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

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

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

Standard laparoscopic equipment consisting of a camera, a monitor, a light and an insuflator

• Atraumatic clamps, endodissectors, endoscissors, endohooks, endoclapms, endoaspirators

A single dose of 1 g second-generation cephalosporin as prophylactic antibiotic is injected half an hour before the onset of operation. The patient should urinate before operation and pre-operatory fluid resuscitation should be kept to a minimum. With general anesthesia, the operation starts in supine position. In method of TEP, the patient should be wider painted than the TAPP technique, from the nipple to the perineum. Infraumbilical, slightly lateralized incision is made on the hernia side and then the rectus sheath is opened by transverse incision. Rectus fibers are removed with Farabeuf retractor and blunt dissection is performed to reach the Bogros area. A tunnel is made between umbilicus to pubis. In front of this tunnel, there is a parietal peritoneum from the back of the rectus muscle and from the end of this fascia to the transverse course of the linea semilunaris. After blunt dissection and cannula is completely inserted from the preperitoneal tunnel to the pubis, it is removed from the trocar cannula and replaced with a telescope, and the cannula is inflated with a balloon attached to the mandrel. Air is discharged 20–25 times with puar after waiting for 30 s and this process is repeated three times. With some balloons, it is possible to view inside with scope as it inflates. It can also be monitored whether the definite surgical area is viewed during this observation. Upper view of rectus fibrils and lower view of parietal peritoneum indicates the

both men and women.

**9.2. Surgical supplies**

• 10 mm diameter balloon trocar

• 5 mm diameter vessel sealing device

**9.1. Operating room layout**

82 Hernia Surgery and Recent Developments

assistant to sit on the same side of the surgeon.

• Laparoscope with a diameter of 10 mm and a 30° angle

• 15 × 15 cm polypropylene or polyester special shaped patch

**9.3. Preparation of the patient, application of extraperitoneal trocars**

• Fixation material (mechanical staple or tissue adhesive)

• A 10 mm, two 5 mm diameter, totally 3 trocars

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

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

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

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

**Figure 8.** Potential hernia areas for TEP procedure.

from the top and laid to the extraperitoneal space by the 10 mm camera trocars. With the help of two endograspers placed in the working ports, the patch is unfolded in the opposite direction and is laid to cover the existing hernia defect and potential hernia areas. It should be ensured that the area where the patch is applied covers it with a proper tension. When a limb patch is applied, the lower limb is passed under the spermatic cord and it is wrapped in a tie and is laterally joined to the lower limb (**Figure 9**). The lower edge of the patch is placed so that it remains at least 2 cm above the released hernia sheath. The locations and numbers are very important if the absorbable staple is preferred for the detection of the mesh. The basic rule, with different suggestions about this, is that the mesh must be placed on the ileo-pubic tract. We prefer to fix it with a total of two absorptive staples, one medially to the Cooper ligament and one to the back of the transverse fascia laterally. On the lateral edge of the spermatic cord there are anatomical areas defined as the triangle of pain mentioned above and the death triangle at the medial border. Staples must be avoided in these areas. Tissue adhesives have also been used today as fixing material. The use of drains varies according to experience and habits. We routinely use aspirative drain after TEP.

**10. Pitfalls**

**Figure 9.** After mesh fixation.

**10.1. TAPP**

In this chapter, details take place as noted; details in current practice are given while applying the laparoscopic hernia repair. The points to be considered are evaluated for both techniques.

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• As all laparoscopic operations, the first point to note in laparoscopic hernia surgery is trocar entry sites. Correct positioning of the appropriate points will prevent intestinal injuries that may occur at the time of first entry and bleeding which may be caused by the injury of

• A complete exploration should be done in terms of hernia type, size, presence of accompa-

• Taking enough width for dissection during the preparation of the peritoneal flap will ensure that the exploration area is convenient. Working on a sufficient width of dissection will facilitate the spread of the patch, the adequate closure of the hernia defect and the

• A very careful dissection should be performed in order to avoid damage to the spermatic cord structures, especially in the presence of indirect hernia, when the hernia incision is

nying incarceration and other pathologies in intraabdominal exploration.

In addition, the difficulties faced by the surgeon are itemized.

the abdominal wall, especially the epigastric vessels.

operator's work during the detection of the patch.

#### **9.6. Postoperative care**

Oral intake can be started a few hours after surgery and the patient is mobilized the same evening. The following day the patient can be discharged by removal of the drain. There is no need to regulate postoperative medical treatment other than oral analgesics.

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**Figure 9.** After mesh fixation.
