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Anatomical and surgical study of totally extraperitoneal laparoscopic hernioplasty.

BACKGROUND
Laparoscopic surgery provides direct access to the extraperitoneal inguinal space for a clear, amplified view of the anatomical structures. However, the variety of terms used to describe the fascial elements has partly prevented the promulgation of this approach.


MATERIAL/METHODS
Two hundred patients received surgery for inguinal hernia at an outpatient surgery unit by means of totally extraperitoneal laparoscopy. Regional anatomical dissection was performed during the operation, which was filmed for later analysis.


DISCUSSION
The totally extraperitoneal laparoscopic technique is described anatomically, including management of the internal spermatic fascia to create an opening for the use of fenestrated meshes. The technical maneuvers are discussed, with comparison of other possible methods of approach.


CONCLUSIONS
From our experience we would recommend: 1) a consensus on terminology is necessary for dissemination of the TEP approach; 2) the ISF must be dissected to avoid ruptures of the sac and ensure parietalization; 3) the "sling of the TF" must be preserved, and 4) the TEP approach does not require dissection medial or inferior to the Cooper ligaments.