Laparoscopic Total Extraperitoneal
Inguinal Hernia Repair
Bruce Ramshaw, MD, FACS
T he laparoscopic approach for inguinal hernia repair
was first reported by Ger, who performed a high liga-
tion of the sac without mesh placement.1 In the early
1990s, a variety of trans-abdominal laparoscopic ap-
proaches were reported, with the trans-abdominal pre-
peritoneal (TAPP) approach and the intraperitoneal onlay
mesh (IPOM) techniques being the most common. Be-
cause of reports of high recurrence rates, the IPOM tech-
nique quickly fell out of favor. In 1993 the laparoscopic
total extraperitoneal (TEP) approach was reported by
McKernan.2 The TEP approach allows for mesh placement
within the preperitoneal space, without entering the ab-
dominal cavity. Another benefit of this approach is the
avoidance of the incision and closure of the peritoneum
typically required in the TAPP approach.
I had the fortune of being a resident in Atlanta in 1993,
allowing me to travel only a few miles to watch Barry Mc-
Kernan perform several laparoscopic TEP hernia repairs.
With the help of fellow residents and my attendings, we
integrated this technique into all general surgery practices at
Georgia Baptist Medical Center that year. Because it is an
extremely difficult procedure to learn, it was advantageous to
have over 10 surgeons helping each other learn the tech-
nique. On completing residency, the laparoscopic TEP ap-
proach became my procedure of choice for essentially all
inguinal hernia repairs in my practice. Contraindications for
performing the TEP technique include age (prepubertal chil-
dren) and the inability to tolerate general or regional anes-
thesia. Relative contraindications include large scrotal her-
nias, previous lower midline abdominal surgery, and
previous mesh placement in the preperitoneal space. I cur-
rently use a TAPP approach without reperitonealization, us-
ing mesh designed for intraabdominal placement, in these
patients.
The primary barrier to performing a successful laparo-
scopic TEP inguinal hernia repair is the difficulty associated
with learning the technique. Once mastered, the repair can
be performed faster, with better visualization and wider mesh
Division of General Surgery, University of Missouri Hospital & Clinics, One
Hospital Drive, MC414 McHaney Hall, Columbia, MO.
Address reprint requests to Bruce Ramshaw, MD FACS, Associate Professor
of Surgery, Chief, Division of General Surgery, University of Missouri
Hospital & Clinics, One Hospital Drive, MC414 McHaney Hall, Colum-
bia, MO 65212. E-mail: ramshawb@health.missouri.edu
34 1524-153X/06/$-see front matter © 2006 Elsevier Inc. All rights reserved.
doi:10.1053/j.optechgensurg.2006.04.007
coverage than the commonly performed open tension-free
inguinal hernia repairs, especially for bilateral and recurrent
hernias. There are several barriers to learning the technique.
First, access to the extraperitoneal space through a small
infra-umbilical incision is not something a general surgeon
has typically done. The extraperitoneal dissection of the
lower abdomen, exposing the myopectineal orifice bilater-
ally, can be a daunting task. Balloon dissectors can signifi-
cantly help a surgeon perform a safe, consistent extraperito-
neal dissection, especially early in the learning curve.
However, even with the balloon, accidental placement into
the subcutaneous tissue, within the rectus muscle and inside
the abdominal cavity has occurred. A laparoscopic view
through the balloon helps ensure that it has been placed in
the correct space. Usually, the pubis and Cooper’s ligament
are the first structures visualized when the balloon is placed
correctly. However, even when placed in the correct space,
inflation of the balloon can injure the bowel or bladder, es-
pecially in patients with previous lower abdominal surgery.
Directing the balloon more laterally toward the side of the
defect and inflating it less than usual can minimize the like-
lihood of injury in these patients, including those who have
undergone previous open prostatectomy.
Another barrier is the variability of the initial presentation
of the anatomy. Significant preperitoneal fat, presence of an
unreduced direct hernia, bleeding from the balloon dissec-
tion, and previous lower abdominal surgery, can obscure the
anatomy. Probably the most dangerous portion of the oper-
ation is the lateral dissection, where dissecting too far poste-
riorly can increase the risk of inadvertent iliac vessel injury.
To minimize this dangerous complication, lateral dissection
should be done near the anterior extraperitoneal plane, just
posterior to the rectus muscle and inferior epigastric vessels.
All structures posterior and lateral to the epigastric vessels
should be carefully dissected posteriorly and medially to
open up the lateral extraperitoneal space.
Probably the most difficult dissection, even in experienced
hands, is the reduction of a chronic, large indirect sac that is
often adherent to the cord and surrounding structures. Re-
duction of the indirect sac can add several minutes to the
procedure in experienced hands, and may necessitate con-
version to an open approach for the surgeon early in the
learning curve. Another barrier to learning the operation is
the mesh manipulation. Manipulating and orienting a large
mesh in a relatively small space can be challenging.
Laparoscopic total extraperitoneal inguinal hernia repair 35

Operative Technique

Figure 1 (A–C) The skin incision is made at

the inferior aspect of the umbilicus. Dissec-
tion is carried down to the anterior fascia of
the rectus muscle just lateral to the midline.
If the incision is made away from the hernia,
there will be less dissection of that groin by
the balloon (more dissection in the ipsilat-
eral groin). However, there will be more
room to work because the 10 mm trocar and
scope will be farther away from the groin
with the hernia defect. If the hernia is bilat-
eral, I usually place the incision on the side
away from the larger hernia defect, to allow
more room to work there. If, however, there
is previous lower abdominal surgery on one
side or the other (a previous RLQ appy scar
for example), I will direct the balloon to the
contralateral side, away from the previous
scar to minimize the chance of tearing the
peritoneum. (Color version of figure appears
online.)
36 B. Ramshaw

Figure 2 (A–D) Following the anterior fascia incision, I use my finger to sweep the rectus muscle off the posterior fascia
from the midline. This is important to ensure proper balloon dissector placement. If this space cannot be entered, or if
the peritoneum is injured, the same dissection may be performed on the contralateral side. There are advantages and
disadvantages of placing the balloon dissector on the side of the hernia. The dissection is better; however, the balloon
may dissect the inferior epigastrics off the anterior abdominal wall, making the repair more difficult. Also, with the
laparoscope closer to the ipsilateral groin, there is a smaller space in which to work. (Color version of figure appears
online.)
Laparoscopic total extraperitoneal inguinal hernia repair 37

Figure 3 (A–C) The balloon dissector is placed in the space between rectus muscle and posterior fascia, and directed
down to the pubis. The canula is removed and the zero degree, 10 mm laparoscope is used. The dissector is inflated
while the space is viewed laparoscopically. The pubis and Cooper’s ligaments should be identified as well as rectus
muscle fibers, which are seen anteriorly, not posteriorly, through the balloon. After appropriately dissecting the
preperitoneum, the balloon is left in place briefly for tamponade and then deflated and removed. (Color version of
figure appears online.)

Figure 4 A 10 mm balloon tip or other Hassan type trocar is placed, and

the extraperitoneal space is insufflated to a maximum pressure of 10 to
12 mmHg. Two 5 mm trocars are placed in the low midline between the
rectus muscles. I usually place the first trocar about one finger breadth
above the pubis and the final trocar halfway between the end of the 10
mm trocar and the suprapubic 5 mm trocar. (Color version of figure
appears online.)
38 B. Ramshaw

Figure 5 (A–D) Medial dissection is usually accomplished by the balloon dissector. However, an unreduced direct
hernia will obscure the medial anatomy. Careful reduction of the hernia sac and counter traction of the weakened
transversalis fascia with graspers will allow for complete reduction and exposure of the medial anatomy. Hernias may
also be reduced from the femoral space, between the iliopubic tract and Cooper’s ligament, and the obturator space,
posterior to Cooper’s ligament. (Color version of figure appears online.)
Laparoscopic total extraperitoneal inguinal hernia repair 39

Figure 5 Continued
40 B. Ramshaw

Figure 6 (A,B) The lateral anatomy is usually not exposed by the balloon dissection and it is important to attempt to
identify inferior epigastic vessels to guide initial lateral dissection. The vessels should be retracted anteriorly and all cord
contents should be carefully dissected off of the anterior and lateral abdominal wall to expose the lateral anatomy. The
transversus arch fibers join the iliopubic tract to form the lateral border of the indirect space. The iliopubic tract travels
laterally, parallel and deep to the inguinal ligament. The cutaneus nerves (lateral femoral cutaneous, femoral branch of
the genitofemoral and their branches) usually travel on the psoas muscle and leave the extraperitoneal space at or near
the level of the iliopubic tract. For this reason, fixation lateral to the cord and posterior to iliopubic tract is avoided.
However, it is possible, because of previous surgery or anatomic anomaly, for nerves to course anterior to the iliopubic
tract. Therefore, fixation anterior to the iliopubic tract should be approached with caution. (Color version of figure
appears online.)
Laparoscopic total extraperitoneal inguinal hernia repair 41

Figure 7 (A,B) Once the lateral dissection is complete, the cord is explored for an indirect sac and/or a lipoma of the
cord. The indirect hernia sac will usually be located on the anteriomedial portion of the cord and may be more difficult
to reduce than a direct hernia. A lipoma of the cord is usually found at the end of the sac anteriolaterally on the cord.
Fatty tissue within the cord vessels or fat posterior to the iliopubic tract will bleed if grasped and reduced, but a lipoma
of the cord will usually reduce easily from the internal ring, with minimal or no bleeding. (Color version of figure
appears online.)
42 B. Ramshaw

Figure 8 The vas deferans lies posteriomedially and the vessels lie on the psoas muscle posteriolaterally. They join at the
internal ring and form a triangle (with the peritoneal reflection forming its base) called the triangle of doom, where the
iliac vessels are found posteriorly. Posteriolaterally, the peritoneal reflection should be taken back to the level of the
umbilicus by gently peeling the peritoneum off the cord structures, psoas muscle, and lateral abdominal wall. Medially,
the peritoneum should be dissected off the iliac vein and obturator foramen. Sometimes, a plug of preperitoneal fatty
tissue may be reduced from the obturator space. This dissection will allow for appropriate placement of a large mesh
and minimize the chance of herniation around the mesh edges. (Color version of figure appears online.)
Laparoscopic total extraperitoneal inguinal hernia repair 43

Figure 9 (A,B) With the TEP technique for inguinal hernia repair, there are traditionally two types of mesh preparation: a mesh with
a slit or a mesh without a slit. The mesh that is slit is passed around the cord allowing the cord to hold the mesh down posteriorly,
preventing herniation at the posterior edge of the mesh. The slit should be overlapped and fixed, attempting to prevent herniation
through the mesh slit. If the mesh is not slit it is very important to make sure that the peritoneum does not protrude under the mesh
with the cord. To avoid recurrence, the peritoneum is dissected to the level of the umbilicus, and the posterior edge of the mesh is
held down with a grasper during deflation of the extraperitoneal space. There are now newer meshes with different shapes and
designs, adapted for laparoscopic inguinal hernia repair. I currently use a mesh that is shaped to conform to the preperitoneal
inguinal anatomy. It has a posterior flap with a velcro-like patch that is placed behind the cord. Another flap is then placed anterior
to the cord and fixed to the velcro-like patch to provide fixation posteriolaterally where point fixation devices cannot be used. This
mesh was designed to minimize the chance of herniation through a slit in the mesh, or from under the posterior edge of mesh. Other
potential solutions include using an additional piece of mesh to completely cover the slit if a slit mesh is used or using a glue to fix
the mesh posteriolaterally if a mesh without a slit is used. I continue to use minimal point fixation because of the possibility of mesh
contraction or migration, and/or folding that may occur with any type of mesh material. Multiple animal studies appear to show that
heavyweight polypropylene mesh is more likely to contract than polyester or lightweight polypropylene. I usually use three points
of fixation in addition to the velcro-like fixation posteriolaterally. One is at the superiolateral corner of the mesh. This corner is
located at the lateral abdominal wall above the iliac crest at the level of the umbilicus, well away from the nerves at risk for injury. The
other two points of fixation are medial, to Cooper’s ligament posteriorly and anteriorly to the lower rectus muscle. For bilateral
hernias, the mesh should overlap at the midline and the mesh overlap is fixed in two areas, one near the pubis and one at the lower
rectus muscles. The mesh should cover all hernia and potential hernia defects and widely cover the myopectineal orifice. It is fixed
well away from the nerves. (Color version of figure appears online.)
44
Summary
The patient is usually able to go home on the day of surgery
and is allowed to return to activity as tolerated. A prescription
for pain medicine is given to the patient and the patient is
usually able to switch to antiinflammatories in the first few
days. Bruising and swelling of the groin, penis, and scrotum
is not uncommon and ice and/or a jockstrap may be used for
comfort. Urinary retention in the first 24 hours and consti-
pation in the first few days are also possible and management
strategies should be discussed with the patient. Significant
wound and mesh complications are extremely rare with the
laparoscopic TEP inguinal hernia repair. Drainage from the
10 mm incision is the most common wound complication
and usually only requires a dry dressing. After the repair of
large hernias, seromas, and/or hematomas are possible as a
result of serous fluid and/or blood collection in the space
created by the hernia reduction. The patient should be edu-
cated and forewarned of this possibility and told that usually
B. Ramshaw
no treatment is required. Rarely, aspiration may be consid-
ered if there are significant symptoms.
In conclusion, the total extraperitoneal approach for lapa-
roscopic inguinal hernia repair can be utilized for almost all
adult inguinal hernias. The ability to visualize the entire groin
bilaterally, widely cover the myopectoneal orifice, and se-
curely fix the mesh to healthy abdominal wall tissue away
from nerves will result in a highly effective repair.
Acknowledgments
The author thanks Bill Winn (Medical Illustrator) and Brandy
Stockton (Administrative Assistant).
References
1. Ger R, Monroe K, Duvivier R, Mishrick A: Management of indirect in-
guinal hernias by laparoscopic closure of the neck of the sac. Am J Surg
159:370-373, 1990
2. McKernan JB, Laws HL: Laparoscopic repair of inguinal hernias using a
totally extraperitoneal prosthetic approach. Surg Endosc 7:26-28, 1993