Important milestones are the classical basini repair which all of us as residence have mastered as one of our early surgeries. Shouldice and Lichtenstein are important landmarks, nevertheless the Great prosthetic reinforcement by Reve stoppa is critical in changing our approach and view of hernia. TAPP in 1992 followed by Mc Kernan and Dulucq's description of TEP have revolutionized the Hernia surgery. TEP totally extraperitoneal technique of hernia The cornerstone of our surgical experties is to achieve a critical view of myopectineal orifice of Fruchaud, which is a quadrilateral area as on the screen and has all the three important sites of herniation- the direct and indirect inguinal and the femoral Triangle of Doom which contains iliac vessels, the triangle of pain which lies laterally and contains the nerves. Tacking should never be done below the ileopubic tract, which is marked by a line joining pubic tubercle to anterior superior iliac spine to avoid nerve and trapment and vascular injury. Corona mortis lies over Cooper's ligament and contains accessory obturator vessels, which should be identified and managed before fixation of mesh is attempted here 8. The image here shows pre peritoneal space which should be harvested by dissecting close to peritoneum letting the fatty layer of facial transversalis be intact 9. Beauty of the surgery is in the quick recovery and minimal post operative pain which can be seen in the patient walking on the day of surgery. Being based on the time tested reves stoppa technique it is closest to the ideal technique and avoids any entry into abdominal cavity with less risk of visceral or trocar site hernias and can potentially be done under local anesthesia with IV sedation 10. Shows the alternative port positions for accessing TEP plane 11. 26 year male with right inguinal hernia taken for TEP. Surgeons position on the left side along with camera person cranial to the operating surgeon. Port positions: camera port sub umbilical over left rectus and with secondary 5 mm ports slightly offset from the midline for triangulation on the side of hernia Initial view of incised rectus sheath with Hassan trocar placement and initial scope guided dissection. Rectus muscle with pubis and cave of retzius. Inferior epigastric artery and the space of Bogros laterally which shall be developed soon Lateral dissection working close to peritoneum and leaving the fat intact without disturbing the nerves underneath it. Dissection is mainly traction and countertraction to release the sack from chord structures and glistening cord like Vas deferens visualization brings joy to the operating surgeon to preserve it. The triangle of Doom marked by VAs deferens , gonadal vessels and the peritoneal reflection containing iliac vessels. The pubis with Cooper's ligament and the cave of Retzius below. The mesh placed without crevices and ensuring the divided hernia sack lying proximal to the inferior edge of the mesh

1. Totally extraperitoneal
repair for inguinal hernia
Jagpreet Singh Deed
FRCS, FACS, MS, DNB (General Surgery)
Specialist General Surgery, Zulekha hospital, Sharjah
Adjunct Clinical Faculty, College of Medicine, University of Sharjah
Honorary Clinical Tutor, University of Edinburgh
jpsdeed@gmail.com
TEP

2. Transversalis fascia

3. Indications
 Tailored approach:
 Surgeon’s expertise
 Patient &
 Hernia characteristics
 Resources available
 Shared decision making
 Discuss watchful waiting
with patients in
asymptomatic hernias
International guidelines for groin hernia management. HerniaSurge Group. Hernia 2018
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP

4. Challenges
 Unfamiliar anatomy
 Small space
 Crowding of instruments
 Loss of space (pneumoperitoneum)
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP

5. Contraindications
 Contraindications to general anesthesia
 Relative- previous posterior repair
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP

6. Advantages
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP

7. Instrumentation
 Laparoscopic set with
 10mm zero and 30 degrees viewing scope
 Hassan trocar
 Two 5mm trocars
 S retractors
 Balloon is optional
 PDS endoloop for closing sac- optional
 Vessel sealer with dividing blade- optional but preferred
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP

8. Instrumentation
 Laparoscopic set with
 10mm zero and 30 degrees viewing scope
 Hassan trocar
 Two 5mm trocars
 S retractors
 Balloon is optional
 PDS endoloop for closing sac- optional
 Vessel sealer with dividing blade- optional but preferred
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP

9. Instrumentation
 Laparoscopic set with
 10mm zero and 30 degrees viewing scope
 Hassan trocar
 Two 5mm trocars
 S retractors
 Balloon is optional
 PDS endoloop for closing sac- optional
 Vessel sealer with dividing blade- optional but preferred
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP

10. Instrumentation
 Laparoscopic set with
 10mm zero and 30 degrees viewing scope
 Hassan trocar
 Two 5mm trocars
 S retractors
 Balloon is optional/ Indigenous balloon can be used
 PDS endoloop for closing sac- optional
 Vessel sealer with dividing blade- optional but preferred
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP

11. Instrumentation
 Laparoscopic set with
 10mm zero and 30 degrees viewing scope
 Hassan trocar
 Two 5mm trocars
 S retractors
 Balloon is optional/ Finger dissection
 PDS endoloop for closing sac- optional
 Vessel sealer with dividing blade- optional but preferred
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP

12. Instrumentation
 Laparoscopic set with
 10mm zero and 30 degrees viewing scope
 Hassan trocar
 Two 5mm trocars
 S retractors
 Balloon is optional
 PDS endoloop for closing sac- optional
 Vessel sealer with dividing blade- optional but preferred
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP

13. Video Totally extraperitoneal for right inguinal hernia
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP

14. Tips and tricks
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP

15. Pathway to success
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP

16. Enhanced exposure
 Division of posterior rectus sheath at Arcuate line
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP

17. Alternative port position
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP

18. eTEP (extended TEP)
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP

19. Corona mortis
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP

20. Mesh size and placement
 15cm x 12 cms is appropriate
 Half roll
 Overlap to contralateral side in direct defect
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP
Image courtesy: Techniques of Abdominal Wall Hernia Repair. Ed P
Chowbey, D Lomanto. 1st Edition 2020

21. Mesh fixation
Options
 No fixation
 Necessary in large direct hernias:
 Tacker
 Suture
 glue
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP

22. Complications
 Seroma
 Chronic postoperative inguinal pain (CPIP)
 Bleeding
 Injury- bladder/ intestine/ gonadal vessels
 Mesh infection
 Recurrence
 Non progress
 Pneumoperitoneum
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP

23. Conclusions
 Safe and effective technique with rapid return to normal life
 Potential benefits over TAPP- reduced risk of injury to abdominal organs
and port site hernia
 High quality of life as compared to open technique
 Learning curve needs to be overcome (100 cases)
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP

24. Thanks for kind attention
Fear of failure leads to failure
Paulo Coelho