Anatomy & Technique of the Laparoscopic Totally

Extra-Peritoneal Approach for Groin Hernia Repair

Abeezar I. Sarela

Consultant Surgeon

St James’s University Hospital, Leeds

Agenda

• Preparation & Positioning

• Access to Pre-Peritoneal Space

• Surgical Anatomy

• Dissection

Preparation & Position

• Ask patient to empty bladder just prior to transport to theatre

– Catheterization is not routinely necessary

• Position on operating table: Supine with arms tucked in the sides.

– Do not fold arms across the chest

– Do not have contralateral arm extended on a arm-board

Theatre Set-Up

• Stand on left to introduce primary port

• Surgeon and assistant stand on side of the patient opposite to the hernia

• Scrub nurse on same side as the surgeon

• Slight head-down position

Steps for TEP Repair

1. Access to the pre-peritoneal space

2. Blunt dissection with laparoscope

3. Insertion of additional 5 mm ports (x 2)

4. Complete dissection of pre-peritoneal space

5. Dissection of retro-pubic space

6. Dissection of the hernia

7. Placement of mesh

Access to Pre-Peritoneal Space

• Infra-umbilical transverse incision, sited over medial end of ipsilateral rectus abdominus

• Exposure of anterior rectus sheath. Transverse incision of anterior sheath.

• Identification of medial border of rectus abdominus muscle, followed by lateral retraction

• Introduction of a short-port with a blunt trocar, posterior to the rectus muscle. Fix port and achieve seal around port with a suture.

• Insufflation of CO2 – 12 mmHg

Creation of Pre-Peritoneal Space

• Mid-line tunnel directed to pelvis

• Remember: No posterior rectus sheath below the umbilicus

• Aim to stay just superior to posterior lamina of fascia transversalis, so that all fat is reflected anteriorly with rectus muscle.

Placement of Accessory Ports

• Two additional 5 mm ports

• Higher port

– Midline or offset towards side of hernia

– As close as possible to primary port

– Direct vertically and then obliquely toward pelvis

– Introduce grasper and dissect supra-pubic area

• Lower port:

– Just above the symphysis pubis

– Offset to contra-lateral side

Steps of Dissection

• Identify pubis in midline and develop the space of Retzius

• Trace Cooper’s ligament• Work superiorly to identify inferior epigastric

vessels• Dissect posterior to inferior epigastric vessels.• Dissect lateral to inferior epigastric vessels

(space of Bogros)• Continue dissection up to ASIS

Direct Hernias

• Majority contain pre-peritoneal fact only – no peritoneal sac

• “Pseudo-sac”

Indirect Hernias

Sac is antero-lateral to vas deferens and testicular vessels

Caution

• Triangle of pain: area lateral to the internal spermatic vessels. Contains femoral branch of genitofemoral nerve and lateral cutaneous nerve of thigh.

• Triangle of Doom: Area between vas deferens medially and internal spermatic vessels laterally

Placement of Mesh

• Create a wide pre-peritoneal space

• Use a large piece of mesh

• Avoid fixation