**9. Laparoscopic total extraperitonal approach**

Despite discussions about the use of laparoscopy in the repair of primary unilateral groin hernias, the superiority of TEP in bilateral or recurrent hernias is accepted. The major advantages of this method are that it is extraperitoneal and there is no break in peritoneum. The dominance of the anatomy of the posterior wall is not as good as TAPP, but sufficient parietalization is possible with TEP. Nowadays it becomes the first choice especially for athletes both men and women.

right position. A 10 mm trocar is placed in the infraumbilical incision to prevent gas leakage and the telescope is placed. The preperitoneal space is inflated with 10–12 mmHg CO<sup>2</sup>

Laparoscopic Inguinal Hernia Repair: Technical Details, Pitfalls and Current Results

http://dx.doi.org/10.5772/intechopen.76942

After the 30° camera is inserted, the inferior epigastric artery and vein are observed along the bottom of the rectus muscle. The parietal peritoneum is dissected in the medial and lateral directions to remain underneath. The Cooper ligament is visible in the inferomedial area and it is removed. The lateral aspect of the rectus is up to the border of the crista iliaca and the fascia transversalis is opened with blunt and sharp dissections posteriorly. The potential hernia areas are examined and the hernia type is determined (**Figure 8**). In the indirect inguinal hernia, the hernia sac is found adhered to the spermatic cord. The hernia sac should be dissected from the pubic tuberculum to the level of the external iliac vein. Large scrotal or indirect hernia may be released by Zig technique if it is confirmed that the hernia sac does not contain omentum or intestinal contents. The anatomic regions described as Femoral and Hasselbach triangles should be examined in terms of direct and femoral hernia that may be accompanied. The ililopubic tract must be detected not to injure the femoral and lateral femoral cutaneous nerves of the underlying genitofemoral nerve. The lateral dissection does not need to be as wide as the TAPP technique. The hernia sac should be gently released and reduced from the spermatic cord and cremaster fibers. If the peritoneum is wounded during the dissection procedure, the defect can be closed with a clip. If gas insufflation flows through the gap to the peritoneal defect, the enlarged abdomen will restrict the area of dissection. In order to prevent this, intraperitoneal air could be taken out from the upper left quadrant of the midclavicular line through the abdominal cavity (Palmer's point) with Veress needle. The valve is left open,

5 mm ports are placed at a distance of 5 cm from the midline in direct view (**Figure 7**).

**9.4. The dissection of extraperitoneal area and herniated sac**

the evacuation of the gas is provided and the operation can be continued.

Special shaped 15 × 15 cm polypropylene or polyester patch can be used according to the anatomy of the patient. The patch can be prepared with limb or without limb. It is rolled up

**9.5. Preparation, placement and detection of the mesh patch**

**Figure 7.** Trocar placement for TEP procedure.

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#### **9.1. Operating room layout**

The opposite side of the surgical field and both legs are in closed position. In bilateral hernia repair, both arms are in closed position. The videomonitor laparoscopy tower is placed on the patient's foot, on the side to be operated. The operator can be placed on the opposite side of the area to be operated and the camera assistant can be placed on the same side or opposite side of the surgeon depending on the experience and habits of the team. We prefer the camera assistant to sit on the same side of the surgeon.
