From the Research
The commonest complication during dissection of the peritoneal plane in Totally Extraperitoneal (TEP) hernia repair is penetration to the peritoneum (option D). This occurs when the surgeon inadvertently breaches the peritoneal sac while creating the extraperitoneal space. Peritoneal tears happen frequently, especially during the learning curve of TEP, due to the delicate nature of the peritoneal membrane and the limited working space. When peritoneal penetration occurs, it can lead to loss of the pneumopreperitoneum, making visualization difficult and potentially converting the procedure to a transabdominal preperitoneal (TAPP) approach. Small tears can sometimes be managed by repositioning the laparoscope to maintain the working space, while larger defects may require closure with sutures or clips. Surgeons performing TEP should be particularly careful when dissecting near previous surgical sites or in thin patients where the peritoneal layer may be more fragile. While the other complications listed (bladder injury, inferior epigastric artery injury, and iliac vessel injury) can occur during TEP, they are less common than peritoneal penetration, as supported by a study published in 2021 1. Additionally, a recent review published in 2024 2 compared TAPP and TEP techniques for inguinal hernia repair and found that the evidence is very uncertain about the effects of TAPP versus TEP techniques on chronic pain and other outcomes, but it did not specifically address the commonest complication during dissection of the peritoneal plane. However, the study from 2021 1 reported an incidence of peritoneum injury in 10.1% of cases, which is consistent with the idea that peritoneal penetration is a common complication during TEP. Therefore, penetration to the peritoneum (option D) is the most likely correct answer, based on the available evidence and the principles of minimizing morbidity, mortality, and improving quality of life. Some key points to consider when performing TEP include:
- Careful dissection near previous surgical sites or in thin patients
- Use of techniques to minimize the risk of peritoneal penetration, such as atraumatic peritoneal dissection and exploratory puncture using a Cathelin needle 3
- Being prepared to manage peritoneal tears, including repositioning the laparoscope or closing larger defects with sutures or clips.