This document describes the technique of laparoscopic herniorrhaphy (TEP). It involves: 1) Dissecting the preperitoneal space to create working space; 2) Reducing any hernia sacs; 3) Placing a large mesh that extends beyond the hernia borders; 4) Optionally fixing the mesh with minimal staples. The goal is to reproduce the open 'Stoppa repair' technique laparoscopically using a large mesh with wide coverage and minimal fixation to reduce risks of nerve injury, pain, and recurrence."

1. Laparoscopic
Herniorrhaphy: TEP
G. Ferzli, MD, FACS
Professor of Surgery, SUNY Downstate
Chairman of Surgery Lutheran Medical Center

2. I- Anatomy of the
preperitoneal space

3. q Bogros (1823) :
Preperitoneal
approach through
the inguinal floor for
aneurysm (Bogros
space)
Bogros space

4. q Retzius (1858) :
Defined the
prevesical space
(Retzius space)
Retzius
space

5. II- Evolution of preperitoneal
herniorrhaphy

6. q Bassini (1884) :
Preperitoneal
approach through Transversalis fascia
the inguinal floor

7. q Nyhus (1959 ) :
Preperitoneal
approach through a
transverse
abdominal incision
for posterior repair

8. q Nyhus, Read
(1975):
Preperitoneal
approach and
posterior
prosthetic
buttress repair for
recurrent hernia

9. q Stoppa (1984):
Giant prosthetic
reinforcement of
the visceral sac
(GPRVS)

10. Principle of the “Stoppa repair”
1) All hernias of the groin begin in the
myopectineal orifice of Fruchaud (1956)
2) GPRVS replaces the transversalis fascia in
the preperitoneal space by a large prosthesis
that extends far beyond the borders of the
orifice of Fruchaud in all directions
3) The prosthesis is held in place by
intraabdominal pressure and ingrowth of
connective tissue

11. III- Technique of the TEP*
It has to reproduce the Stoppa repair
Laparoscopically
*Ferzli G., Sayad P.et al Surg Endosc 1998;12:1311-1313

12. 1-Anesthetic choices
q General anesthesia
– Analgesic
– Neuroleptic
– Neuromuscular blocking agent
q Regional anesthesia
– Sensory block
q Local anesthesia*(with or without
LMA)
*Ferzli G, Sayad P.(1999) The feasibility of laparoscopic extraperitoneal hernia repair under local
anesthesia. Surg. Endosc. 13, 588

13. 2- Patient preparation
q No NGT
q No Foley ( patient has to empty the
bladder before entering the operation
room)
q Slight Trendelenburg
q Flexed table

14. 3- Initial trocar placement
Transverse incision of the anterior rectus sheath, lateral retraction of the muscle

15. 4- Finger dissection of the preperitoneal
space

17. Disadvantages of balloon dissection
q Higher cost
q Longer operative time
q Asymetric dissection
q More traumatic with risk of vascular
injury (epigastic)

18. 5- Insufflation of the preperitoneal space to
10mmHg

19. Type of insufflation gas
Price Solubility Pain Flammable Metab. Lap hernia
activity under
local/reg.
CO2
NO2
Helium

20. 6- Trocars placement

21. 7-Dissection of the hernia spaces
Direct
Indirect
Femoral
Obturator

22. What to do if a peritoneal tear
occurs during the dissection?
q No need for
decompression of the
peritoneal cavity (using
needle or Veress)
q If the tear is away from
where the mesh is going
to be placed it can be
left alone
q An initial generous
dissection of the Retzius
and Bogros spaces can
easily preserve an
excellent working space

23. 8- Reduction of the hernia sac
Direct Hernia
•Easily identified medial to the epigastric vessels
•Easily reduced away from the thinned transversalis
fascia
Direct hernia sac

24. Reduction of Hernia Sac
Indirect Hernia
q In the presence of
hernia:
– The vas deferent is
not visible
– The sac is seen over
the spermatic cord
q The sac has to be
always separated from
the cord structures prior
to any attempt of
reduction

25. Scrotal Hernia
Scrotal Hernia
q May need to divide
epigastric vessels in scrotal
hernia
q Use additional 5mm trocar
in the anterior axillary line at
the level of ASIS
q If necessary, open the sac in
the upper outer quadrant in
order to avoid visceral injury
if a sliding hernia exists
q May need to amputate
hernia sac

26. Reduction of Hernia Sac
Femoral Hernia
q The femoral space
has to be explored
systematically
q Careful dissection to
avoid femoral
vessels and nerve
injuries

27. Reduction of Hernia Sac
Obturator Hernia
q Obturator hernia can be
repaired
laparoscopically
q Bilateral inspection is
mandatory
q Bowel viability must be
assessed
q Mesh repair can be
performed

28. 9- Placement of the mesh
Placement of a large prosthesis ( 5x6 in polypropylene) that extends
far beyond the borders of the orifice of Fruchaud in all directions

29. Is mesh slitting necessary?
Parietalization of the cord
q The Stoppa repair
uses a large
prosthesis that is
not slit
q The spermatic Peritoneum
cord is part of the
retroperitoneal Spermatic
cord
structures

30. Disadvantage of mesh slitting
q It increases testicular
pain and discomfort*
q Increases testicular
swelling*
q Increases the risk of
recurrence through
the key hole**
*Felix EL. et al Surg Endosc 1995;9:984-989
** Bittner et al Ann Surg 2000

31. 10- Fixation of the mesh
q Stapler
q Tacker
q Adhesive butyl-2-
cyanoacrylate*
q Fibrin sealant**
(fibrinogen plus
thrombin)
q No fixation
*Farouk et al Br J Surg 1996;83:1100
** Katkhouda Ann Surg. 2001;233:18-25.

32. Disadvantage of mesh
fixation
q 1) Nerve irritation after laparoscopic hernia repair
(E. Stark et al Surg Endosc 1999)
Nerve TAPP Shouldice Total
(n=448) (n=445) (n=893)
Genitofemoral 9 6 15
Ilioinguinal 5 1 6
Lat.fem.cut. 5 1 6
Total 19 8 27
% 4.2 1.8 3

33. Disadvantage of mesh fixation
q 2) “meshalgia”
“Stapalgia”
“tackalgia”
secondary to
fixation?
q 3) Stapling
increases the
cost of the
procedure

34. 11- Systematic contra-lateral
exploration *
q No need for complete contra-lateral dissection*
q Incidence of incipient contra-lateral hernias :
11.2%* (724 patients)
q Safe and does not considerably increase the
operative time (2-5min)*
q Obviate the need for re-operation, reduces the
overall costs to the health care system and
eliminates any further work loss for the patient*
*Sayad P, Ferzli G. Surg Endosc 1999;13:1168-1169

35. In conclusion
Important!
q Generous dissection of the Bogros space
q Complete parietalization of the cord
structures
q Placement of a large mesh
q Minimal or no placement of staples