatectomy
or previous lower abdominal surgery: is it safe? A
prospective study. Surg Endosc. 2006;20(3):473–6.
The Extended-View Totally Extraperitoneal (eTEP) Technique for Inguinal Hernia Repair
Jorge Daes
Introduction
Five laparoscopic techniques are currently available for repairing an inguinal hernia: totally
extraperitoneal (TEP) repair , extended view totally
extraperitoneal (eTEP), transabdominal preperitoneal (TAPP) , intra-peritoneal onlay mesh (IPOM) ,
and reduction of the sac with or without closure of
the ring. It is our philosophy that surgeons interested in a laparoscopic approach should be skillful
in all of the available techniques to accommodate
the needs of all patients and to be able to convert to
a different technique when necessary.
Since 1996, we have favored the endoscopic
extraperitoneal approach for the repair of nearly all
inguinal hernias [ 1 ]. The major advantage of this
approach is that it does not involve entry in the
abdominal cavity, thus lessening the risk of intestinal and vascular injuries as well as herniation at the
trocar sites [
hernia repair under local anesthesia with intravenous sedation or under regional anesthesia [
and provides a great view of the local structures.
Electronic supplementary material: The online version
of this chapter (doi:
tains supplementary material, which is available to authorized users.
J. Daes , M.D., F.A.C.S. (*)
Department of Minimally Invasive Surgery ,
Clinica Bautista , Carrera 58 no. 79-223 PH B ,
Barranquilla , Colombia
e-mail:
2 , 3 ]. This approach may even allow
4 , 5 ],
10.1007/978-3-319-27470-6_45 ) con-
jorgedaez@gmail.com
4 5
The extraperitoneal approach is based on the timetested Rives-Stoppa technique. However, the classical TEP technique has several drawbacks, including
the limited space for dissection and mesh placement, restricted port placement, possible intolerance of pneumoperitoneum, and diffi culty in
teaching and learning the technique. These disadvantages may explain the low implementation of
the technique outside the circle of experts [ 6 ].
We have noticed the diffi culties our trainees
experienced in learning TEP, and this inspired us
to modify the TEP technique based on the principle that the preperitoneal space can be reached
from virtually anywhere in the anterior abdominal wall. We named this modifi ed protocol eTEP;
the small “e” stands for “extended view.” The
technique has been standardized since its fi rst
publication in Surgical Endoscopy [
The most salient features of the eTEP technique are:
1. Fast and easy creation of the extraperitoneal
space.
2. A large surgical fi eld.
3. A fl exible port setup adaptable to many clini-
cal situations.
4. Unencumbered parietalization of the cord
structures (proximal dissection of the sac and
peritoneum).
5. Easier management of the distal sac in cases
of large inguinoscrotal hernias [ 8 ].
6. Improved tolerance of pneumoperitoneum,
which is a common complication.
7 ].
Y.W. Novitsky (ed.), Hernia Surgery, DOI 10.1007/978-3-319-27470-6_45
467© Springer International Publishing Switzerland 2016
468
J. Daes
Indications for eTEP
We use the eTEP technique to repair most cases
of inguinal hernias; however, there are cases for
which eTEP is especially useful.
1. For the novel surgeon: eTEP is easier to master for surgeons new to the technique. In our
clinical immersion courses, most of the trainees are surgeons who have only performed
TAPPs and have no TEP experience. Notably,
in follow-up surveys, most of the surgeons
(80%) incorporated the eTEP technique in
their practices.
2. Obese or post-bariatric patients: eTEP allows
the surgeon to avoid the diffi culties caused by
the pannus; in addition, the subcutaneous tissue is thinner higher in the abdomen.
3. When the distance between the umbilicus and
pubic tubercle is short.
4. In patients with previous pelvic surgeries.
5. Wide variety of indications: with experience, surgeons can expand the indications
for eTEP for inguinal hernia repair to cases
of large inguinoscrotal, sliding, or incarcer-
ated hernias. This may require combination
with a 5 mm laparoscopic intraperitoneal
approach to verify the viability of the intestine or assist in reducing the incarcerated
content.
Key Technical Aspects of eTEP
High Camera Port Placement
In most unilateral hernias, a 10–12 mm incision
is placed high in the upper lateral quadrant of the
abdomen approximately 5 cm cephalad and 4 cm
lateral to the umbilicus on the same side of the
hernia (Fig. 45.1 ). This incision serves as the
camera port, but the incision can alternatively be
placed on the hemi-abdomen opposite to the hernia side, especially in patients with previous pelvic surgeries interfering with this setup
(Fig. 45.2 ), patients with large inguinoscrotal,
incarcerated, or sliding hernias, or according to
surgeon preference. For bilateral hernias, the
camera port can be placed on either side.
Figure 45.3 shows the camera port location in the
Fig. 45.1 Port setup for a unilateral left inguinal
hernia. The camera port is placed high in the upper
abdominal quadrant ipsilateral to the hernia. The working
port for the left hand is placed at the umbilicus. The
surgeon and camera assistant always stand opposite the
hernia side