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INTRODUCTION

The 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. The preoperative preparation, anesthesia considerations, patient position, operating room setup, and operative preparation are the same as those for the TAPP procedure (see Chapter 115). Sterile drapes are applied according to the surgeon’s specifications. Then a time-out is performed.

INCISION AND EXPOSURE

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 S-retractors or a finger opens the preperitoneal space (FIGURE 1A and 1B). 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 insufflation, the surgeon monitors the dissection process with the laparoscope, which lies within the dissecting balloon (FIGURE 2A and 2B). The expansion is gradual. It is important to have all the creases in the dissecting balloon flatten out. The balloon is deflated and removed. The smaller stay balloon is then inserted (FIGURE 2C) 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 carbon dioxide 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 1A). The first is two finger breadths above the pubic tubercle and the second five finger breadths above the pubic tubercle just below the camera port.

FIGURE 3 shows the anatomy of the region, which is explained in detail in Chapter 114. A right direct inguinal hernia is identified and reduced (FIGURE 4). Cooper’s ligament is identified and cleared for at least 2 cm. Blunt dissection with a 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 a 5-mm trocar can be placed in the peritoneal cavity to release the carbon dioxide 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 mesh placement are similar to the TAPP. The mesh is cut to the size and shape shown in FIGURE 5. It is then rolled and inserted under direct vision through the ...

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