How is the dissection performed in totally extraperitoneal (TEP) laparoscopic inguinal hernia repair?

Updated: Apr 16, 2020
  • Author: Danny A Sherwinter, MD; Chief Editor: Kurt E Roberts, MD  more...
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Answer

The most consistent anatomic landmark in this area is the Cooper ligament. It is common to begin the dissection with exposure of the Cooper ligament and the pubic tubercle. This can be done with a two-handed technique, whereby two blunt graspers are placed against the bone at a single point, then gently spread apart (see the video below). Gentle dissection with meticulous hemostasis is continued to expose the direct space and the femoral space by clearing the Cooper ligament down to the iliac vessels.

Laparoscopic inguinal hernia repair: TEP. Direct space dissection.

Direct and femoral hernias will be encountered during this initial dissection. A direct hernia often reduces spontaneously with pneumopreperitoneum, but careful, gentle traction and freeing of fibrous bands may be necessary to achieve complete reduction. Clearing the Cooper ligament in its entirety ensures that a direct hernia is fully reduced. On occasion, a large direct hernia may obscure the anatomy, in which case its reduction should be postponed until other anatomic structures are clarified.

Great care must be exercised as the dissection approaches the iliac vessels. In addition, obturator vessels often cross the dissection planes and may need to be clipped and divided.

The inferior epigastric vessels are identified, and dissection lateral to the vessels leads to the space of Bogros, the cord structures, and indirect hernias (see the video below). The proper plane of dissection is between the transversalis fascia and the peritoneum. This is identified by retracting the inferior epigastric vessels upward against the rectus muscle. A plane containing areolar tissue is identified, and this plane is dissected toward the pelvic sidewall. [56, 57, 13, 95]

Laparoscopic inguinal hernia repair: TEP. Lateral abdominal wall dissection.

Care must be exercised in separating the peritoneum from the muscle layers of the abdominal wall. The peritoneum is often very thin and may be tightly adherent. Attempting to disconnect these structures may result in a peritoneal rent; this is especially evident cephalad. Inferolaterally, the abdominal wall must be cleared to below the iliopubic tract.


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