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F.C. Berrevoet
7.2 Surgical Technique
7.2.1 Indications and Contraindications
are eligible for this technique. In cases of previous preperitoneal surgery, e.g.,
surgery, or in cases of previous inguinal hernia surgery using the preperitoneal
have a high conversion rate to a Lichtenstein repair. No other contraindications
seem apparent.
7.2.2 Preoperative Preparation
For all techniques approaching the preperitoneal space, it is helpful and
and no Foley catheter is needed.
7.2.3 Anaesthesia
spinal anaesthesia. Straining and coughing might help to spread the mesh and
enable the surgeon to check the correct position of the mesh at the end of the
procedure. Because manipulation of the peritoneum during dissection can lead to
additional stress and pain, it might be more troublesome to use local anaesthesia
unacceptably high urinary retention rates leading to unplanned admissions. An
especially in day-care treatment. In other situations general anaesthesia might be
the option of choice.
7.2.4 Incision
After disinfection and sterile draping of the groin area, the operation starts by
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7 Transinguinal Preperitoneal (TIPP) Repair
and serve as an important reference point at the time of mesh introduction.
7.2.5 Superficial Dissection
technique [7] is not
defect. There is absolutely no reason to completely section the cremasteric muscle
and to skeletonise the cord structures. This may only increase the harm done to
the inguinal nerves.
7.2.6 Approach for Indirect Hernias (Fig. 7.3)
In the case of an indirect hernia, the sac is completely dissected until its entrance
Fig. 7.1 Skin incision for a
right inguinal hernia starting
iliac spine and the pubic
tubercle over 3 cm to the
medial side
62
F.C. Berrevoet
entering the preperitoneal space. The posterior sheet of the transversalis fascia
should be opened at the level of the dilated deep internal ring to enter the space
a b
Fig. 7.2 a b Incision of the
Fig. 7.3 The approach for
entering the preperitoneal
space in case of an indirect
hernia
63
7 Transinguinal Preperitoneal (TIPP) Repair
from the iliopubic branch of the iliac bone, the pubic symphysis, the rectus muscle
and the transverse muscle in succession, thus enlarging the preperitoneal space to
accommodate the mesh.
this is essential for preventing later recurrences. By doing this there is no need to
spine easily.
Fig. 7.4 Complete
structures
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F.C. Berrevoet
7.2.7 Approach for Direct or Femoral Hernias (Fig. 7.5)
In case the surgeon feels more comfortable to completely dissect the direct
hernia sac, in the absence of an indirect component, he can incise the direct
hernia sac (both layers of the transversalis fascia have to be incised) at its base
you can enter the preperitoneal space. Again, the epigastric vessels should be
indirect hernia. In cases of a femoral or obturator hernia, the transversalis fascia
has to be incised from the internal ring.
internal ring as it is very easy to reduce direct hernias by approaching these from
7.2.8 Introduction of the Mesh and Adequate Mesh Placement
medially to recline peritoneum, preperitoneal fat and the lateral aspect of the
the malleable retractor.
Fig. 7.5 The approach for entering
the preperitoneal space in the case
of a direct hernia defect
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7 Transinguinal Preperitoneal (TIPP) Repair
iliac vessels. The main disadvantage of this mesh is the interrupted memory at
introduced in the direction of the pubis, up to the tendon of the rectus muscle,
keeping the malleable retractor still in place (Fig 7.6). The clamp can then be
pocket is medially large enough to do so, it is important not to introduce the mesh
too medially. Especially for indirect hernias, an adequate overlap of the mesh
lateral to the deep internal ring is necessary.
the iliac vessels until the outer tip of the prosthesis almost reaches the superior
anterior iliac spine. By placing a retractor in the lateral pocket and keeping it up,
this aspect of the technique can be facilitated.
Fig. 7.6 Introduction of the mesh by sliding it over the retractor
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F.C. Berrevoet
7.2.9 Final Position of the Patch (Fig. 7.7)
Further accommodation of the mesh can be achieved by a Valsalva manoeuvre,
by increasing the pulmonary end-expiratory pressure by the anaesthesiologist, or
by letting the patient strain and cough in the case of local or spinal anaesthesia.
Once the mesh seems to be in position, it is important to check medially that there
mesh deployment towards the iliac spine.
7.2.10 Fixation and Closure
hold tension on the mesh and as the created preperitoneal pocket just matches
aponeurosis of the external oblique muscle is then closed using resorbable sutures
3/0. Subcutaneous tissue and skin are closed as well with absorbable sutures 2/0
and 4/0, respectively.
7.2.11 Postoperative Recommendations
In total this procedure takes between 15 and 45 minutes depending on the size of the
hernia and the dissection necessary to completely free the sac. We advise patients
Fig. 7.7
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7 Transinguinal Preperitoneal (TIPP) Repair
7.3 Discussion
The avascular preperitoneal space is biomechanically and physiologically an
aesthetics and postoperative pain. Although perhaps not important to surgeons
(“the greater the incision, the greater the surgeon”), patients tend to compare the
Although this transinguinal approach still includes dissection around the
canal itself as in a Lichtenstein repair. Checking for indirect hernias in the case of
medial defects is of course mandatory to prevent early recurrences.
although the transinguinal preperitoneal approach itself is far from innovative
as in laparoscopic inguinal hernia repair, that this mesh needs no or minimal
the plug-and-patch techniques, this might most probably decrease the amount of
postoperative pain.
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F.C. Berrevoet
chronic pain [12–15].
References
inguinal herniorrhaphy. Hernia 10:316–321
repair of indirect inguinal hernia in young males. Br J Surg 91:1372–1376
repair. Br J Surg 86:1528–1531
surgery. Ann Surg 244:212–219
6. Neumayer L, Giobbie-Hurder A, Jonasson O et al (2004) Open mesh versus laparoscopic
mesh repair of inguinal hernia. N Engl J Med 350:1819–1827
7. Muldoon RL, Marchant K, Johnson DD et al (2004) Lichtenstein vs anterior preperitoneal
Hernia 8:98–103
Original procedure of groin hernia repair:
Chirurgie 99:119–123 [Article in French]
9. Rives J, Lardennois B, Flament JB et al (1973) The Dacron mesh sheet, treatment of choice
of inguinal hernias in adults. Apropos of 183 cases. Chirurgie 99:564–575 [Article in French]
management of recurrent inguinal hernia. Chirurg 68:1235–1238 [Article in German]
hernia repair. Am J Surg 193:697–701
12. Berrevoet F, Sommeling C, De Gendt S et al (2009) The preperitoneal memory-ring patch
for inguinal hernia: a prospective multicentric feasibility study. Hernia 13:243–249
patch versus Lichtenstein repair for unilateral inguinal hernias. Langenbecks Arch Surg
395:557–562
14. Berrevoet F, Vanlander A, Bontinck J et al (2013) Open preperitoneal mesh repair of inguinal
hernia repair. Br J Surg 99:1365–1373
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G. Campanelli (Ed), Inguinal Hernia Surgery,
Updates in Surgery
DOI: 10.1007/978-88-470-3947-6_8, © Springer-Verlag Italia 2017
J. Rosenberg ()
Department of Surgery, Herlev Hospital
Herlev, Denmark
8
Open New Simplified Totally Extraperitoneal
(ONSTEP) Technique for Inguinal Hernia Repair
Jacob Rosenberg and Kristoffer Andresen
8.1 Introduction
aponeurosis as in the Lichtenstein repair. The reason for this has been reports of
mesh replacement as in laparoscopic repair [2].
There are several different operative techniques available for preperitoneal
mesh replacement including the transinguinal preperitoneal approach (
and
easier approach and therefore a shorter learning curve for the young surgeons.
evaluating the technique [5, 6]. Currently, the technique has only been spread
to some countries in Europe, mainly because the mesh has not been available in
evaluating the pros and cons.
hernia repair in adults.