Total extraperitoneal hernia repair and its associated pitfalls

Minimally invasive surgery over the last three decades has provided a credible alternative for the treatment of inguinal hernias. One of the main techniques involved utilises the creation of an extraperitoneal space, thereby avoiding the need to enter the abdominal cavity. The totally extraperitoneal (TEP) inguinal hernia repair is described as well as the common and more serious complications that are possible. TEP has a proven track record of expertise for the surgical treatment of inguinal hernias, but has a steeper learning curve, with more serious complications such as vascular and bladder injuries, which are explored in more detail. The key to managing any such serious complications is early recognition. Rectus sheath hematomas secondary to inferior epigastric artery injury usually require only conservative measures such as close observation with the requirement for any embolization of any arterial bleed a rare event. Bladder injuries if recognized at the time of surgery require immediate repair, with late presentation inevitably needing more invasive intervention for a potentially septic patient. TEP remains an excellent repair with caveats of serious complications which are rare at < 0.5% however, they must be discussed and be part of the consent process prior to any repair taking place