ree trocars are placed in the midline in a stan­dard fashion [2]. In TEP, the umbilicus-pubis distance and panniculus thickness are critical for trocar placement such that in obese patients with a thick pannus and a lower umbilicus, inadequate placement of the trocars can lead to a decreased working space and excessive torque (see . Fig. 14.1). Insertion of an additional fourth 5mm trocar may be needed to facilitate the exposure (. Fig.14.2). Dissection is initiated in the midline with identication of the pubic symphysis and Cooper’s ligament. e space of Retzius is developed and extended into the space of Bogros. At this point, the epigastric vessels are identied and preserved (. Fig.14.3). Dissection and reduction of cord lipomas when present will help delineate the extent of the hernia sac and create more room to work (. Fig. 14.4). In the case of large and incarcerated hernias, the trans­versalis sling is divided with hook cautery at the 10 o’clock position (if necessary division of the epigastric vessels may be done) to allow complete reduction of the sac ( tunica vaginalis are present in the space, it is preferable to divide the sac rather than reduce it to minimize devascularization (. Fig.14.6). e mesh is then placed and tacked only to Cooper’s ligament and held in place by the peritoneum. A closed suction drain is inserted to prevent the inevitable incidence of post-op seroma.