Laparoscopic Totally Extraperitoneal (TEP) Left Indirect Inguinal Hernia Repair with Mesh

This video demonstrates the surgical technique for a laparoscopic totally extraperitoneal (TEP) left inguinal hernia repair with mesh. This is a technically challenging operation with a steep learning curve; however, it is one useful option for patients with bilateral hernias, recurrent hernias, or when a minimally-invasive approach is desired. It provides tension-free repair and allows exposure to the entire groin area to evaluate and repair indirect, direct, and femoral hernias. The only absolute contraindication to laparoscopic TEP repairs is the inability to undergo general anesthesia due to significant cardiopulmonary disease or other factors.

Laparoscopic; totally extraperitoneal repair; TEP; inguinal hernia.

This is a case of a healthy 60-year-old man who presented with a left groin bulge and underwent an ultrasound showing a fat-containing left inguinal hernia. He was referred to our minimally-invasive surgery clinic and subsequently underwent a laparoscopic totally extraperitoneal (TEP) left inguinal hernia repair with mesh. Patient was discharged home on the same day of surgery in stable condition.

This patient is a healthy 60-year-old male with a past surgical history of an appendectomy who presented as an outpatient with complaints of a left groin bulge and symptoms including worsening discomfort and swelling of the area throughout the day. He was sent for an ultrasound, which was interpreted as a fat-containing left inguinal hernia and was subsequently referred to surgery for consultation. Of note, the patient expressed concern about the possibility of a femoral hernia during his preoperative visit. He was scheduled for an elective laparoscopic TEP left inguinal hernia repair.

On focused physical exam of the abdomen, patient’s abdomen was soft, nondistended, and nontender. Both spermatic cords and testicles were in normal position without any palpable abnormalities. No hernia was identifiable on the right side; however, there was an easily identifiable inguinal hernia on the left side in either the direct or indirect space. The femoral space was also examined and no hernia was identified in that area.

The diagnosis of an inguinal hernia is mostly based on clinical findings and patients only need further investigation if there is diagnostic uncertainty or features of complication. This patient did undergo an ultrasound prior to surgical consultation, which was interpreted as a fat-containing left-sided inguinal hernia.

There are two types of inguinal hernias, direct and indirect, and they are defined by their relationship to the inferior epigastric vessels. Direct inguinal hernias are medial to the inferior epigastric vessels, while indirect are located laterally.^1,4 Indirect hernias are due to a patent processus vaginalis, while direct hernias are due to a weakening in the fascia of the abdominal wall. Indirect inguinal hernias are more common than direct regardless of gender, and it is more common for indirect inguinal hernias to occur on the right side due to the delay in closure of the processus vaginalis compared to the left side.¹ Femoral hernias are also a subtype of groin hernias, but are less common than inguinal hernias. Women have an increased occurrence of femoral hernias in comparison to men, but direct and indirect inguinal hernias are still the most common in females.⁵ The most common risk factors for developing a hernia include male sex, advanced age, raised intra-abdominal pressure, and high body mass index (BMI).

Inguinal hernia repair is one of the most commonly performed general surgery operations. If hernias are asymptomatic or minimally symptomatic, it is reasonable to do a watchful waiting approach; however, patients need to understand the possible complications that could occur including incarceration, obstruction, and strangulation. The three main types of inguinal hernia include open tissue-based, open tension-free (mesh), and minimally invasive (laparoscopic or robotic, mesh tension-free). Minimally-invasive approaches include (transabdominal preperitoneal (TAPP) and TEP). The TEP procedure does not require entry into the peritoneal cavity, which can be advantageous in patients with prior surgery.^1,3 Minimally-invasive repairs also have decreased rates of hematoma and seroma formation, as well as decreased postoperative pain, which allows patients to return to work and daily activities quicker compared to open operations leading to an overall improved quality of life.^5,6 With the laparoscopic approach, there is improved visualization of all anatomical areas for hernia formation (indirect, direct, and femoral space) compared to that of an open technique.⁵ However, surgeons need to be aware of the triangle of doom and triangle of pain when performing a laparoscopic repair. The triangle of doom is where you can find the external iliac artery and vein, and the triangle of pain holds the lateral femoral cutaneous nerve, the femoral branch of the genitofemoral nerve, and the femoral nerve. It is critical to avoid fixation of the mesh to these areas as it can cause major vascular injuries or nerve injury that could result in chronic pain.⁴  Figure 1 depicts the anatomic relationship of these critical structures described above.

Figure 1. Laparoscopic anatomy of inguinal hernia depicting the indirect, direct, and femoral hernia spaces along with the triangle of doom and pain in relationship to the epigastric vessels, spermatic cord, and iliopubic tract.

The goal of treating inguinal hernias with surgery is to reduce the long-term risks of incarceration, obstruction, and strangulation. This is done by reduction of the contents within the hernia and reinforcement of the weakness within the abdominal wall. Laparoscopic approach allows for bilateral groin visualization while providing a tension-free repair and providing exposure to all sites of possible hernia defects (direct, indirect, and femoral).²

This procedure is done laparoscopically with the following equipment: 

• Laparoscopic equipment including a 5-mm or 10-mm 30-degree camera
• Two 5-mm trocars
• Initial balloon dissector trocar to create preperitoneal space
• Operating balloon trocar
• Insufflation tubing
• Two laparoscopic graspers  
• Mesh of choice (synthetic or biologic): we used lightweight polypropylene (will need one for each side if doing a bilateral repair)
• Fixation method of choice (tacks, glue, suture)
• Sutures for fascia and skin closure (0 Vicryl and 4-0 Monocryl)

The decision to perform each surgical approach for an inguinal hernia repair is patient specific, as well as based on surgeon experience. Laparoscopic TEP repairs are generally indicated for bilateral hernias, recurrent hernias following open repair, or patients with prior intra-abdominal surgery. It is a technically challenging operation with a steep learning curve; however, it is a great tool to have as it allows exposure to all sites of potential groin hernias and avoids entry into the abdomen.² The only absolute contraindication to laparoscopic TEP repairs is the inability to undergo general anesthesia due to significant cardiopulmonary disease.³

Nothing to disclose.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.