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Totally extraperitoneal
repair for inguinal hernia
Jagpreet Singh Deed
FRCS, FACS, MS, DNB (General Surgery)
Specialist General Surgery, Zulekha hospital, Sharjah
Adjunct Clinical Faculty, College of Medicine, University of Sharjah
Honorary Clinical Tutor, University of Edinburgh
jpsdeed@gmail.com
TEP
Transversalis fascia
Indications
 Tailored approach:
 Surgeon’s expertise
 Patient &
 Hernia characteristics
 Resources available
 Shared decision making
 Discuss watchful waiting
with patients in
asymptomatic hernias
International guidelines for groin hernia management. HerniaSurge Group. Hernia 2018
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP
Challenges
 Unfamiliar anatomy
 Small space
 Crowding of instruments
 Loss of space (pneumoperitoneum)
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP
Contraindications
 Contraindications to general anesthesia
 Relative- previous posterior repair
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP
Advantages
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP
Instrumentation
 Laparoscopic set with
 10mm zero and 30 degrees viewing scope
 Hassan trocar
 Two 5mm trocars
 S retractors
 Balloon is optional
 PDS endoloop for closing sac- optional
 Vessel sealer with dividing blade- optional but preferred
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP
Instrumentation
 Laparoscopic set with
 10mm zero and 30 degrees viewing scope
 Hassan trocar
 Two 5mm trocars
 S retractors
 Balloon is optional
 PDS endoloop for closing sac- optional
 Vessel sealer with dividing blade- optional but preferred
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP
Instrumentation
 Laparoscopic set with
 10mm zero and 30 degrees viewing scope
 Hassan trocar
 Two 5mm trocars
 S retractors
 Balloon is optional
 PDS endoloop for closing sac- optional
 Vessel sealer with dividing blade- optional but preferred
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP
Instrumentation
 Laparoscopic set with
 10mm zero and 30 degrees viewing scope
 Hassan trocar
 Two 5mm trocars
 S retractors
 Balloon is optional/ Indigenous balloon can be used
 PDS endoloop for closing sac- optional
 Vessel sealer with dividing blade- optional but preferred
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP
Instrumentation
 Laparoscopic set with
 10mm zero and 30 degrees viewing scope
 Hassan trocar
 Two 5mm trocars
 S retractors
 Balloon is optional/ Finger dissection
 PDS endoloop for closing sac- optional
 Vessel sealer with dividing blade- optional but preferred
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP
Instrumentation
 Laparoscopic set with
 10mm zero and 30 degrees viewing scope
 Hassan trocar
 Two 5mm trocars
 S retractors
 Balloon is optional
 PDS endoloop for closing sac- optional
 Vessel sealer with dividing blade- optional but preferred
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP
Video Totally extraperitoneal for right inguinal hernia
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP
Tips and tricks
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP
Pathway to success
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP
Enhanced exposure
 Division of posterior rectus sheath at Arcuate line
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP
Alternative port position
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP
eTEP (extended TEP)
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP
Corona mortis
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP
Mesh size and placement
 15cm x 12 cms is appropriate
 Half roll
 Overlap to contralateral side in direct defect
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP
Image courtesy: Techniques of Abdominal Wall Hernia Repair. Ed P
Chowbey, D Lomanto. 1st Edition 2020
Mesh fixation
Options
 No fixation
 Necessary in large direct hernias:
 Tacker
 Suture
 glue
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP
Complications
 Seroma
 Chronic postoperative inguinal pain (CPIP)
 Bleeding
 Injury- bladder/ intestine/ gonadal vessels
 Mesh infection
 Recurrence
 Non progress
 Pneumoperitoneum
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP
Conclusions
 Safe and effective technique with rapid return to normal life
 Potential benefits over TAPP- reduced risk of injury to abdominal organs
and port site hernia
 High quality of life as compared to open technique
 Learning curve needs to be overcome (100 cases)
 Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com
TEP
Thanks for kind attention
Fear of failure leads to failure
Paulo Coelho

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TEP Totally extraperitoneal inguinal hernia repair.pptx

  • 1. Totally extraperitoneal repair for inguinal hernia Jagpreet Singh Deed FRCS, FACS, MS, DNB (General Surgery) Specialist General Surgery, Zulekha hospital, Sharjah Adjunct Clinical Faculty, College of Medicine, University of Sharjah Honorary Clinical Tutor, University of Edinburgh jpsdeed@gmail.com TEP
  • 3. Indications  Tailored approach:  Surgeon’s expertise  Patient &  Hernia characteristics  Resources available  Shared decision making  Discuss watchful waiting with patients in asymptomatic hernias International guidelines for groin hernia management. HerniaSurge Group. Hernia 2018  Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com TEP
  • 4. Challenges  Unfamiliar anatomy  Small space  Crowding of instruments  Loss of space (pneumoperitoneum)  Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com TEP
  • 5. Contraindications  Contraindications to general anesthesia  Relative- previous posterior repair  Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com TEP
  • 6. Advantages  Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com TEP
  • 7. Instrumentation  Laparoscopic set with  10mm zero and 30 degrees viewing scope  Hassan trocar  Two 5mm trocars  S retractors  Balloon is optional  PDS endoloop for closing sac- optional  Vessel sealer with dividing blade- optional but preferred  Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com TEP
  • 8. Instrumentation  Laparoscopic set with  10mm zero and 30 degrees viewing scope  Hassan trocar  Two 5mm trocars  S retractors  Balloon is optional  PDS endoloop for closing sac- optional  Vessel sealer with dividing blade- optional but preferred  Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com TEP
  • 9. Instrumentation  Laparoscopic set with  10mm zero and 30 degrees viewing scope  Hassan trocar  Two 5mm trocars  S retractors  Balloon is optional  PDS endoloop for closing sac- optional  Vessel sealer with dividing blade- optional but preferred  Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com TEP
  • 10. Instrumentation  Laparoscopic set with  10mm zero and 30 degrees viewing scope  Hassan trocar  Two 5mm trocars  S retractors  Balloon is optional/ Indigenous balloon can be used  PDS endoloop for closing sac- optional  Vessel sealer with dividing blade- optional but preferred  Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com TEP
  • 11. Instrumentation  Laparoscopic set with  10mm zero and 30 degrees viewing scope  Hassan trocar  Two 5mm trocars  S retractors  Balloon is optional/ Finger dissection  PDS endoloop for closing sac- optional  Vessel sealer with dividing blade- optional but preferred  Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com TEP
  • 12. Instrumentation  Laparoscopic set with  10mm zero and 30 degrees viewing scope  Hassan trocar  Two 5mm trocars  S retractors  Balloon is optional  PDS endoloop for closing sac- optional  Vessel sealer with dividing blade- optional but preferred  Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com TEP
  • 13. Video Totally extraperitoneal for right inguinal hernia  Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com TEP
  • 14. Tips and tricks  Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com TEP
  • 15. Pathway to success  Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com TEP
  • 16. Enhanced exposure  Division of posterior rectus sheath at Arcuate line  Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com TEP
  • 17. Alternative port position  Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com TEP
  • 18. eTEP (extended TEP)  Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com TEP
  • 19. Corona mortis  Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com TEP
  • 20. Mesh size and placement  15cm x 12 cms is appropriate  Half roll  Overlap to contralateral side in direct defect  Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com TEP Image courtesy: Techniques of Abdominal Wall Hernia Repair. Ed P Chowbey, D Lomanto. 1st Edition 2020
  • 21. Mesh fixation Options  No fixation  Necessary in large direct hernias:  Tacker  Suture  glue  Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com TEP
  • 22. Complications  Seroma  Chronic postoperative inguinal pain (CPIP)  Bleeding  Injury- bladder/ intestine/ gonadal vessels  Mesh infection  Recurrence  Non progress  Pneumoperitoneum  Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com TEP
  • 23. Conclusions  Safe and effective technique with rapid return to normal life  Potential benefits over TAPP- reduced risk of injury to abdominal organs and port site hernia  High quality of life as compared to open technique  Learning curve needs to be overcome (100 cases)  Totally extraperitoneal hernia repair Jagpreet Singh Deed jpsdeed@gmail.com TEP
  • 24. Thanks for kind attention Fear of failure leads to failure Paulo Coelho

Editor's Notes

  1. Burns and wound cover lecture