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INTRODUCTION

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Total extraperitoneal (TEP) approach avoids entering the peritoneal cavity; hence, there is the theoretical advantage of less probability for visceral injury or incisional hernias. In addition, it avoids the problem of closure of the peritoneal flap. It is more difficult than TAPP because the operative space is tight. The preoperative preparation, anesthesia considerations, patient position, and operating room setup are the same as those for TAPP.

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EQUIPMENT AND SUPPLIES

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A one- or three-component dissecting balloon should be used to do the initial dissection of the preperitoneal space (figure 1a, b, and c).

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INCISION AND EXPOSURE

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A 2-cm incision is made just lateral and inferior to the umbilicus on the same side as the hernia. The muscle is retracted laterally so as to expose the posterior rectus fascia. Blunt dissection with the s-retractors or finger opens the preperitoneal space (figure 2b). The dissection of this space is facilitated by the use of a single- or three-component dissecting balloon. This is inserted into the space via the umbilical incision. The bulb insufflator device is used to expand the balloon. During the insufflation, the surgeon monitors the dissection process with the laparoscope which lies within the dissecting balloon (figures 1a, b). The expansion is gradual. It is important to have all the creases in the dissecting balloon flatten out. The balloon is desufflated and removed. The smaller stay balloon is then inserted (figure 1c) and filled with 40 mL of air. It is used to hold traction on the fascia by being retracted back and locked. This is attached to the CO2 insufflator, which is set to a pressure of 15 mm Hg. The patient is placed in a slight Trendelenburg position to avoid external compression of the preperitoneal space by the abdominal viscera. The hernia spaces are examined. Two 5-mm trocars are placed in the midline inferior to the umbilicus (figure 2a) The first is two fingerbreadths above the pubic tubercle and the second five fingerbreadths above the pubic tubercle just below the camera port. Figure 3 shows the anatomy of the region which is explained in detail in Chapter 111. A right direct inguinal is identified and the area is cleared (figure 4). The pubic tubercle is identified and slight lateral dissection is continued until the obturator vein is visualized. Blunt dissection with laparoscopic Kittner is used to open the preperitoneal space. Small tears in the peritoneum should be repaired in order to prevent competing pneumoperitoneum. If this becomes problematic, a Veress needle or 5-mm trocar can be placed in the peritoneal cavity to release the CO2 pressure. The spermatic cord is then skeletonized and the preperitoneal space dissected to the same extent as the TAPP. Although the orientation is different, the dissection and the mesh placement are similar to the TAPP. ...

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