27 percent of men and 3 percent of women suffer an inguinal hernia in the course of their lives. Inguinal hernias are the most common reason for soft tissue surgery. There are well-established surgical procedures available, including open surgery with sutures or mesh or endoscopic/keyhole surgery. A safe and frequently recommended procedure is total extraperitoneal hernioplasty (TEPP). After this procedure, you can usually return to work a few days after the operation.
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Article overview
TEPP / Total extraperitoneal mesh implantation - Further information
Background information on inguinal hernias
The most common form is the lateral inguinal hernia, which occurs in 70 percent of patients. An inguinal hernia occurs unilaterally or bilaterally. The right side of the body is more frequently affected.
The following types can be classified:
- The lateral inguinal hernia
- The medial hernia
- The femoral hernia
In men, the groin area with the inguinal canal is a natural weak point in the abdominal wall. The spermatic cord runs through this canal through the abdominal wall into the scrotum.
In women, the uterine ligament runs through this canal from the uterus to the pubic bone. The peritoneum partially extends into the inguinal canal in the shape of a finger. The peritoneum can push out through a gap in the abdominal wall and contain abdominal contents or parts of the intestine.
Doctors call such a gap in the abdominal wall a hernia orifice, and the peritoneum that pushes out is called a hernia sac. If the hernia is large, it may be visible or palpable under the skin. A lateral hernia can extend into the scrotum and, in women, into the labia majora.
Sometimes the hernia sac only becomes visible when coughing or pushing, as the internal abdominal pressure increases. The hernia sac then pushes outwards.
The doctor uses this during the physical examination to make a diagnosis. Other imaging procedures, such as a painless ultrasound examination, are rarely required.
An inguinal hernia often occurs in connection with heavy strain on the abdominal wall @ Satjawat /AdobeStock
Treatment options for an inguinal hernia
Doctorsdo not always have to operate on a hernia . As long as it does not cause any symptoms, they wait for a while (''watchful waiting'').
However, the German Hernia Society recommends that the indication for surgery should be generous. Experts believe that a hernia never heals spontaneously and that it can enlarge with every increase in intra-abdominal pressure.
If sections of intestine are trapped in the hernial orifice, there is a risk to life, as the affected section of intestine can die. An incarceration causes great pain. Emergency surgery is mandatory. Fortunately, an incarceration is a rare event.
Patients with a hernia do not necessarily have to refrain from physical activity. However, they should avoid or adapt to obstructive movements and strain.
Open and minimally invasive procedures
There are several open and minimally invasive procedures to choose from in hernia surgery. In inguinal hernia surgery, doctors move the hernia sac back into the abdominal cavity in order to permanently close the hernial orifice.
As this is one of the most common operations, many surgeons are proficient in this procedure. However, there are also specialized doctors.
In open surgical procedures, the surgeon opens the inguinal canal with a 5 - 8 cm incision above the groin.
In minimally invasive or endoscopic surgery (keyhole surgery), only three tiny incisions are required to insert the instruments.
- Open surgery
Open procedures are called Shouldice or Lichtenstein surgery. In both procedures, doctors open the inguinal canal, retract the hernia sac and close the hernial orifice with a suture.
In the Lichtenstein procedure, the surgeon also inserts a plastic mesh to reduce the recurrence rate . Open surgical procedures can be performed under general or local anesthesia.
In open hernia surgery, a 5-10 cm incision is made in the groin region @ luciano /AdobeStock
- Minimally invasive surgery
Minimally invasive procedures are:
- Transabdominal preperitoneal plasty(TAPP) or
- Total extraperitoneal hernioplasty (TEP)
In the TAPP technique, an approach is made through the abdominal cavity. The surgeon covers the hernial orifice with a mesh from the inside. The advantage of this method is that a previously unknown hernia or other problems in the abdominal cavity become visible, which doctors can also treat. TEP and TAPP are always performed under general anesthesia.
Although both procedures are quite safe, total extraperitoneal hernioplasty has very few complications and the lowest risk of recurrence.
Procedure for a total extraperitoneal hernioplasty
First, the surgeon makes a tiny incision below the navel. Here he inserts the camera. He advances it over the peritoneum, which he does not penetrate. He therefore does not have to open the abdominal cavity. This is why the operation is called extraperitoneal, which literally means outside the peritoneum.
Using the camera, he expands the space between the peritoneum and the fascia with a balloon. The surgeon introduces CO₂ gas into the resulting cavity to keep it open and create good visibility.
Next, the surgeon inserts two more trocars to the right and left of the first via small incisions. The first trocar carries the camera and provides an overview of the surgical cavity. The other two guide the instruments.
He carefully releases the hernia sac and places it back into the abdomen. To prevent it from pushing out again, he inserts a wafer-thin mesh between the abdominal wall and the peritoneum.
This consists of various plastic materials. The surgeon does not need to fix the mesh in place as it is held in place by the abdominal pressure and the abdominal muscles. Sometimes doctors (in the TEP technique) fix the plastic mesh in place with surgical glue, a suture or staples.
What happens after the operation
The tiny incisions for the trocars usually heal quickly and without complications. Light exercise is possible the day after the operation. Anyone who does not perform heavy physical work will be able to return to work within a few days.
Possible complications of a TEPP
The usual anesthetic risks should be mentioned . These are extremely rare. In order to minimize them, the anaesthetist who administers the anaesthetic will talk to you in detail before the operation.
The risk of bleeding is low as long as you are not taking blood thinners. In consultation with the surgeon and responsible family doctor or cardiologist, you must stop taking these around the time of the operation.
As the doctor does not have to open the abdominal cavity during total extraperitoneal hernioplasty, no abdominal organs (intestines) are injured.
All hernia operations rarely cause nerve irritation after the procedure. This is usually temporary and very rare with TEP!
Fortunately, the risk of recurrence after TEP is very low(if the mesh is positioned correctly).
Conclusion on total extraperitoneal mesh implantation
Total extraperitoneal hernioplasty is a safe surgical procedure for the treatment of inguinal hernias.
As hernias do not heal spontaneously and can worsen (intestinal incarceration), experts recommend surgery in all cases . There is a low risk of recurrence with total extraperitoneal hernioplasty. Patients recover very quickly after the operation.
References
https://www.chirurgie-minimalinvasiv.de/leistenbruch/tapp-technik/
https://flexikon.doccheck.com/de/Total_extraperitoneale_Hernioplastik
https://www.aerzteblatt.de/archiv/175103/Evidenzbasierte-Behandlung-der-Leistenhernie-des-Erwachsenen