This video demonstrate How to do Safe TEP Hernia Surgery - Lecture by Dr R K Mishra. The Totally Extraperitoneal Repair (TEP) is a keyhole technique for inguinal hernia repair. With this technique hernias are repaired using a piece of mesh which is placed behind the muscle of the abdominal wall. The TEP repair is particularly recommended for the repair of bilateral inguinal hernias and recurrent inguinal hernias. The procedure is performed under general anaesthesia (Asleep). Three small incisions are made in the midline between the umbilicus and the pubic bone.

Laparoscopic hernia repair has revolutionized the management of inguinal hernias, offering patients reduced pain, faster recovery, and smaller scars compared to open surgery. One of the most advanced and widely used minimally invasive techniques is the Totally Extraperitoneal (TEP) repair. In his lecture on How to do Safe TEP Hernia Surgery, Dr R K Mishra—a renowned laparoscopic surgeon—explains the principles, steps, and safety strategies involved in performing this procedure effectively. 

What Is TEP Hernia Repair?

The Totally Extraperitoneal (TEP) technique is a laparoscopic surgery for inguinal hernia repair that avoids entering the abdominal cavity. Instead, it creates a working space in the preperitoneal area just behind the abdominal wall where mesh is placed to reinforce the hernia defect. Because the peritoneum (lining of the abdominal cavity) is not opened, risks related to intra-abdominal organ injury are reduced.

TEP is especially useful for:

• Bilateral inguinal hernias

• Recurrent hernias after previous repairs

• Patients who benefit from minimally invasive surgery

Why Safety Matters

Although TEP offers many benefits, its safety depends heavily on careful technique and thorough understanding of groin anatomy. Common complications—such as bleeding, nerve injury, or peritoneal tears—can be minimized with meticulous attention to detail. Experienced laparoscopic surgeons emphasize that TEP has a steep learning curve and must be mastered gradually to ensure safe outcomes for patients.

Step-by-Step Guide to Safe TEP Hernia Surgery

1. Preoperative Preparation

Before surgery:

• General anesthesia is administered to ensure patient comfort and muscle relaxation.

• The patient is positioned supine on the operating table.

• The abdomen is prepped and draped in sterile fashion.

• A Foley catheter may be placed to keep the bladder empty—reducing risk of inadvertent injury.

2. Creating the Preperitoneal Space

• A small infra-umbilical incision is made.

• The surgeon enters the preperitoneal space using blunt dissection and insufflates carbon dioxide to develop the plane between the abdominal wall and peritoneum.

• Correct insufflation pressure is essential to maintain space without undue tension.

This initial space creation is critical; improper entry can lead to peritoneal tears and loss of working space.

3. Insertion of Trocars

Typically, three trocars are placed:

1. A 10 mm camera port through the infra-umbilical incision.

2. One or two 5 mm working ports along the lower midline just above the pubic bone.
   Care must be taken to avoid injury to inferior epigastric vessels during port placement.

4. Anatomical Dissection & Hernia Reduction

Once the preperitoneal space is established:

• Retract the rectus muscle to expose anatomical landmarks such as the pubic bone, Cooper’s ligament, and arcuate line.

• Identify and gently reduce the hernia sac.

• Recognize danger zones:

  • Triangle of Doom (contains major vessels)

  • Triangle of Pain (contains sensory nerves)

Dissection should be gentle and precise to avoid nerve and vascular injury.

5. Mesh Placement

A mesh prosthesis is inserted into the preperitoneal space and positioned to cover all potential hernia defects:

• Medially to the pubic bone

• Laterally toward the anterior superior iliac spine

Proper placement ensures adequate reinforcement. Some surgeons fix the mesh with tacks or fibrin glue; others may forego fixation depending on the situation.

6. Closure

Unlike TAPP, TEP does not involve peritoneal closure since the peritoneal cavity is not entered. However, careful inspection is done to ensure no peritoneal rents occurred. If a tear is found, it may be repaired or the case may be converted to another approach.

Principles of Safe Practice

✔ Understand Anatomy Thoroughly
Clear recognition of landmarks prevents vascular and nerve injuries.

✔ Avoid Peritoneal Tears
If peritoneal disruption does happen, repair, or convert to TAPP/open safely.

✔ Patient Selection
Prior lower-abdominal surgeries or complex anatomy may present challenges and should be evaluated preoperatively.

✔ Skill and Experience Matter
TEP has a learning curve; safe outcomes are more likely with experienced surgeons.

Conclusion

TEP Hernia Repair, when done safely, offers patients a minimally invasive, low-pain option with rapid recovery and excellent outcomes. Dr R K Mishra’s lecture emphasizes that mastery of anatomy, careful dissection, and adherence to safety principles are the foundations of a successful hernia repair. By following structured steps and prioritizing surgical safety, surgeons can achieve optimal results while minimizing complications.