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72
G. Voeller and B.S. Powell
the novice surgeon. Lastly, when done properly, the unilateral
repair makes for a very satis fi ed patient.
2. Recurrent hernia: This is the ideal hernia to repair if the prior
repair was done open since the surgeon is avoiding all the scar
tissues left from the previous repair.
3. Bilateral hernias: These hernias probably have the most bene fi t
for repair of all indications for obvious reasons.
Contraindications
The only absolute contraindication for TEP inguinal hernia repair is
inability to tolerate general anesthesia. For these patients, we recommend
open repair under local anesthesia with mesh. We also believe that in
patients that have had previous preperitoneal surgery such as prostate
removal, the TEP approach is too dif fi cult, and even though studies show
it is possible, it has higher risks than an open operation in virgin tissues.
In addition, if the hernia cannot be completely reduced such as large
scrotal hernias, we will opt for the easier to do open approach. We will
perform the TEP repair in large, older teenagers if the hernia is signi fi cant
in size and requires mesh.
Lastly, in men in whom there is concern about elevated PSA levels
and prostate cancer, they should be told that the TEP may make
preperitoneal prostate removal more dif fi cult in some cases, depending
on the mesh used and the experience of the urologist. Even though studies
show that in expert hands preperitoneal prostate removal is readily done
after a previous TEP repair, this should be discussed at length with this
patient population.
Patient Positioning and Room Setup
Patient positioning for laparoscopic inguinal hernia repair is the same
for TAPP and TEP inguinal hernia repair.
1. The patient is positioned supine on the operating table, with both
arms tucked at his or her sides. Having the arms tucked allows for
adequate room for the surgeon and other assistants to stand.
2. The video monitor is placed at the foot of the table.
73
6. Technique: Laparoscopic TEP
3. A Foley catheter can be placed if so desired to decompress the
bladder; we only place 5 cm
3
of fl uid in the Foley balloon. There
have been reports of bladder injury, and one mechanism may be
sheer force between the Foley balloon with 10 cm
3
and the
preperitoneal distention balloon. The bladder must be totally
decompressed to place the mesh far down over Cooper’s
ligament, especially in direct hernias. Voiding prior to surgery
is not adequate since anesthesia begins giving fl uids that quickly
fi ll the bladder and thus limit proper placement of the mesh
down over the pubic bone.
4. The assistant stands on the side of the hernia to hold the camera,
while the operative surgeon stands on the opposite side.
Pertinent Anatomy
A thorough knowledge of preperitoneal anatomy is required to
perform an excellent TEP. Complete visualization of the myopectineal
ori fi ce is accomplished with the laparoscope, and any type of groin
hernia is adequately visualized (Fig. 6.1 ). Initial dissection of a TEP
Fig. 6.1. Male groin anatomy. In the female, the round ligament of the uterus
leaves the internal ring (From Scott-Conner CE, ed. The SAGES Manual:
Fundamentals of Laparoscopy, Thoracoscopy, and GI Endoscopy, 2nd Ed., New
York, Springer, 2006, with permission of Springer Science + Business Media).
74
G. Voeller and B.S. Powell
hernia begins in the posterior rectus space. This space becomes the
preperitoneal space below the arcuate line and is continuous with the
space of Retzius of the pelvis. Some authors have used phrases such as
“triangle of pain” and “triangle of doom”; however, we believe these
terms should be used sparingly. There is a large amount of variability of
the iliac artery and nerves in this region; hence, a thorough understanding
of this region and its variabilities is paramount to avoid complications.
In some 3,000 TEP repairs, we have not had an injury to bladder, colon,
or iliac artery or vein, showing that this operation can be done safely if
the surgeon learns the anatomy. Understanding the anatomy depicted in
Fig. 6.1 is the key to a successful TEP repair. Key landmarks are
necessary to keep orientation in this small space. A surgeon needs to
recognize the pubic bone, Cooper’s ligament, inferior epigastric vessels,
and cord structures if they are to adequate and safely perform TEP
procedures.
Operative Approach
1. After patient positioning, an infraumbilical incision is made in
the midline. Dissection is carried down to the fascia with
S-shaped retractors. We prefer to incise the rectus sheath on the
same side as the hernia.
2. A longitudinal incision in the rectus sheath is made just off
midline on the side of the hernia. A hemostat is used to widen
incision to accommodate an S-shaped retractor behind the
rectus sheath. The rectus muscle is then retracted laterally.
3. A balloon dissector is used next to facilitate dissection in the
preperitoneal space. We prefer the original round unilateral
balloon since it will not tear the epigastric vessels or damage
tissue layers as can the bilateral balloon. While the dissection
can be done without the balloon, we have found it is quicker,
more uniform, and less bloody when the balloon is used.
4. The balloon dissector is passed along the posterior sheath until
it contacts the pubic bone. Once the pubis is felt with the
balloon dissector, the balloon is insuf fl ated under direct vision
with the laparoscope. Careful placement of the dissector is
key so as not to tear the peritoneum or cause bleeding along
the pubic bone.
75
6. Technique: Laparoscopic TEP
5. The balloon dissector is removed, and a balloon-tipped trocar is
placed into the retrorectus space. Carbon dioxide is then used to
insuf fl ate the preperitoneal space. Lower pressures of 12 mmHg
are used to prevent subcutaneous emphysema which will
compromise the operative space.
6. A 45° 10-mm laparoscope is used, and two more 5-mm trocars are
placed. The fi rst 5-mm trocar is placed suprapubic, and the second
is placed halfway between the other two trocars (Fig. 6.2 ). The 45°
laparoscope allows the surgeon to mimic the open repair as described
by Rives, i.e., sweeping the peritoneum back to the level of the
umbilicus. The patient is then placed in Trendelenburg position.
7. Initial dissection is done to clear off tissue along the pubic bone
to clearly visualize Cooper’s ligament. In direct hernias, this
means reducing the fat from the defect and pushing the
transversalis sac back down into the defect. If the patient has a
low insertion of the arcuate line, this is cut at this time and
retracted to the level of the umbilicus.
Fig. 6.2. Trocar placement for TEP
(From Scott-Conner CE, ed. The
SAGES Manual: Fundamentals of
Laparoscopy, Thoracoscopy, and GI
Endoscopy, 2nd Ed., New York,
Springer, 2006, with permission of
Springer Science + Business Media) .
76
G. Voeller and B.S. Powell
8. The lateral space is then dissected to allow for adequate
placement of the mesh. The peritoneum must be dissected off of
the cord, anterior abdominal wall, and the retroperitoneum. The
peritoneum overlying the psoas is swept cephalad so that the
mesh will lie on the muscle.
9. During this dissection, the nerves are often seen. Care should be
taken at this point to leave a fat layer on the abdominal wall to
minimize bleeding and possible damage to these nerves. Once
the lateral space has been dissected free, attention is then turned
to dissection of the cord structures. The peritoneum is usually
pulled medially and cord structures swept laterally. This allows
the surgeon to see the proper plane which is between the
peritoneum and the vessels on the vas deferens.
10. Any hole in the peritoneum can be dealt with by decreasing the
insuf fl ation pressure to 10 mmHg, and if necessary, a Veress
needle can be placed into the peritoneal cavity above the
umbilicus for decompression. Holes in the peritoneum do not
need to be closed as long as the CO
2
is evacuated completely
from the peritoneal cavity. Once this is done, the edges of the
defect come together and heal quickly.
11. We use a polyester mesh (Parietex™) for the repair since Rives
and Stoppa believed it was soft and readily would contour to all
the curves of the preperitoneal space (unlike polypropylene).
Our mesh is anatomically shaped (there are right and left
meshes) and speci fi cally designed for laparoscopic placement
in the preperitoneal space. The key is to do a large dissection of
the space so the mesh simply falls over the myopectineal area
with coverage of all potential hernia defects.
12. The mesh is positioned so that there is adequate coverage of
both the direct and indirect spaces. Direct hernias must have the
mesh extending at least 2 cm beyond the defect in all directions.
More important than an overlap of 2 cm, the medial extent of
the mesh should be aligned or even pass the midline of the
abdomen, and if bilateral, both medial aspects of each mesh
should overlap in the midline. It is imperative to understand that
the medial extent of large direct defects can extend to within
2 cm of the midline. We use an onlay technique over the cord
structures and do not keyhole our mesh, mimicking the original
open repair of Rives (Fig. 6.3 ).
13. While some believe the mesh does not need to be fi xated, we
believe in most situations, at least some fi xation is key for
77
6. Technique: Laparoscopic TEP
long-term success. Rives and Stoppa both sutured the mesh
when they described the open preperitoneal technique, and we
try to mimic what they described. Kes, Schwab, and Katkhouda
all have shown the mesh does move and migrate and is displaced
without fi xation. The Tisseel™ brand of fi brin glue works the
best as a true adhesive and is our choice for use in our TEP
repair, and so the remainder of this section will focus on our
technique with the use of glue. That being said, the editors of
this manual point out that there are a variety of ways of fi xing
the mesh other than the use of glue (permanent tacks, absorbable
tacks, self-gripping mesh, no fi xation), and all methods can
produce optimal outcomes in the hands of someone experienced
in that technique.
The fi brin glue works very well with the pore size and fl exibility of
the mesh. The use of the fi brin glue is an off label use of the product, but
it has been used for years in Europe for hernia repair, and we have used
it since 2003 for our TEP repairs. Not all fi brin glue is the same, and not
all meshes work well with fi brin glue. The fi brin glue dries immediately
and disappears in a few weeks postoperatively. The advantage of the glue
is we can mimic the open repair as described by Rives and fi x the mesh
Fig. 6.3. Mesh placement for TEP inguinal hernia repair (From Scott-Conner
CE, ed. The SAGES Manual: Fundamentals of Laparoscopy, Thoracoscopy, and
GI Endoscopy, 2nd Ed., New York, Springer, 2006, with permission of Springer
Science + Business Media) .
78
G. Voeller and B.S. Powell
over the psoas, the cord, and other areas where mechanical fi xation is not
safe. We do NOT use the spray applicator but prefer to use the white
applicator made by Baxter.
14. Once the glue has dried, the pneumoperitoneum is evacuated,
and we watch the peritoneum and abdominal contents fall onto
the mesh. The fascial defect in the anterior rectus is closed with
a 0 vicryl suture. The skin is then closed with sutures, and sterile
dressing is applied. Early unrestricted activity is important, and
following this technique, most patients have rather rapid
recoveries and return to usual daily activities.
Complications
Complications from TEP repair should be extremely rare and will be
thoroughly covered in a separate chapter in this manual. Catastrophic
complications such as major vascular, visceral, or cord injuries should be
virtually nonexistent in experienced hands, and we have yet to experience
these complications. Mesh infections should be few, if at all with TEP
repair. This section will discuss some of the complications that are seen
and their management.
Vascular Injuries
External iliac vessel injury is by far the most dreaded vascular
complication and requires immediate repair. More common vessel
injuries include inferior epigastric or spermatic vessel injury. These can
often be controlled with either clips or cautery. Vessels along the pubic
bone making up the “corona mortis” can also bleed, leading to massive
preperitoneal hematoma postoperatively. Care must be used when
dissecting along the pubic bone to prevent this complication. Obturator
vessels need to be avoided as well.
Nerve Injury
A thorough knowledge of the nerves of the inguinal region is required
to perform this procedure well and to minimize inguinodynia. The femoral
79
6. Technique: Laparoscopic TEP
branch of the genitofemoral nerve and branches of the femoral nerve, as
well as the lateral cutaneous nerve of the thigh, are at risk for damage.
We no longer tack with our repairs and feel that these complications
should be infrequent. If tacks are used, these nerves should be carefully
avoided.
Other
Urinary retention or hematuria tends to be one of the more common
immediate sequelae after TEP repair. It is usually self-limited but might
require replacement of a urinary catheter. Bladder injury should be rare
and immediately repaired if seen.
Hernia recurrence is very rare with this approach. This can be due to
a number of factors. Incomplete dissection, missed hernias, inadequate
mesh coverage, and mesh displacement are all thought to lead to hernia
recurrence.
Mesh-related complications are very infrequent in our experience.
Prophylactic antibiotics are not required with TEP, and we have not
experienced any known mesh infections in our patients. The TEP
procedure also keeps the mesh away from intraabdominal structures;
hence, erosion and adhesion formation that is possible with a TAPP
approach should be minimal with a TEP.
Conclusions
TEP inguinal hernia repair gives excellent results for all types of
inguinal hernias. Knowledge of anatomy, gentle dissection, and hundreds
of repairs are required for minimal morbidity and low recurrence rates.
Suggested Reading
1. Ceccarelli G, Casciola L, Pisanelli MC, Bartoli A, Di Zitti L, Spaziani A, Biancafarina
A, Stefanoni M, Patriti A. Comparing fi brin sealant with staples for mesh fi xation in
laparoscopic transabdominal hernia repair: a case control-study. Surg Endosc.
2008;22(3):668–73.
2. Clarke T, Katkhouda N, Mason RJ, Cheng BC, Algra J, Olasky J, Sohn HJ, Moazzez
80
G. Voeller and B.S. Powell
A, Balouch M. Fibrin glue for intraperitoneal laparoscopic mesh fi xation: a comparative
study in a swine model. Surg Endosc. 2011;25(3):737–48.
3. Descottes B, Bagot d’Arc M. Fibrin sealant in inguinal hernioplasty: an observational
multicentre study in 1,201 patients. Hernia. 2009;13(5):505–10.
4. Katkhouda N, Mavor E, Friedlander MH, Mason RJ, Kiyabu M, Grant SW, Achanta K,
Kirkman EL, Narayanan K, Essani R. Use of fi brin sealant for prosthetic mesh fi xation
in laparoscopic extraperitoneal inguinal hernia repair. Ann Surg. 2001;233(1):18–25.
5. Novik B. Randomized trial of fi xation vs non fi xation of mesh in total extraperitoneal
inguinal hernioplasty. Arch Surg. 2005;140(8):811–2. author reply 812.
6. Novik B, Hagedorn S, Mörk UB, Dahlin K, Skullman S, Dalenbäck J. Fibrin glue for
securing the mesh in laparoscopic totally extraperitoneal inguinal hernia repair: a study
with a 40-month prospective follow-up period. Surg Endosc. 2006;20(3):462–7.
7. Olmi S, Scaini A, Erba L, Bertolini A, Croce E. Laparoscopic repair of inguinal hernias
using an intraperitoneal onlay mesh technique and a Parietex composite mesh fi xed
with fi brin glue (Tissucol). Personal technique and preliminary results. Surg Endosc.
2007;21(11):1961–4.
8. Ramshaw BJ, Tucker JG, Mason EM, Duncan TD, Wilson JP, Angood PB, Lucas GW.
A comparison of transabdominal preperitoneal (TAPP) and total extraperitoneal
approach (TEP) laparoscopic herniorrhaphies. Am Surg. 1995;61:279–83.
9. Ramshaw BJ, Tucker JG, Conner T, Mason EM, Duncan TD, Lucas GW. A comparison
of the approaches to laparoscopic herniorrhaphy. Surg Endosc. 1996;10:29–32.
10. Ramshaw B, Abiad F, Voeller G, Wilson R, Mason E. Polyester (Parietex) mesh for
total extraperitoneal laparoscopic inguinal hernia repair: initial experience in the
United States. Surg Endosc. 2003;17(3):498–501.
11. Taylor C, Layani L, Liew V, Ghusn M, Crampton N, White S. Laparoscopic inguinal
hernia repair without mesh fi xation, early results of a large randomised clinical trial.
Surg Endosc. 2008;22(3):757–62.
12. Topart P, Vandenbroucke F, Lozac’h P. Tisseel versus tack staples as mesh fi xation in
totally extraperitoneal laparoscopic repair of groin hernias: a retrospective analysis.
Surg Endosc. 2005;19(5):724–7.
13. Voeller GR. Management of peritoneal tear during endoscopic extraperitoneal inguinal
hernioplasty. Surg Endosc. 2003;17(8):1335. author reply 1336.
14. Voeller GR, Mangiante EC, Britt LG. Preliminary evaluation of laparoscopic
herniorrhaphy. Surg Laparosc Endosc. 1993;3(2):100–5.
81
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_7,
© Springer Science+Business Media New York 2013
7. Technique: Laparoscopic TAPP
and IPOM
William S. Cobb IV
The ideal inguinal hernia repair should provide adequate coverage of
the myopectineal ori fi ce of Fruchaud with durable results that are
reproducible when taught to other surgeons. While a low recurrence rate
is desirable, the incidence of long-term groin pain must be considered as
well. Placing mesh posterior to the defect utilizes the intra-abdominal
pressures to support the repair. Additionally, the transabdominal
laparoscopic approach provides excellent visualization of the inguinal
region from a vantage point that all surgeons are comfortable with.
Anatomy
A successful laparoscopic inguinal hernia repair relies on the
surgeon’s grasp of the inguinal anatomy, particularly from a posterior
vantage point. The laparoscopic repair of groin hernias provides minimal
access but not minimal invasion. It is imperative to understand the
location of the iliac vessels, genitofemoral and lateral femoral cutaneous
nerves, and bladder to avoid catastrophic complications. Other landmarks
of the posterior abdominal wall and inguinal region assist in describing
the repair correctly (Fig. 7.1 ).
The umbilical ligaments are important landmarks for the TAPP
inguinal hernia repair. The median umbilical ligament consists of the
atretic urachus and courses from the dome of the bladder to the umbilicus.
The paired medial and lateral umbilical ligaments are folds of the
peritoneal that contain the obliterated umbilical arteries and the inferior
epigastric vessels, respectively.