1
Asoc. Prof.Dr. Orhan Yalçın
Ministry of Health Okmeydanı Education and Research Hospital
İstanbul / Turkey

2

3
There are three techniques
1- Intra peritoneal only mesh ( IPOM )
2- Trans abdominal pre peritoneal ( TAPP )
3- Totally extra peritoneal ( TEP )
In all techniques, three trocars are used.

4
IPOM TECHNIQUE
One from umbilicus
Other two trocars , lateral to rectus muscles
Mesh is placed to overlap the defect
Fixed with tacks, sutures or combination
It is not used in routine practice

5
TAPP TECHNIQUE
Trocar sites are same for IPOM
Periton is incised 2 cm above to hernia defect at the medial umbilical ligament and peritoneal flaps are created
Dissection of hernia sac
Placement of mesh
Closure of peritoneum
In TAPP and TEP, dissection area and mesh placement area the same. Difference is “ to approach to the pre peritoneal area”

TEP TECHNIQUE
Trocar position : There are two techniques
1.
Umbilicus ( 10 mm )
Above the pubic arch ( 5 mm )
Midway between two trocars ( 5 mm)
2.
Umbilicus ( 10 mm )
Above the pubic arch ( 5 mm )
Medial to anterior superior iliac spine or the side of hernia (5 mm )
6

TEP –CONT.
A- First trocar is applied in a plane between posterior surface of rectus muscle and posterior rectus sheath and peritoneum with balloon – preperitoneal retzius area are dissected
B- Second and third trocars are inserted
C-
1- First landmark is pubic bone and Cooper ligament
2- Medially direct hernia reduction
3- Laterally indirect hernia sac: superio-laterally from spermatic vessels. Medially vas deferens is dissected.
7

TEP CONT.
Cord parietalization to a point that crosses iliac vessels
Preperitoneal dissection should be so big that “ When preperitoneal area is closed, prosthesis should lie flat in the preperitoneal space and should not roll up.”
D- Placement of mesh ( 12 x 15 cm polypropilen, polyester from umbilical port )
E- Fixation with tacks, staples, biologic glue. Fixation should be applied superior to iliopectineal ligament.
8

Advantages
-Minimal dissection
-Minimal postoperative pain
Disadvantages
-Risk of bowel injury
-Adhesive complications or herniations
9

10
Advantages
Easier to learn, anatomy is more familiar for the surgen.
The work space is larger than TEP
Allows to see the hernia sac contents
Disadvantages
Potential intra abdominal injury risk
More time consuming than TEP
Potential adhesive complication at where peritoneum has been closed

11
ADVANTAGES
-reduced risk of potential intra abdominal injury
-reduced risk of adhesive complications
-operation time is less than TAPP
DISADVANTAGES
-learning curve is longer than TAPP
-the working space is limited
- inadvertently peritoneum can be torn.

12
TAPP preference
- Recurrence after TEP
Patients in who had radical prostatectomy operation
Patients who has midline incision for major surgery
In the absence of this two conditions TEP is preferred technique.

Absolute
Infection
Coagulopathy
In whom general anesthesia has increased risk
Relative
Previous surgery in Retzius space
Incarcerated sliding scrotal hernia
13

14