How is the hernia sac managed in totally extraperitoneal (TEP) laparoscopic inguinal hernia repair?

Updated: Apr 16, 2020
  • Author: Danny A Sherwinter, MD; Chief Editor: Kurt E Roberts, MD  more...
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After the initial medial and lateral dissection, the surgeon should assess the anatomy and location of the hernia. The Cooper ligament should be clearly visualized. Small direct hernias may already have been reduced by the dissecting balloon, rendering the defect visible. The location of the cord structures should be clear. Cord lipomas and indirect hernias lie lateral to the cord structures. The location of the external iliac vein should be assessed; it may not yet be eminently clear, but the approximate location should be noted.

With the anatomy clarified, the hernias can now be safely reduced. Direct and femoral hernias are reduced by applying cephalad traction to the hernia sac with appropriate countertraction (see the video below). The trajectory of dissection should be away from the external iliac vessels.

Laparoscopic inguinal hernia repair: TEP. Reduction of small direct hernia.

Next, attention is shifted to the internal ring to identify an indirect hernia sac, which may be more difficult to reduce than a direct hernia. The indirect hernia sac is located on the superolateral aspect of the spermatic cord as it enters the deep inguinal ring. It is carefully and gently separated from the cord structures by elevating the cord-sac bundle and then delicately stripping the areolar tissue downward until a window is found between the sac and the cord structures (see the video below). [56, 57, 13, 95]

Laparoscopic inguinal hernia repair: TEP. Indirect sac isolation.

Once the sac is separated cephalad, retraction of the sac from its apex typically allows it to be reduced. Cord lipomas may also be visualized during these maneuvers. They are situated lateral to the cord and course toward the deep ring. Cord lipomas should be reduced cephalad and laterally.

If the sac cannot be reduced back into the peritoneal cavity, it should be ligated proximally and left open to drain distally so as to prevent hydrocele formation. The simplest way of doing this in a wide-mouth sac is to fire a vascular 30-mm linear stapler across the sac and then divide the sac distal to the staple line. An alternative method is to use endoscopic clips or an endoscopic loop ligature. Care must be taken to avoid injury to any intra-abdominal sac contents or sliding component.

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