Inguinal hernia repair using TEP technique

1 cm long skin incision below the navel. Separate the adipose tissue with Langenbeck hooks and expose the fascia or anterior rectus sheath. This is incised with the scalpel on the side to be treated or, in the case of a bilateral hernia as in the example, on the side of the larger hernia, paramedian over a length of approximately 1 cm. The medial edge of the fascia is grasped with a sharp clamp. Using a Langenbeck hook, the medial rectus muscle is lifted anteriorly and laterally, thus exposing the posterior layer of the rectus sheath.

Tip: With a precisely median incision of the fascia, one enters directly into the abdomen and not into the rectus sheath. The fascia must then be closed again and incised further laterally!

A long preparation swab is advanced on the posterior leaf towards the symphysis and the preperitoneal space is bluntly dissected up to the retropubic area. Then, a 10mm trocar is inserted and CO2 gas is applied with pressures between 10 – 15 mmHg. The camera optics are introduced. Under visual control, a 5mm trocar is now inserted in the midline exactly between the navel and the symphysis.

Tip: Before inserting the 5mm trocar, pay attention to the epigastric vessels, which are usually visible. Use trocars with a locking mechanism, as they otherwise slip and significantly complicate the preparation!

Through the 5mm trocar, the extraperitoneal space is now mainly bluntly opened with scissors. To do this, begin retrosymphysially and push the tissue from the back of the pubic bone towards the bladder in a ventral to dorsal motion. Small crossing vessels can be coagulated. The retropubic space must be opened below the symphysis.

Subsequently, dissection is performed laterally in the same manner until the lateral boundary of the rectus sheath appears. This is now incised in tiny steps with scissors until the level of the anterior superior iliac spine is reached. Approximately 3cm above the spine, the second 5mm trocar is inserted under vision.

Tip: The lateral edge of the rectus sheath should be sharply incised as far ventrally as possible, otherwise, you may enter the abdomen directly!

From now on, use a dissector and fine grasping forceps through the two 5mm trocars. By applying traction and countertraction, a thorough blunt dissection of the preperitoneal space is achieved. A small indirect hernia sac is found lateral to the epigastric vessels within the spermatic cord.
The hernia sac is bluntly separated from the spermatic cord structures by traction and countertraction and, together with the peritoneum, pushed dorsally as far as possible. Preperitoneal lipomas can be managed in the same way. 

Note 1: A lipoma in the inguinal canal must be dissected out in any case to prevent chronic pain.

Note 2: The hernia sac should be dissected out of the inguinal canal as completely as possible to avoid a postoperative seroma.

Note 2: Lateral to the spermatic cord, there are many lymph nodes. In an unnecessary dissection here by the inexperienced, it can lead to bleeding that is difficult to control!