Laparoscopic totally extra-peritoneal (TEP) inguinal hernia repair with DynaMesh ENDOLAP 3D - general and visceral surgery

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date of publication: 29.01.2015
  • DRK Krankenhaus Clementinhaus

    Dr. med.  Andreas  Kuthe

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  • Access to the preperitoneal space


    After infraumbilical transverse skin incision, expose the anterior rectus sheath with two Langenbeck retractors and incise it transversely with the scalpel. Retract the medial edge of the rectus muscle with the retractor and insert the dissecting balloon. Slides it on the posterior lamina of the rectus sheath to the pubic bone. Under direct vision with the 0° laparoscope, balloon dilation will bluntly dissect and thus help to clearly identify the guiding structures of the pubic bone, rectus muscle, and epigastric vessels. Remove the balloon and arm the incised anterior rectus sheath with braided size 0 absorbable sutures.

  • Inserting the laparoscope and first working trocar


    Now, insert a Hasson trocar is inserted and securely fixed with the preplaced sutures.  In most cases, a working pressure of 7 mmHg suffices to adequately unfold the preperitoneal space. Insert a 5 mm trocar at least 5 cm above the pubic bone in the midline.

    An insulated 5 mm trocar with short thread is recommended.

  • Dissecting the preperitoneal space and inserting the third trocar


    While expand the medial preperitoneal space with the Overholt and laparoscope, the midline will be crossed. From here, the dissection proceeds laterad, with a large medial hernia readily apparent. Continue the lateral dissection along the transversus abdominis muscle to the level of the umbilicus. At this level in the anterior axillary line, insert the third trocar, either as a 5 mm or, as in the video, as a 10 mm trocar.


    • This position of the second working trocar allows good triangulation.
    • Particular attention must be paid to the course of the lateral femoral cutaneous nerve during lateral preparation, especially when electrocoagulation is used.
  • Freeing the hernial sac from the structures of the spermatic cord

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    Once all trocars have been inserted, the camera operator changes position and now stands behind the surgeon. Tilt the table to the side of the team; it often helps to tilt the table downward 10°.
    Now detach the large direct hernial sac from the spermatic cord, identifying the ductus deferens and vessels, and dissect it sufficiently far craniad to allow for optimum mesh placement at a later stage.

  • Dissecting off the peritoneum (parietalization)

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    If the arcuate linea extends far caudad, as in the video, it should be incised laterally. The final act of dissection is the dissection of the peritoneum off the spermatic cord or fascia beyond the middle of the psoas muscle toward the anterior abdominal wall. Divide all, even the smallest, fibrous attachments between the peritoneum and retroperitoneum. This will expose the inguinal nerves, the lateral femoral cutaneous nerve lateral to the psoas muscle and the genitofemoral nerve medial to the latter.

  • Gathering the transversalis fascia

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    Preperitoneal lipomas accompanying the structures of the spermatic cord should be  mobilized far craniad or resected as in the video. In medial hernias, the overstretched transversalis fascia should be gathered or inverted to avoid seroma, which otherwise may resemble early recurrence.

  • Principles and landmarks in Endolap 3D positioning

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    Incorporated markers to be aligned with anatomical landmarks ( inguinal ligament, inferior epigastric and external iliac vessels) ensure simple, always correct and thus standardized implant positioning in each patient.

  • Inserting the mesh

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    Fold the net lengthwise and pull it into a reduction sleeve. After pain prophylaxis by instilling 8 ml of 0.5% bupivacaine into the preperitoneal space, introduce the mesh from the lateral side. A minimum net mesh size of 10 × 15 cm is adequate in most cases.

  • Mesh positioning

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    With the inguinal ligament paralleling the middle of the mesh, unfold the mesh without wrinkles. Medially, the mesh reaches the symphysis and laterally the anterior superior iliac spine. Its inferior border must overlap Cooper's ligament. Its lateral inferior corner will rest on the psoas muscle lateral to the vessels of the spermatic cord.

  • Controlled CO2 deflation; wound closure

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    While the lateral trocar maintains the upper edge of the mesh against the abdominal wall, deflate the CO2 pneumoperitoneum in controlled fashion via the gas port.  Observe the peritoneal sac rolling up onto the mesh under direct vision and, if necessary, correct the mesh position from the medial side with the Overholt forceps.

    Tip: If in doubt, repeat this procedure until the result is good.

    Finally, close the anterior lamina of the rectus sheath with the preplaced stay sutures. Infiltrate the umbilical trocar site with 2 ml of 0.5% bupivacaine and then close all incisions with subcuticular absorbable interrupted sutures.