1. INGUINAL HERNIA REPAIR: OPEN vs TEP APPROACHES
Prof Dr Orhan Alimoğlu
Department of General Surgery
Istanbul Medeniyet University

2. 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

3. General Precautions
No place for routine antibiotic and thromboembolic prophylaxis, only in selected patients
Risk factors for wound and mesh infection
Advanced age
Corticosteroid use
Immunosuppression
Obesity
Diabetes
Malignancy

4. Characteristics of mesh
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

5. 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

6. Advantages Every type of inguinal hernia Local anesthesia
Easy to learn and perform
Low rate of recurrence
Gold standard?

7. Disadvantages Postoperative chronic pain Return to daily activity
Higher than TEP or TAPP ?
Return to daily activity
Later than TEP or TAPP ?

8. 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

10. 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

15. Dissection and Landmarks
Superior
Subumblical area
Inferior
Space of Retzius
Inferolateral
Psoas muscle and Bogros space
Medial
Beyond midline
Pubic bone
Cooper’s ligament
Inferior epigastric vessels
Cord structures
Myopectineal orifice boundaries
Fascia over psoas muscle

19. 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

20. 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

21. 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)

23. Advantages of TEP repair
Early return to daily activities
Low rate of postoperative chronic pain
Exploration of contralateral side for hidden hernias ?

24. 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

25. 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