EXTENDED TOTALLY EXTRA-PERITONEAL REPAIR {eTEP}

Extended totally extraperitoneal repair (eTEP) is a novel technique that was first introduced by Jorge Daes in 2012 to address difficult inguinal hernias.

1. EXTENDED TOTALLY EXTRAPERITONEAL HERNIA REPAIR {e TEP} By Dr. satbir singh

2. Hernia Abnormal protrusion of an organ or tissue through a defect in its surrounding walls

3. HERNIA SURGERY OPEN LAPAROSCOPIC LAPAROSCOPIC TEP : TOTALLY EXTRAPERITONEAL E TEP: EXTENDED TOTALLY EXTRAPERITONEAL TAPP : TRANSABDOMINAL PREPERITONEAL IPOM : INTRAPERITONEAL ONLAY MESH REPAIR.

4. Introduction Extended totally extraperitoneal repair ( eTEP ) is a novel technique that was first introduced by Jorge Daes in 2012 to address difficult inguinal hernias. The principle is to create a larger space than what is done in TEP to tackle large groin hernias.

5. Procedure STEPS IN BRIEF STEP 1: Entering the Intra-abdominal Cavity STEP 2 : Crossing the midline to opposite side STEP 2: Identifying the Anatomical Landmarks STEP 3: Dissecting the Hernia Sac STEP 4: Deploying and Anchoring the Mesh STEP 5: Closing the Peritoneum STEP 6: Taking out Sutures & Port Closure

6. Anterior rectus sheath Posterior rectus sheath

7. STEP 1 : Entering the Intra-abdominal Cavity > Trocar placement > Establishing the carbon dioxide pneumoperitoneum using the Veress needle. > The 10 mm Camera trocar – supraumbilical > Under laparoscopic view - Two 5 mm operating trocars on the midclavicular line 2 cm below the level of the horizontal line from the optical trocar.

8. Loose areolar tissue

9. STEP 2: Identifying the Anatomical Landmarks • Exploration and anatomical landmarks The two dangerous “triangles”, 1) vascular triangle- Triangle of Doom and 2) Triangle of Pain has to be well identified And Corona Mortis

10. CORONA MORTIS • Latin - [corona] meaning "crown' & [mortis] meaning "death‘ the "crown or circle of death". The corona mortis refers to an anatomical variation, a vascular anastomosis between the obturator & the external iliac vascular systems that passes over Pectineal (Cooper's) ligament . In some cases, the corona mortis is the actual obturator artery- arises from the inferior epigastric artery instead of the internal iliac artery. can also arise from the external iliac artery. In both cases, it has been called an "aberrant obturator artery" The Preperitoneal dissection ends when the anatomic landmarks previous described are well exposed and the two dangerous triangles (vascular and pain triangle) can be identified

11. S TEP 3 : Dissecting the Hernia Sac • The indirect inguinal hernia sac should be dissected carefully from the Spermatic Cord • It is essential to expose and know at all times where the spermatic cord is located. Direct hernia sacs are easily dissected • Particular care should be taken not to dissect lateral and inferior to Cooper's ligament, as the Iliac Artery and Vein will enter the femoral canal at this site The hernia sac dissection is performed using traction contra-traction maneuvers and fine coagulation. To avoid the injuries of the ductus deferens and spermatic vessels the sac dissection always starts anteriorly A large indirect sac may be ligated proximally and divided distally without the risk of a higher postoperative pain & recurrence rate, but with an increased postoperative seroma rate * 

12. STEP 4: Ligation of Sac

13. STEP 5: Deploying and Anchoring the Mesh • A large (15x12 cm) polypropylene mesh. • The mesh is inserted from the Camera trocar. Then, the mesh is placed in the appropriate position and fixed by 1 Polypropylene sutures (or tacking staples, glue in some center's). The first suture is at the level of pubis • The mesh is fixed on the upper and internal edge • The mesh shouldn’t be sutured/stapled at the level of dangerous triangles and epigastric vessels

14. Contraindications for TEP Multiple prior lower abdominal surgeries Large Irreducible Hernias Previous Pre-peritoneal Surgeries (prostate / inguinal hernia) Patient not fit for GA

15. Complications Seroma formation in 1-12% Wound or scrotal hematoma 1-8% Infections Urinary retention Bladder injury in patients of prior midline scars or prostate operations Injury to vas Ischemic orchitis though very rare in TEP Nerve injury m/c lateral femoral cutaneous nerve pain and numbness in upper lat thigh MERALGIA PARASTHETICA

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