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Page 2 of 8 Alam et al. Mini-invasive Surg 2021;5:48 https://dx.doi.org/10.20517/2574-1225.2021.65

INTRODUCTION
Inguinal hernias are a common problem worldwide and have a prevalence of 1.7% in the adult population.
This rises to 4% in patients aged over 45 years as their incidence increases with age and they constitute 75%
of all abdominal wall hernias . It affects men more commonly than women (lifetime risk 27% in men and
[1]
[1,2]
3% in women) . Surgical management is advised to reduce the complications associated with inguinal
hernias including strangulation and subsequent bowel obstruction. Hernia repairs were commonly carried
out using Lichtenstein or plug repairs but with the advent of minimally invasive techniques, laparoscopic
repairs are becoming more common, more so, over the last two decades. In 2015, the Swedish Hernia
Registry reported that 28% of inguinal hernias were repaired using minimally invasive surgery and 64% were
using a Lichtenstein hernioplasty .
[3]

Several studies have demonstrated the advantages of laparoscopic repair over conventional open repair
techniques, including reduced post-operative pain and a shorter recovery time . The abdomen can also be
[4-6]
examined for other unsuspected hernias, such as femoral hernias in women. However, there is an associated
longer learning curve and a greater risk of intra-operative complications with the laparoscopic approach .
[7]
Laparoscopic repair is more commonly used for the repair of bilateral inguinal hernias and recurrent
hernias, as well as recently increasingly for some specialised hernias such as a sportsman’s hernia .
[8]

The two widely used laparoscopic techniques are trans-abdominal peritoneal repair (TAPP) and totally
extraperitoneal (TEP) repair. Despite some clear advantages over open repair, laparoscopic techniques have
associated complications, which are not seen with traditional open repairs . The recognised learning curve
[9]
for both minimal access methods invariable remains steeper, with TAPP shown to be marginal as quicker to
learn than TEP, due to the latter’s increased dissection in the extraperitoneal plane which is required, but
both have the risk of visceral & vascular injury, albeit small. But in TAPP as the peritoneal cavity is entered
it has the additional risks of adhesions, small bowel injury as well as the risk of port-site hernias over TEP
(0.27% vs. 0.1% for TEP) [10-12] . Some reports suggest that for TEP the learning curve is between 50 and 100
cases to gain full proficiency of the operation as well as the ability to deal with complications . In this
[13]
review, we will focus on TEP repair and its complications.

TECHNIQUE
TEP hernia repair involves a transverse incision lateral to the umbilicus, followed by identification and an
incision of the nterior rectus sheath to identify the rectus muscle, which is then retracted to expose the
posterior rectus sheath on the affected side. Above the posterior rectus sheath, the
retromuscular/preperitoneal space developed and entered using a balloon trocar or blunt port, confirming
[8]
its position with the camera . The balloon trocar is moved laterally, back and forth, opening up the Retzius
space and Bogros’ space laterally. Once the pre-pneumoperitoneum has been established, two 5 mm ports
are inserted in the midline above the pubic symphysis and blunt dissection is carried out from the midline,
lateral and below the inferior epigastric vessels and to the level of the anterior superior iliac spine to the
pubic bone inferiorly (cooper’s ligament). The triangle of doom is exposed by retracting the peritoneum, the
hernia sac dissected off the cord structures, and the vas deferens and testicular vessels are elevated. The
indirect hernia sac and any significant cord lipoma are reduced and there should be a wide view of the pubic
tubercle, and the insertions of the conjoined tendon and rectus muscles . A polypropylene or other
[7,8]
synthetic lightweight mesh is placed flat over the dissected area, above the defect to Cooper’s ligament and
across the midline, covering the regions of direct, indirect (myopectineal orifice), femoral and obturator
hernias . In a bilateral inguinal hernia repair, the same dissection is undertaken on the contralateral side
[14]
with another mesh placed ensuring an overlap is achieved with the first mesh in the midline over cooper’s
ligament. Methods for fixation include metal tacks, absorbable tacks, no fixation, sutures, self-fixating mesh