Totally Extraperitoneal Approach (TEP) for Inguinal Hernia Repair

Abstract

Laparoscopic inguinal herniorrhaphy was initially described by Ger in the early 1980s. Nowadays, two techniques are worldwide adopted: the transabdominal preperitoneal approach (TAPP) and the totally extraperitoneal approach (TEP). In these repairs, the myopectineal orifice is approached posteriorly and allows for inguinal, femoral, and obturator hernia repairs to be performed simultaneously. TEP is a relatively new technique. McKernan and Law first introduced TEP in 1993. Some proponents of TEP advocate for this technique over the transabdominal approach due to the shorter operative times, especially for bilateral hernias, and decrease the risks of vascular, bowel, and bladder injuries as well as bowel obstructions, adhesions, or fistula formation potentially associated with intraperitoneal dissection and intraperitoneal mesh exposure. When compared with open hernia repair, and in particular for recurrent (after open) and bilateral hernias, many surgeons prefer the laparoendoscopic approach due to quicker recovery times and less postoperative and chronic pain. In experienced hands, there are no absolute contraindications to TEP, although a careful decision should be made to tailor the approach to both patient and surgeon factors. In this chapter, we will describe the technical steps of totally extraperitoneal hernia repair, the potential complications, and troubleshooting when needed.

1. Introduction

Repair of groin hernia is one of the most common elective operations performed in general surgical practice. Bassini’s [1] sutured repair became a milestone in the repair of groin hernia. Lichtenstein [2] popularized the tension-free open mesh repair using polypropylene mesh claiming rapid ambulation and recovery with a 99% probability of permanent cure. Minimal access approaches to inguinal hernia repair have added to the ongoing debate over the best groin hernia repair [3, 4]. Ger and associates [5] in 1990 introduced laparoscopic inguinal hernia repair. The current concept of laparoscopic repair is based on Stoppa’s [6] concept of preperitoneal reinforcement of fascia transversalis over the myopectineal orifice with a large piece of mesh. In 2004, the National Institute of Health and Clinical Excellence (NICE) [7] published guidelines after a meta-analysis of over 40 randomized controlled trials and reported that laparoscopic repair was indeed associated with less pain and faster recovery, but also with increased cost and longer operating times and that laparoscopic surgery is considered as one of the treatment options for the repair of inguinal hernia. There are two standardized laparoscopic techniques: transabdominal preperitoneal approach (TAPP) described by Arregui et al. [8] in the early 1990s and totally extraperitoneal approach (TEP) described by Mckernon and Laws [9] in 1993.

TEP laparoscopic inguinal hernia repair has gained popularity in the past few years and is preferred over TAPP repair as it is less invasive and avoids entry to the peritoneal cavity. TEP procedure combines the advantages of minimal invasive surgery and those of tension-free mesh repair. TEP is a complex procedure that is performed in a space created during operation. It is necessary to be skilled in laparoscopic surgery and familiar with the anatomy of the abdominal wall from within to perform the operation with good results. During the learning curve, one of the difficulties is finding the correct plane in the preperitoneal space. If dissection is performed in the wrong surgical plane, there is increased risk of hemorrhage, loss of anatomical plane, or both. Laparoendoscopic inguinal hernia repair when compared with open approaches in various trials, either randomized or prospective, revealed significant benefits and advantageous outcomes, such as less postoperative pain, faster recovery and return to physical activity, as well as superior cosmesis [10, 11]. Furthermore, during laparoendoscopic hernia repair, the surgeon has the ability to inspect the entire myopectineal orifice and evaluate the presence of other types of hernia, such as a femoral hernia, which may be repaired in the same procedure [12, 13]. Although, a variety of laparoendoscopic techniques have been described for the management of groin hernias [14, 15, 16, 17, 18, 19]; two among them are the most popular regarding inguinal hernioplasty: TAPP and TEP repair. In both methods, a mesh prosthesis is implanted into the preperitoneal space dorsal to the transversalis fascia. These techniques therefore represent minimally invasive versions of open mesh implantation techniques. In TAPP, the surgeon enters the peritoneal cavity and places a mesh through a peritoneal incision over possible hernia sites. TEP is superior because the peritoneal cavity is not entered and mesh is used to seal the hernia from outside the peritoneum. This approach is considered to be more difficult than TAPP but may result in fewer complications. The TAPP approach has been advocated for complicated hernias (sliding or incarcerated inguinal hernias) and hernias with previous pelvic surgery (radical prostatectomy). This technique has been criticized for exposing intraabdominal organs to potential complications, including small bowel injury and obstruction. Laparoscopic TEP hernia repair has gained ground in recent years and is preferred over TAPP as it is less invasive and is associated with fewer complications. In their comparative study, Felix et al. reported 11 major complications in the TAPP group (two recurrences, six hernias in the trocar site, and others), whereas only one recurrence was observed in the TEP group, with no intraperitoneal complications [14]. Khoury et al. found that patients who underwent TEP received less narcotic analgesia than those who underwent TAPP and that they were discharged more frequently at the operative day [20]. Although, traditionally, open hernia repair was favored over laparoendoscopic repairs, as far as cost-effectiveness is concerned [21, 22], nowadays, it seems that in a cost analysis context, TEP is comparable with conventional open repair [23, 24]. Taking into account that in experienced surgeons, operating time and morbidity, especially recurrences, are significantly reduced, laparoendoscopic inguinal hernia repair techniques became more popular, and more and more surgeons favor them for most types of inguinal hernias. Furthermore, more surgeons prefer TEP over TAPP because the peritoneal cavity is not entered and in such a way less intraabdominal complications may occur.

2. Anatomy of the inguinal preperitoneal space

The preperitoneal space lies between the peritoneum and the posterior lamina of the transversalis fascia. There are two important spaces in the setting of laparoendoscopic inguinal hernia repair: the space of Retzius, the most medial of which lies superior to the bladder, and the space of Bogros, which is a lateral extension of the space of Retzius that extends to the level of the anterior superior iliac spine. Dissection of these spaces gives the surgeon access to the myopectineal orifice of Fruchaud, which is bound superiorly by the aponeurotic arch of the internal oblique and the transversus abdominis muscle, inferiorly by the Cooper ligament, medially by the lateral border of the rectus muscle, and laterally by the iliopsoas muscle. The inguinal ligament and iliopubic tract pass obliquely through this space (Figure 1).

Figure 1.

Anterior and posterior views of myopectineal orifice (from Elliott and Novitsky [25]).

Three potential sites of hernia formation are associated with the myopectineal orifice: the indirect, the direct, and the femoral space. The direct and indirect spaces are located medial and lateral to the inferior epigastric vessels, respectively, and both are above the iliopubic tract. The femoral canal lies in the area bounded anterosuperiorly by the inguinal ligament, posteriorly by the pectineal ligament lying anterior to the superior pubic ramus, medially by the lacunar ligament, and laterally by the femoral vein (Figure 2).

Figure 2.

Potential hernia sites within the myopectineal orifice (direct, indirect, obturator, and femoral). Placement of mesh over entire myopectineal orifice. Usually, no stapling devices are used for placement of mesh.

Furthermore, three triangles are important in laparoscopic hernia repair: Hesselbach’s triangle with its’ medial border consisted of the lateral margin of the rectus sheath, the superolateral border defined by the inferior epigastric vessels, whereas the inferior border is the Poupart ligament, the “triangle of Doom” bordered medially by the vas deferens and laterally by the vessels of the spermatic cord, with its base opposite to the deep ring (the contents of this space include the external iliac vessels, deep circumflex iliac vein, femoral nerve, and genital branch of the genitofemoral nerve) and the “triangle of Pain,” which is bounded by the gonadal vessels medially, the reflected peritoneum laterally, and the iliopubic tract superiorly (the femoral nerve, the genitofemoral nerve, the anterior femoral cutaneous nerve, and the lateral femoral cutaneous nerve are found in this region).

3. Indications and contraindications

It is generally accepted that laparoscopic inguinal hernia repair is indicated for bilateral hernias or recurrent following open repair [26]. The laparoendoscopic approach avoids the morbidity associated with bilateral groin incisions and allows for bilateral repair with one operation. Furthermore, it obviates the necessity to dissect in the anterior plane where the surgical field may be jeopardized from previous repairs, especially if a mesh has been used. Increasingly, surgeons have been offering laparoscopic repair upfront, even in the setting of unilateral, previously unrepaired hernias due to the reduction in postoperative acute pain and time away from work and daily activities, as well overall improved quality of life [27]. This is particularly true for surgeons who are familiar and have experienced the laparoendoscopic technique. Surgeons during their early experience should preferably operate on thin patients fit for general anesthesia with small, direct, uncomplicated, or indirect reducible hernias.

Although there are no absolute contraindications to totally extraperitoneal hernia repair in the elective setting, apart from patient’s inability to tolerate general anesthesia or pneumoperitoneum due to cardiopulmonary disease, previous pelvic irradiation or surgery, lower midline or ipsilateral paramedian incisions, large inguinoscrotal or chronically irreducible hernias as well as recurrent hernias from a previous TEP are relative contraindications. With the blind balloon dissection required for the TEP technique, there is a risk of injury to the contents of the incarcerated hernia sac. Extraperitoneal endoscopic repair is difficult and time-consuming in these circumstances. In these instances, one may elect to attempt a TAPP repair and convert to the open operation if it is obvious that this, too, is not feasible. Modifications from a traditional TEP should include mandatory Foley catheter placement to allow for full development of the space of Retzius as well as surgeon comfort with ligating the epigastric vessels, if needed, as well as knowledge on how to incise the transversalis fascial sling to aid in indirect hernia sac reduction [28]. Previous appendectomy is usually not a problem, but the surgeon should be more careful during the lateral dissection. Acute abdomen with strangulated and/or infected inguinal hernias that will require bowel resection and pediatric patients are absolute contraindications.

4. Preoperative planning and patient preparation

A complete history and physical examination are mandatory to assess the patient’s fitness for general anesthesia. The patient is examined while standing and supine for both inguinal and femoral hernias on both left and right sides. A preoperative imaging with ultrasonography or computed tomography is justified to rule out any doubt in the diagnosis of the inguinal hernia. Special measures must be taken if the patient is on drugs such as anticoagulants; if the patient is on acetylsalicylic acid and related drugs (these must be discontinued at least a week before surgery); and if the patient is on oral warfarin (should be placed on heparin or its long-acting derivatives). A pre-anesthetic check-up must be done to get clearance for surgery.

The patient should be informed that there is a risk of conversion to TAPP or to an open approach depending on the difficulty and the safety of the procedure. Any possible complications such as vascular or nerve injuries, mesh infection, chronic postoperative pain, hematoma, seroma or injury to the spermatic cord, bowel and urinary bladder, as well as risks from CO₂ insufflation (hypotension, hypercapnea, subcutaneous emphysema, etc.), should be thoroughly explained to the patient [29].

Prophylactic antibiotic administration such as a single dose of a first-generation cephalosporin before the induction of anesthesia is recommended in the presence of risk factors for wound and mesh infection, such as advanced age, steroid use, obesity, diabetes mellitus, immunosuppression, malignancy, prolonged operating time and/or insertion of drains [30, 31]. Umbilical disinfection is recommended, and possibly shaving or depilation from the umbilicus halfway down to the symphysis. The patient should have emptied their bladder shortly before surgery and a catheter is not necessary, unless the operation takes more than 1.5 h. No bowel preparation is necessary. All patients undergoing totally extraperitoneal hernia repair receive deep vein thrombosis prophylaxis.

5. Anesthesia

Totally extraperitoneal hernia repair may be performed using local, epidural, or general anesthesia. Many surgeons find that spinal anesthesia is adequate for the TEP repair most of the time. Rarely, especially if the peritoneum is breached, conversion to general anesthesia may be required. However, it is our preference to operate under general anesthesia, because this type of anesthesia ensures that any cardiovascular or respiratory effect of CO₂ insufflation is minimized. Furthermore these effects are comparable to those attributed to intraperitoneal CO₂ insufflation [32].

6. Suggested equipment

• A 5- or 10-mm, 0° or 30° angled laparoscope

• A 5- or 10-mm Hasson’s trocar for the laparoscope

• One balloon/space-making trocar (optional; based on the International Endohernia Society guidelines, it is recommended to use a balloon dissector when creating the preperitoneal space, especially during the learning curve, when it is difficult to identify the correct preperitoneal plane and space [31])

• Two 5-mm trocars

• Two 5-mm fenestrated grasping forceps

• A 5-mm strong grasping forceps

• Monopolar energy device and cable

• A pair of dissecting and coagulating shears

• Scissors

• Laparoscopic clips (5 mm)

• A 5-mm endoscopic needle holder

• A Verres needle

• Synthetic mesh (i.e., a preshaped 3-D polypropylene mesh) (size may vary i.e., 15 × 10 cm or 17 × 12 cm)

• A suction cannula

• Endoloops

• Tackers and fixation devices

7. Technical considerations

7.1 Operating room setup

The patient is placed, under—usually—general anesthesia, in the supine position, with the arm on the side of the hernia extended, although many surgeons prefer both arms to be tucked. It is helpful to put the patient in a 15° Trendelenburg position. The monitor is positioned at the foot end of the patient. The surgeon stands on the side opposite of the hernia and the camera operator (assistant) and the scrub nurse at the side of the hernia.

7.2 Extraperitoneal access, trocar placement, and dissection of the preperitoneal space

We have adopted Dulucq’s [33] technique and a Veress needle is initially inserted above the pubis in the midline in order to penetrate the linea alba (Figure 3). The needle enters the preperitoneal space and is inserted in the Retzius space, which is insufflated with 2 lit of CO₂. This initial “pneumodissection” of Retzius space facilitates the insertion of the working trocars and further dissection of the surgical planes. After the insufflation of CO₂, a 1 cm periumbilical incision, ipsilateral to the hernia is made and the anterior rectus sheath is incised at the level of arcuate line, a point roughly level with the anterior superior iliac spine, and a 10-mm trocar is inserted into the preperitoneal space. The laparoscope is then introduced and the space is progressively expanded by blunt telescope dissection with a 0° or 30° laparoscope and CO₂ insufflation at a continuous pressure of 12 mmHg. Alternatively, a dissecting balloon may be used to save time and facilitate the creation of the space, but this is not mandatory while it increases the cost of the procedure. Gentle side-to-side movements of the laparoscope are used to dissect the areolar tissue. The inferior epigastric vessels are clearly visualized laterally on the posterior surface of the rectus muscle, and special care is taken not to injure them to avoid an unpleasant intraoperative bleeding that may be difficult to control. The retropubic space of Retzius and the space of Bogros are easily expanded by the telescopic approach and under direct view a 5-mm working trocar is introduced in the midline, midway between the umbilicus and pubic symphysis. Thereafter, the preperitoneal space is widened by sharp and blunt dissection under direct view and a second working trocar is placed two finger breadths medially to the superior anterior iliac spine on the side of the hernia, thereby respecting the triangulation principle and allowing adequate lateral mesh placement. An alternative is to place both working trocars in the infraumbilical midline, a setup that allows bilateral inguinal repair with the same trocars, although it makes dissection more difficult due to the lack of triangulation. The lower border of the pubic bone and Cooper’s ligament should be exposed, noting the iliac vein and structures of the obturator foramen. This is the first anatomical landmark and appears as a white glistening structure (Figure 4). The space beyond the symphysis pubis is exposed for 2–3 cm to the obturator fossa, thus allowing the medial lower placement of the mesh. Extra care should be paid to avoid an injury in the urinary bladder. An injury to corona mortis at this stage should be avoided at all costs, as an intractable and uncontrollable hemorrhage may occur. Moving toward the anterior superior iliac spine in a surgical plane that is below the inferior epigastric vessels and above the peritoneum, the lateral dissection is made by pushing down the peritoneum until the psoas muscle can be seen. The space of Bogros is delineated and cleaned all the way up to the anterior superior iliac spine. Attention should be paid to avoid dissecting further laterally, in the so-called “triangle of pain.” This will prevent injury to the latero-cutaneous and genitofemoral nerves. Once the medial and lateral dissection is completed, the surgeon is able to identify the entire hernia defect, followed by a proper hernia sac reduction and repair.

Figure 3.

A Veress needle is initially inserted above the pubis in the midline in order to penetrate the linea alba. The needle enters the preperitoneal space and is inserted in the Retzius space, which is insufflated with 2 l of CO₂.

Figure 4.

Cooper’s ligament is the first anatomical landmark of our dissection and appears as a white glistening structure.

7.3 Dissection of hernial sac

The hernia sac is gradually dissected by gentle traction on the cord elements to identify and free the peritoneal sac from the spermatic cord, vas deferens, and spermatic vessels. It is useful to isolate the hernial sac from the spermatic cord close to the deep inguinal ring, approaching from the lateral side, and then mobilize it from the inguinal canal by blunt dissection [31]. A large hernia sac may be left reverted inside the peritoneal cavity without resection. However, it can also be divided at the deep ring; this is strongly recommended for larger lateral hernias as extensive dissection may result in scrotal edema and postoperative pain. Such a sac should be separated from the cord, ligated (i.e., with an endo-loop), and divided distal to the ligature leaving the distal part of the sac open. A direct hernia sac is easily dissected bluntly from the transversalis fascia by simple traction, inverted, and anchored to the Cooper’s ligament with a suture or a clip to prevent a seroma formation or a pseudo-recurrence. The peritoneum is pushed back as far as possible into the abdominal cavity. The anterior part of the psoas muscle, as well as the crossing of the iliac vein by the vas deferens, must be fully exposed [33]. Laterally, the peritoneal sac is mobilized posteriorly at least 5 cm from the inguinal ligament usually possible without sharp dissection. The cord should be completely skeletonized to the extent where the vas deferens is seen turning medially. This maneuver exposes the “triangle of Doom.” Dissection should be avoided within this triangle. A lipoma is often present in the inguinal canal and ideally should be resected or at least completely reduced. In case of bilateral hernias, the surgeon and camera assistant change sides and a similar dissection is performed on the opposite side (Figure 5).

Figure 5.

Indirect hernia sac dissection.

A lateral hernia is usually found in females, and in such cases, skeletonization of the round ligament may result in injury of the peritoneum. It is important to close all peritoneal holes with absorbable suture loops or clips to prevent any internal herniation or adhesion formation with the mesh. It is advisable that the round ligament should be divided at the level of the deep inguinal ring between clips because of the arteries within it.

The sac in femoral hernias is reduced by gentle traction with fenestrated forceps. Widening of the femoral defect by using a hook diathermy at its medial-superior aspect in cases of small-sized defects may be necessary to facilitate the hernia sac reduction. An obturator hernia sac may be reduced in the same manner by gentle traction.

7.4 Mesh preparation and placement

Once the anatomic elements are properly identified, including dissection of the peritoneum covering the floor of the anterior pelvic wall, the final step is the hernia repair, which is achieved by covering and reinforcing the entire myopectineal orifice with a suitable mesh. A preshaped 3-D anatomical mesh or a synthetic large-pore prosthesis at least 15 × 11 cm may be used. The ideal mesh should cover all areas of potential herniation, and it should cross the midline for at least 2–3 cm (Figure 6). Usually, a 15 × 11 cm mesh is appropriate for a patient with average body habitus. Large hernias will require even larger meshes of 15 × 15 cm. In cases of bilateral hernias, two meshes should be inserted overlapping each other in the midline for at least 3 cm. However, placement of only a large mesh seems a reasonable alternative, although not widely adopted.

Figure 6.

The ideal mesh should cover all areas of potential herniation, and it should cross the midline for at least 2–3 cm.

A “no-touch technique” is mandatory to avoid mesh infection. Changing glove before handling the mesh is a wise precaution. The mesh is rolled and introduced through the 10 mm umbilical trocar into the preperitoneal cavity avoiding any contact with the skin. The mesh is then placed horizontally and unrolled over the myopectineal orifice making sure to cover sufficiently all potential hernia sites in the inguinal region. One-third of the mesh should be below the symphysis pubis and the upper margin reaching the lower trocar medially. The mesh is placed in the preperiotneal space of Bogros and Retzius in such a way that the inferior edge of the mesh is on the psoas muscle and the lateral edge close to the anterior superior iliac spine, whereas the medial and inferior aspect of the mesh is placed under Cooper’s ligament. The inferior edge of the mesh covers the spermatic cord, the vas deferens, and the iliac vessels, while the superior aspect of the mesh is against the rectus and transversus abdominis muscles. It is important to make sure that no part of the peritoneum is under the mesh to prevent any recurrence.

Unlike TAPP, the mesh is usually placed without fixation, and after hemostasis has been achieved, the CO₂ is deflated under vision to ensure that the mesh is not rolled. Folds or wrinkles in the mesh should be avoided because they lead to increased scar or adhesion formation and can be the cause of chronic pain in the future [26]. The lateral inferior edge of the mesh can be held with a grasper, if necessary, especially in cases of bilateral hernias. However, many surgeons prefer to anchor the mesh, with means such as tackers, sealants, or sutures, to prevent mesh migration and associated recurrences. Fixation is usually done on Cooper’s ligament, medial to the inferior epigastric vessels at the rectus muscle and, if necessary, lateral to the inferior epigastric vessels (Figure 7). Placement of tackers below the iliopubic tract and too laterally considering should be avoided. However, in cases of large direct or femoral hernias, it is advisable to fix the inferior edge of the mesh, either with stapler or sutures, to the pectineal ligament to prevent any slippage into the defect. Drainage of the extraperitoneal space is required rarely, mainly after sharp dissection of adhesions in the surgical field. If carbon dioxide is trapped within the peritoneal cavity, it is evacuated with a Veress needle, inserted at Palmer’s point. The ports are then removed and the anterior rectus sheath incision at the 10-mm trocar site is sutured. Gas trapped in the scrotum can also be evacuated by gentle pressure on the scrotum to push the gas into the preperitoneal space and then evacuate through the umbilical port or with a small needle at the end of the procedure, if this is necessary. The skin incisions are then closed with sutures, clips, or glue.

Figure 7.

Fixation of the mesh on Cooper’s ligament with tackers.

8. Postoperative care

Totally extraperitoneal hernia repair is usually performed under general anesthesia and thus a postoperative surveillance for at least 3–5 h is mandatory before discharge, once voiding freely and if they are hemodynamically stable and normal. Analgesics such as paracetamol or non-steroidal anti-inflammatory drugs are given either through oral route or as rectal suppositories for 2–3 days, if necessary. Diet is resumed as tolerated. Generally, no restrictions are placed upon the patients, and they are allowed to resume physical activity and return to work as soon as their pain tolerance allows them to do so.

9. Complications

Serious intraoperative complications specific to ΤΕΡ are less frequent than with TAPP [30], occur in about 4–6% of the cases, and can be due to injury to vascular, visceral, nerve, and spermatic cord structures [34].

Vascular injuries would include injury to the external iliac vessels, inferior epigastric or spermatic vessels or the vessels over the pubic, arch including the corona mortis vessels. The most frequent cause of hemorrhage is injury of the epigastric vessels and their branches during extraperitoneal dissection and usually is controlled by clips and/or coagulation with bipolar shears. The lateral or anterior parietal perforating vessels may be controlled by coagulation. However, caution is required during electrocautery in the vicinity of nerves. Bleeding from corona mortis, which represents an anastomosis between the external iliac or the inferior epigastric and the obturator arteries, may occur during the medial dissection in approximately 1.5–2% of cases and results in significant bleeding that may lead to retroperitoneal hematoma, conversion to open or reoperation [35]. The iliac vein can be mistaken for an irreducible hernia and injured, thus necessitating conversion to laparotomy. Injury to the major vessels is catastrophic, a correct lateral traction of the sac and spermatic structure with medial approach may be helpful in avoiding it. Α careful practice should be used when retracting or dissecting closer to the “triangle of doom.”

Previous lower abdominal surgery poses a risk to injuries of the urinary bladder especially during midline adhesiolysis. The incidence of such a complication is reported to be less than 0.3% [36]. When identified, should be repaired endoscopically and a urinary catheter should be left in the bladder for a week [31]. This type of injury is not an absolute contraindication for mesh implantation.

Bowel injuries may occur during reduction of irreducible hernias or lateral adhesiolysis or as a result of transmitted energy through the thin peritoneal layer. It is mandatory to detect and manage them intraoperatively.

Nerve injuries, usually of the genitofemoral nerve and/or lateral cutaneous nerve of the thigh, and the intermediate cutaneous branch of the femoral nerve occur intraoperatively due to entrapment of the nerve when tacks are used to fix the mesh, thermal injury caused by excessive use of electrocoagulation or irritation caused directly by the mesh. This type of injuries become apparent postoperatively resulting in neuralgia, usually transient. To minimize the incidence of these injuries, one should maintain the correct plane of dissection, which means that the fascia over the psoas muscle should stay intact and the mesh should only be fixed medially, avoiding the “triangle of pain.” Knowledge of the groin anatomy is of paramount importance in avoiding nerve injury. Immediate postoperative neuralgia should ideally be managed by re-exploration and removal of the offending tack or piece of mesh. Symptoms of nerve injury usually resolve within 8 weeks. Chronic pain, defined as pain that persists after 3 months, may require prolonged injections with local anesthetic and corticosteroids and rehabilitation and in most severe cases exploration and removal of tacks or a neurectomy [37].

Peritoneal tears may occur in up to 47% of cases [38], resulting in pneumoperitoneum, which diminishes the working space and increases the difficulty of the procedure. Small holes do not need to be repaired. In case of an inadvertent opening of the peritoneum, the pressure drops but the operation usually can go on, if a Verres needle or an intraperitoneal trocar fitted with a valve is required to balance the pressures. If a balance cannot be obtained, the peritoneal opening must be closed with a suture or a clip. The peritoneal repair must be performed either during or at the end of surgery [26, 33].

Seroma and hematoma are the commonest complications following any type of hernia repair. Seroma has a reported incidence of 5–7% after laparoscopic repair, while the incidence of hematoma is around 8%. This, in fact, may mimic a recurrence, but resolves in 90% of patients by 6 weeks. These collections should not be aspirated or drained without obvious signs of infection, unless they cause discomfort and pain, especially if they persist more than 6 weeks, and it appears that they are not resolving. Aspiration should be performed under strict aseptic conditions and may be repeated 2–3 times. Physical examination alone usually establishes the diagnosis and no further imaging modalities are necessary. Careful dissection and hemostasis can help to reduce the incidence of postoperative hematoma [39]. It is important to counsel the patients regarding this complication to avoid fear and unnecessary visits to the emergency department and/or unnecessary imaging studies [39, 40].

Recurrence is one of the most important outcomes of hernia repair. Well-defined parameters that contribute to recurrence are surgeon inexperience, inadequate dissection of the myopectineal orifice, inadequate fixation of the mesh, insufficient mesh size, and failure to cover unidentified hernia defects, mesh folding that allows peritoneal slippage and mesh dislodgement secondary to hematoma formation [34]. There is no evidence that fixation of the mesh affects recurrence rates. A crucial step in preventing recurrence is creating a space wide enough for the mesh to overlap all possible sites of herniation with complete coverage of the myopectineal orifice.

10. Conclusions

Several trials and meta-analyses have shown that TEP is a procedure that carries an acceptable low complication rate and low recurrence rate with the advantages of minimally invasive surgery, when performed by experienced surgeons. Thus, it is associated with reduced postoperative pain, less need for postoperative analgesia, earlier resume of physical activities, and fewer recurrences in comparison to open inguinal hernia repair [31]. These benefits will be exaggerated when the laparoendoscopic technique is implemented in cases of bilateral or recurrent hernias. However, we should take into account that careful patient selection, precise knowledge of the anatomy, an adequate surgical technique, and the surgeon’s experience and expertise are the cornerstones of the best clinical outcome with low morbidity. In such a way laparoendoscopic inguinal hernia repair is the procedure of choice for the management of primary and the vast majority of recurrent inguinal hernias.

Conflict of interest

Dr. Ioannis Triantafyllidis declares no conflict of interest.

Abbreviations

TAPP	transabdominal preperitoneal approach
TEP	totally extraperitoneal approach