This advanced surgical video provides a comprehensive, step-by-step demonstration of enhanced-view totally extraperitoneal (eTEP) inguinal hernia repair performed by Dr. R.K. Mishra at World Laparoscopy Hospital. The presentation is designed to help surgeons understand the operative anatomy, technical sequence, ergonomic advantages, and safety principles of this advanced minimally invasive extraperitoneal approach.

The operation begins with appropriate patient selection, preoperative evaluation, anesthesia, positioning, surgical preparation, and careful planning of port placement. Dr. Mishra demonstrates safe entry into the retrorectus space, identification of the rectus abdominis muscle and posterior rectus sheath, and controlled creation of the initial extraperitoneal working space. The crossover technique and subsequent development of the preperitoneal plane are explained in a systematic and reproducible manner.

The video highlights the importance of preserving the peritoneal layer while maintaining adequate insufflation and operative exposure. Important anatomical structures—including the pubic symphysis, Cooper’s ligament, inferior epigastric vessels, iliopubic tract, rectus muscle, direct hernia space, indirect inguinal ring, femoral canal, vas deferens, gonadal vessels, and spermatic cord—are identified clearly during dissection.

A structured approach to medial and lateral dissection is demonstrated. The medial dissection exposes the retropubic space and Cooper’s ligament, while the lateral dissection creates sufficient room for placement of a large prosthetic mesh. The technique for reducing direct and indirect hernia sacs is explained, along with the identification and management of associated cord lipomas. Particular attention is given to protecting the vas deferens, gonadal vessels, bladder, peritoneum, inferior epigastric vessels, and vulnerable neural structures.

Dr. Mishra explains the importance of complete parietalization of the spermatic cord structures. Adequate separation of the peritoneum from the vas deferens and gonadal vessels allows the mesh to lie flat without being lifted or displaced after desufflation. The surgical field is carefully inspected to confirm complete exposure of the myopectineal orifice and all potential hernia sites, including the direct, indirect, femoral, and obturator regions.

The video demonstrates the selection, introduction, orientation, and deployment of an appropriately sized mesh. Adequate medial, lateral, superior, and inferior overlap is essential for durable reinforcement of the entire myopectineal orifice. The mesh must remain flat without folding, rolling, migration, or interference from residual peritoneal attachments. The indications and precautions for mesh fixation are also discussed, with special emphasis on avoiding traumatic fixation in areas associated with major vessels and sensory nerves.

Practical guidance is provided for maintaining hemostasis, preventing peritoneal injury, managing accidental peritoneal tears, and restoring the extraperitoneal working space when pneumoperitoneum compromises exposure. The presentation also explains when the surgeon should alter the operative strategy or convert to another established approach if safe anatomical progression cannot be maintained.

Potential complications—including vascular injury, bladder injury, peritoneal breach, seroma, hematoma, urinary retention, mesh infection, chronic postoperative groin pain, testicular complications, and recurrent hernia—are reviewed with preventive strategies. Dr. Mishra emphasizes gentle tissue handling, precise anatomical identification, adequate dissection, proper mesh coverage, and controlled desufflation under direct visualization.

The eTEP approach can provide a spacious operative field and improved instrument triangulation compared with a restricted conventional extraperitoneal workspace. However, it requires detailed knowledge of the retromuscular and preperitoneal anatomy, familiarity with advanced laparoscopic dissection, appropriate patient selection, and structured training under expert supervision.

This detailed operative demonstration is useful for general surgeons, laparoscopic surgeons, hernia specialists, surgical residents, fellows, and clinicians interested in advanced abdominal wall and groin hernia surgery. It provides a valuable educational overview of the operative steps, anatomical landmarks, technical modifications, complication prevention, and surgical decision-making involved in eTEP inguinal hernia repair.

The procedure is demonstrated by Dr. R.K. Mishra at World Laparoscopy Hospital, an international centre for laparoscopic and robotic surgical education. This video is intended solely for professional education and should not replace accredited surgical training, institutional protocols, patient-specific clinical judgment, or supervised operative experience.