INGUINAL HERNIA REPAIR:
OPEN vs TEP APPROACHES
Prof Dr Orhan Alimoğlu
Department of General Surgery
Istanbul Medeniyet University
Inguinal hernia
• One of the most common surgical problem in
daily practice
• Different operations and approaches
• Gold standard: repair with mesh
• Currently
– Lichtenstein hernia repair
– Endoscopic totally extra-peritoneal (TEP) repair
– Laparoscopic trans-abdominal preperitoneal
(TAPP) repair
General Precautions
• No place for routine antibiotic and
thromboembolic prophylaxis, only in selected
patients
• Risk factors for wound and mesh infection
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Advanced age
Corticosteroid use
Immunosuppression
Obesity
Diabetes
Malignancy
Characteristics of mesh
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Large vs small
Low-weight vs heavy weight
Micropore vs macropore
Conclusion: Efficiency of lighter mesh with
larger pores only during the first few
postoperative weeks
Lichtenstein Inguinal Hernia Repair
• Large mesh (7*15 cm)
– 2 cm medial to the pubic tubercle, 3–4 cm above the
Hesselbach’s triangle, and 5–6 cm lateral to the internal
ring, trimming 3–4 cm from its lateral side
• Crossing and suturing tails of mesh behind spermatic
cord
• Securing mesh with two interrupted sutures on upper
edge and one continuous suture with no more than
three to four passes on lower edge of mesh
• Keeping mesh with a slightly relaxed, tented up, or
dome-shaped configuration
• Identification and protection of the ilioinguinal,
iliohypogastric, and genital nerves
Advantages
•
•
•
•
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Every type of inguinal hernia
Local anesthesia
Easy to learn and perform
Low rate of recurrence
Gold standard?
Disadvantages
• Postoperative chronic pain
– Higher than TEP or TAPP ?
• Return to daily activity
– Later than TEP or TAPP ?
TEP Inguinal Hernia Repair
• Technique
– Trocars
• Direct access of one subumblical 10 mm and two 5 mm
at the midline
– Preperitoneal dissection
– Dissection of hernial sac
– Parietalization of spermatic cord and its content
– Placement of mesh
Technical difficulties
• Preperitoneal space creation
– Baloon dissection in early learning curve besides
its cost
• Peritoneal injury
– Loss of exposure
– Closure of defect via pretied suture, loop ligation,
endoscopic stapling or endoscopic suturing
• Port-site closure
– Closure of fascial defects larger than 10 mm
Dissection and Landmarks
• Superior
• Pubic bone
– Subumblical area
• Cooper’s ligament
• Inferior
• Inferior epigastric
– Space of Retzius
vessels
• Inferolateral
• Cord structures
– Psoas muscle and Bogros • Myopectineal orifice
space
boundaries
• Medial
• Fascia over psoas
– Beyond midline
muscle
Controversies
• Preoperative urinary catheterization
– Preoperative emptying of urinary bladder by
him/herself
– Catheterization in difficult and long-standing
surgery
• Access for pneumopreperitoneum
– Subumblical direct trocar vs suprapubic Veress
Technical Key Points
• Inversion and anchoring of direct sac to
Cooper’s ligament to decrease risk of seroma
and hematoma formation
• Proximal ligation and distal division of large
indirect hernia sac
• Drains only in selected patients
• Fixation of mesh in hernias greater than 4 cm
Recommendations
• Larger mesh (12*17 cm) in larger hernia (>3-4
cm)
• Stapled fixation of mesh to the symphysis,
Cooper’s ligament and rectus muscle in larger
direct hernia (>3-4 cm)
• Overlapping of mesh approximately 1-3 cm
lateral to the spina iliaca anterior superior in
large indirect hernias (>4-5)
Advantages of TEP repair
• Early return to daily activities
• Low rate of postoperative chronic pain
• Exploration of contralateral side for hidden
hernias ?
Disadvantages of TEP repair
• General anesthesia; regional anesthesia in
selected patients
• Longer learning curve
– At least 50 to 60 cases
• Applicability on incarcerated and scrotal
hernias
• Applicability on patients with previous lower
abdominal surgery
Learning Curve for TEP repair
• Can J Surg, 2012, 55: 33-6
– 700 patients
– Learning curve after the first 60 cases
• A plateau of less than 30 min for duration of surgery
• A plateau of 1 day for length of stay
• Conclusion: learning curve for TEP hernia
repair as 60 cases for a beginner surgeon