Totally Extraperitoneal Approach (TEP) for Inguinal Hernia Repair

Abstract

Laparoscopic inguinal herniorrhaphy was initially described by Ger in the early 1980s. Nowadays, two techniques are worldwide adopted: the transabdominal preperitoneal approach (TAPP) and the totally extraperitoneal approach (TEP). In these repairs, the myopectineal orifice is approached posteriorly and allows for inguinal, femoral, and obturator hernia repairs to be performed simultaneously. TEP is a relatively new technique. McKernan and Law first introduced TEP in 1993. Some proponents of TEP advocate for this technique over the transabdominal approach due to the shorter operative times, especially for bilateral hernias, and decrease the risks of vascular, bowel, and bladder injuries as well as bowel obstructions, adhesions, or fistula formation potentially associated with intraperitoneal dissection and intraperitoneal mesh exposure. When compared with open hernia repair, and in particular for recurrent (after open) and bilateral hernias, many surgeons prefer the laparoendoscopic approach due to quicker recovery times and less postoperative and chronic pain. In experienced hands, there are no absolute contraindications to TEP, although a careful decision should be made to tailor the approach to both patient and surgeon factors. In this chapter, we will describe the technical steps of totally extraperitoneal hernia repair, the potential complications, and troubleshooting when needed.