Most Common Complication During TEP Peritoneal Plane Dissection
Peritoneal penetration (option D) is the most common complication during dissection of the peritoneum plane in totally extraperitoneal (TEP) inguinal hernia repair, occurring in approximately 22% of cases.
Evidence for Peritoneal Penetration as the Commonest Complication
The highest quality evidence directly addressing TEP complications demonstrates that peritoneal injury occurs in 21.9% of TEP repairs 1. This represents the most frequent intraoperative complication specific to the peritoneal dissection phase of the procedure.
Primary Mechanisms of Peritoneal Injury
Peritoneal penetration during TEP occurs through two main mechanisms:
- Anatomical misrecognition accounts for 31.3% of peritoneal injuries, where surgeons fail to properly identify the peritoneal reflection during dissection 1
- Unintentional dissection causes 37.5% of peritoneal injuries, occurring when the dissection plane inadvertently enters the peritoneal cavity 1
Laterality Considerations
Right-sided hernias carry significantly higher risk for peritoneal injury compared to left-sided hernias (31.6% vs 11.4%, p=0.049) 1. All cases of peritoneal injury from unintentional dissection occurred on the right side 1.
Comparison with Other Listed Complications
The other options occur far less frequently during TEP:
- Inferior epigastric artery injury (option B) occurred in only 1% of cases in large series 2
- Urinary bladder injury (option A) is rare, with only 8 cases reported in 5,203 TEP repairs (0.15%) 3
- Internal iliac vessel injury (option C) has not been documented in major TEP series 3
Clinical Implications and Management
Impact on Procedure Completion
Peritoneal injury affects surgical approach in a meaningful proportion of cases:
- 11% of patients (9/84) with peritoneal complications required conversion to either anterior approach or TAPP repair 4
- Reasons for conversion included difficulty developing the operative field (5 cases), peritoneal violation (2 cases), and bleeding (2 cases) 4
Prevention Strategies
Inadequate peritoneal dissection accounts for a large number of recurrences among surgeons new to TEP 5. To minimize peritoneal injury:
- Use the suction test after balloon dissection to demonstrate the peritoneal edge by aspirating insufflated gas, causing the peritoneum to bulge anteriorly 5
- This technique resulted in additional necessary dissection in 23% of cases before mesh placement 5
- Perform at least 10 open Stoppa's preperitoneal procedures to learn extraperitoneal anatomy before starting independent TEP 6
Repair Techniques When Injury Occurs
When peritoneal penetration occurs during TEP:
- Ligation clips are the preferred repair method, requiring no additional techniques after introduction 1
- Endoscopic suturing required additional techniques in 75% of cases (3/4) 1
- Pre-tied loop ligation is an alternative option 1
Common Pitfalls
Patients with previous contralateral TEP repair face increased risk for peritoneal injury and may require approach modification 4. The learning curve for TEP is steep, with conversion rates of 50% in the first 10 cases dropping to 0% after 20 cases when proper training protocols are followed 6.