Extended totally extraperitoneal hernia repair (eTEP) is a surgical technique introduced by Jorge Daes in 2012 for difficult inguinal hernias, involving the creation of a larger space to manage these cases. The procedure includes steps such as accessing the abdominal cavity, identifying anatomical landmarks, dissecting the hernia sac, and deploying a polypropylene mesh. Contraindications include multiple prior surgeries and large irreducible hernias, with potential complications like seroma formation and nerve injury.

1. EXTENDED TOTALLY
EXTRAPERITONEAL HERNIA REPAIR
{e TEP}
BY
DR. SATBIR SINGH

2. Hernia
 Abnormal protrusion of an organ or tissue
through a defect in its surrounding walls

3. HERNIA SURGERY
 OPEN
 LAPAROSCOPIC
LAPAROSCOPIC
 TEP : TOTALLY EXTRAPERITONEAL
 E TEP: EXTENDED TOTALLY EXTRAPERITONEAL
 TAPP : TRANSABDOMINAL PREPERITONEAL
 IPOM : INTRAPERITONEAL ONLAY MESH REPAIR.

4. Introduction
 Extended totally extraperitoneal repair (eTEP) is a novel
technique that was first introduced by Jorge Daes in 2012 to
address difficult inguinal hernias. The principle is to create a
larger space than what is done in TEP to tackle large groin
hernias.

6. Procedure
STEPS IN BRIEF
STEP 1: Entering the Intra-abdominalCavity
STEP 2 : Crossing the midline to opposite side
STEP 2: Identifying the Anatomical Landmarks
STEP 3: Dissecting the Hernia Sac
STEP 4: Deploying andAnchoring the Mesh
STEP 5: Closing the Peritoneum
STEP 6:Taking out Sutures & Port Closure

7. Anterior rectus sheath Posterior rectus sheath

8. STEP 1: Entering the Intra-abdominal Cavity
> Trocar placement
> Establishing the carbon dioxide
pneumoperitoneum using the Veress needle.
> The 10 mm Camera trocar – supraumbilical
> Under laparoscopic view - Two 5 mm operating
trocars on the midclavicular line 2 cm below the
level of the horizontal line from the optical trocar.

9. Loose areolar tissue

10. STEP 2: Identifying the Anatomical Landmarks
• Exploration and anatomical landmarks
The two dangerous “triangles”,
1) vascular triangle- Triangle of Doom and
2) Triangle of Pain has to be well identified
And Corona Mortis

11. CORONA MORTIS
• Latin - [corona] meaning "crown' & [mortis] meaning "death‘ the "crown or circle of death".
The corona mortis refers to an anatomical variation, a vascular anastomosis between the
obturator & the external iliac vascular systems that passes over Pectineal (Cooper's) ligament .
In some cases, the corona mortis is the actual obturator artery- arises from the inferior
epigastric artery instead of the internal iliac artery.
can also arise from the external iliac artery. In both cases, it has been called an "aberrant
obturator artery"
The Preperitoneal dissection ends when the anatomic landmarks previous described are well
exposed and the two dangerous triangles (vascular and pain triangle) can be identified

12.  STEP 3: Dissecting the Hernia Sac
• The indirect inguinal hernia sac should be dissected carefully from
the Spermatic Cord
• It is essential to expose and know at all times where the spermatic
cord is located. Direct hernia sacs are easily dissected
• Particular care should be taken not to dissect lateral and inferior
to Cooper's ligament, as the Iliac Artery and Vein will enter the
femoral canal at this site
 The hernia sac dissection is performed using traction contra-
traction maneuvers and fine coagulation. To avoid the injuries of
the ductus deferens and spermatic vessels the sac dissection
always starts anteriorly
A large indirect sac may be ligated
proximally and divided distally
without the risk of a higher
postoperative pain & recurrence
rate, but with an increased
postoperative seroma rate *

13. STEP 4: Ligation of Sac

14.  STEP 5: Deploying and Anchoring the Mesh
• A large (15x12 cm) polypropylene mesh.
• The mesh is inserted from the Camera trocar. Then, the mesh is placed in the appropriate position
and fixed by 1 Polypropylene sutures (or tacking staples, glue in some center's). The first suture is at
the level of pubis
• The mesh is fixed on the upper and internal edge
• The mesh shouldn’t be sutured/stapled at the level of dangerous triangles and epigastric vessels

15. Contraindications for TEP
 Multiple prior lower abdominal surgeries
 Large Irreducible Hernias
 Previous Pre-peritoneal Surgeries (prostate / inguinal hernia)
 Patient not fit for GA

16. Complications
 Seroma formation in 1-12%
 Wound or scrotal hematoma 1-8%
 Infections
 Urinary retention
 Bladder injury in patients of prior midline scars or prostate operations
 Injury to vas
 Ischemic orchitis though very rare in TEP
 Nerve injury m/c lateral femoral cutaneous nerve pain and numbness in upper lat
thigh MERALGIA PARASTHETICA