What is the procedure for placement and fixation of the mesh 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

Wide preperitoneal dissection ensures that adequate space is available for placement of a large mesh prosthesis. The lateral dissection should take the peritoneum up to the umbilicus. The peritoneum should be taken off the spermatic vessels as far cephalad as possible (see the video below). The peritoneum should be dissected off the vas deferens to the point where the vas courses medially. The external iliac vein should be visualized by dissecting the overlying fatty tissue medially, toward the urinary bladder. Finally, the obturator space should be dissected.

Laparoscopic inguinal hernia repair: TEP. Dissection of peritoneum off cord with small hole in peritoneum.

After this complete and meticulous dissection, the operative site is assessed. The deep ring should be visualized with only the cord structures traversing its opening into the inguinal canal. Any holes that were made in the peritoneum should be closed before placement of the mesh.

Once the requisite dissection is complete, the mesh is folded and introduced under direct vision, then dragged as far laterally as possible toward the ASIS (see the videos below). Next, the mesh is flattened out across the myopectineal orifice and draped over the cord structures. A single tack is placed at the pubic tubercle; this serves as a fixation point to facilitate arrangement of the mesh in the tight preperitoneal space.

Laparoscopic inguinal hernia repair: TEP. Pearl mesh deployment.
Laparoscopic inguinal hernia repair: TEP. Mesh deployment and fixation.

The mesh is maneuvered so that its upper border lies above a line from the pubic symphysis to the ASIS. The remaining tacks are then placed down the Cooper ligament, up the midline, and along the upper border of the mesh.

It is essential that each firing of the tacker beyond the inferior epigastric artery-vein complex be above a line from the pubic symphysis to the ASIS. This ensures that no tacks are placed in proximity to nerve structures or iliac vessels (the triangle of pain and triangle of doom). Correct placement can be further verified by carefully palpating the tacker head through the abdominal wall and comparing its relation to this line before each firing. No more than one or two tacks are needed in this hazardous location.

If the patient has bilateral pathology, the surgical team’s attention is now turned to the contralateral side.


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