Total Extraperitoneal (TEP) Procedure Steps
The Total Extraperitoneal (TEP) procedure for inguinal hernia repair follows a standardized eight-step approach that creates a preperitoneal space for mesh placement without entering the peritoneal cavity.
Preoperative Preparation
- Patient should be on liquid diet for 24 hours before procedure to minimize gastric contents
- Administer prophylactic antibiotics effective against enteric pathogens
- Position patient supine under general anesthesia (though spinal anesthesia can be considered as an alternative) 1
Eight Essential Steps of TEP Procedure
1. Creation of Pneumo-Preperitoneal Space
- Make a small infraumbilical incision
- Incise the anterior rectus sheath
- Retract rectus muscle laterally
- Insert balloon dissector in preperitoneal space and inflate to create working space
- Place 10mm trocar and establish CO2 insufflation (low flow) 2
2. Identification of Pubic Symphysis
- Insert laparoscope and identify midline structures
- Dissect toward pubic symphysis as the first anatomical landmark
- Identify Cooper's ligament at the inferior aspect of pubis 2
3. Identification of Inferior Epigastric Vessels
- Locate inferior epigastric vessels on the posterior surface of rectus muscle
- These vessels define the medial border of Hesselbach's triangle
- Place two additional 5mm working ports under direct vision 2, 3
4. Lateral to Medial Dissection of Hernia Sac
- Begin dissection laterally at the level of anterior superior iliac spine
- Develop the lateral space (space of Bogros)
- Identify the iliopsoas muscle and lateral border of the defect 2
5. Identification of Cord Structures and Critical Triangles
- Carefully identify spermatic cord structures
- Locate and protect the triangle of doom (containing external iliac vessels)
- Identify triangle of pain (containing femoral branch of genitofemoral nerve) 2
6. Herniotomy
- For indirect hernias: carefully separate the sac from cord structures
- For direct hernias: reduce the hernia by gentle traction
- For large indirect hernias: divide the sac if it extends into scrotum, leaving distal portion in place 2, 4
7. Parietalization of Hernia Sac
- Free the cord structures from peritoneum for at least 4-5 cm
- This "parietalization" ensures adequate mesh coverage without tension
- Ensure complete reduction of all hernia contents 2
8. Placement and Fixation of Mesh
- Insert appropriately sized polypropylene mesh (at least 10×15 cm)
- Position mesh to cover entire myopectineal orifice with 3-5 cm overlap
- Consider fixation with tacks or glue, avoiding the "triangle of pain" area
- Deflate pneumopreperitoneum under direct visualization to ensure proper mesh positioning 2, 5
Potential Complications and Pitfalls
- Peritoneal tears: Common during dissection, can lead to pneumoperitoneum
- Vascular injury: Carefully identify and protect inferior epigastric and iliac vessels
- Nerve injury: Avoid fixation in the "triangle of pain" to prevent chronic pain
- Conversion to TAPP or open repair: May be necessary in difficult cases 4
Postoperative Care
- Early mobilization to prevent complications
- Progressive resumption of normal activities
- Monitor for signs of infection, seroma, or hematoma formation
- Pain management with appropriate analgesics 5
The TEP approach offers advantages of reduced postoperative pain, faster recovery, and lower recurrence rates compared to traditional open repairs. The standardized eight-step approach helps reduce the learning curve for surgeons and ensures consistent outcomes 2.