An inguinal hernia occurs when tissue, such as part of the intestine, protrudes through a weak spot in the abdominal muscles. This protrusion creates a noticeable lump in the groin area. It is a common condition that will not resolve on its own, and surgical intervention is necessary to alleviate discomfort and prevent serious complications. A strangulated hernia, where the blood supply to the trapped tissue is cut off, is a dangerous development that requires urgent medical attention.
The TEP Surgical Approach
Totally Extraperitoneal (TEP) hernia repair is a minimally invasive surgical technique. The entire repair happens outside the peritoneum, which is the thin membrane that lines the abdominal cavity and covers most of the abdominal organs. Surgeons work in the space between this lining and the abdominal muscles, allowing them to fix the hernia from behind the abdominal wall.
This approach differs from other hernia repair methods. Traditional open surgery involves a single, larger incision made directly over the hernia. Another laparoscopic method, known as Transabdominal Preperitoneal (TAPP) repair, involves entering the abdominal cavity to place the mesh. The TEP technique, by avoiding entry into the peritoneal cavity, reduces the risk of injury to internal organs.
The procedure is performed using a laparoscope, a thin tube equipped with a camera and a light source. This instrument, along with other surgical tools, is inserted through a few small incisions in the lower abdomen. The camera transmits images to a monitor, providing the surgeon a clear, magnified view for a precise repair through incisions that are significantly smaller than those used in open surgery.
The Surgical Procedure
The patient is placed under general anesthetic for the procedure, which takes about 30 to 45 minutes to complete. The surgeon makes a small, often curved, incision just below the navel. Through this cut, the surgeon accesses the space in front of the posterior rectus sheath, a layer of connective tissue behind the main abdominal muscle.
A special instrument, such as a balloon dissector, is used to gently create a working area. Carbon dioxide gas then inflates this space, pushing the peritoneum away from the abdominal wall. The surgeon then inserts the laparoscope and additional surgical instruments through two more minor incisions made in the lower midline of the abdomen.
With the instruments in place, the surgeon identifies the herniated tissue, known as the hernia sac, and pulls it back into its correct position. After the hernia is reduced, a flat sheet of synthetic surgical mesh is introduced. This mesh is positioned to cover the site of the hernia defect and other potential weak spots in the groin, including the direct, femoral, and obturator spaces.
The mesh acts as a scaffold, reinforcing the weakened abdominal wall. It is not typically sutured or tacked in place, as the pressure within the space holds it securely. Over time, the body’s tissues grow into and around the mesh, creating a durable reinforcement. Once the mesh is placed, the carbon dioxide is released, the instruments are removed, and the small incisions are closed.
Recovery and Post-Operative Care
TEP hernia repair is an outpatient procedure, meaning patients return home on the same day. An overnight hospital stay might be necessary if there are other health conditions or if complications arise. For the first 24 hours, patients will need a responsible adult with them as they recover from general anesthesia.
Some pain is expected but can be controlled with over-the-counter medications after the first day or two. Patients are encouraged to move around to promote healing and can return to non-strenuous activities like desk work within one to two weeks. A diet high in fiber is advisable to avoid straining during bowel movements.
Care for the incision sites involves keeping them clean and dry. Contact a doctor for any signs of complication, such as:
- Fever
- Significant redness or drainage from the incisions
- Worsening pain
- The development of a large, firm collection of blood (hematoma) or fluid (seroma) in the groin
A gradual return to physical activity is part of recovery. While gentle walking is encouraged, more strenuous exercise and heavy lifting should be avoided for at least four to six weeks. This period allows the mesh to properly integrate with the surrounding tissue. Before resuming sports or intense workouts, patients should consult with their healthcare team.
Suitability for TEP Repair
The TEP technique is particularly well-suited for individuals with bilateral inguinal hernias, as a surgeon can repair both sides during a single operation using the same small incisions. Athletes and physically active people may also benefit from the faster recovery time and quicker return to normal activities.
TEP repair is also an option for patients who have a recurrent hernia following a previous traditional open repair. By approaching the hernia from behind the abdominal wall, the surgeon can work with fresh, undisturbed tissue planes, avoiding scar tissue from the prior surgery. This can make the procedure easier and safer than a repeat open operation.
However, not everyone is a candidate for TEP repair. Patients with a history of significant lower abdominal surgery, such as a prostatectomy or a caesarean section, may have extensive scarring in the preperitoneal space. This scar tissue can make it difficult for the surgeon to safely create the necessary working space, increasing the risk of complications.
Extremely large or incarcerated hernias, where the intestinal tissue is firmly trapped, may be better addressed with a different surgical technique. An open or TAPP approach might provide the surgeon with better control and access. The choice of surgical method depends on the specific characteristics of the hernia, the patient’s surgical history, and the surgeon’s experience with each technique.