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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.

A three-component dissecting balloon should be used to do the initial dissection of the preperitoneal space (Figure 2A, B, C).

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 1B). The dissection of this space is facilitated by the use of a 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 (Figures 2A and 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 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 CO2 insufflator, which is set to a pressure of 15 mmHg. 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 fingerbreadths above the pubic tubercle and the second five fingerbreadths above the pubic tubercle just below ...

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