Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

29. Prevention of Pain: Optimizing the Laparoscopic TEP…
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Technical Aspects of Preventing Pain After TEP
and TAP Hernia Repair
We inject long-acting local anesthetic into the skin before incision to
reduce postoperative pain [ 1 ]. Surgeons should be able to perform surgery
both in a triangulated position and with the camera lateral to the
working ports, so that they can adapt to different setups.
When using the TEP technique, the use of a balloon trocar to create
the surgical space makes the procedure easier and faster and reduces
blood loss, which may result in less postoperative pain [ 2 ].
The eTEP technique creates a larger surgical space and allows a more
versatile distribution of ports than the TEP technique. The eTEP technique
takes advantage of the fact that the preperitoneal space can be
reached from almost any part of the anterior abdominal wall [ 3 ]. A video
showing this technique can be found online [ 4 ].
The creation of large peritoneal flaps during the TAPP procedure
facilitates complete dissection of the myopectineal orifice of Fruchaud,
placement of a large mesh, and perfect apposition of the peritoneal edges
at the end of the procedure. This is a faster, less expensive, and less painful
alternative to closing the peritoneum using tacks, glue, or sutures.
The peritoneal edges come together as CO 2
is carefully released, and the
wound heals quickly. The findings of an experimental study support this
approach [ 5 ]. We have never closed the peritoneum, and other groups
have also reported that they do not close the peritoneum. We have not
experienced any cases of bowel obstruction or fistula using this
approach. For the same reason, we do not close accidental tears created
during the TEP or eTEP procedures. A video showing peritoneal apposition
at the end of a TAPP procedure can be found online [ 6 ]. However,
not physically closing the peritoneal edges is controversial, and most
consensus statements recommend some type of peritoneal closure, with
suture closure being the most frequently used. The recent development
of barbed sutures has increased the ease of peritoneal closure.
We advise a stepwise approach to dissection. In the TEP procedure,
we dissect Cooper’s ligament (both ligaments in cases of direct hernias),
free the lax transversalis fascia from preperitoneal structures in cases of
direct hernias, dissect the space of Bogros, divide the posterior transversalis
fascia that usually overlaps the indirect sac and peritoneum at the
level of the internal ring, and finally identify the indirect sac. A video
showing the seldom-mentioned posterior transversalis fascia is available
online [ 7 ]. Cauterization should be performed with care and avoided at
the “triangle of doom” and the electrical hazard zone or “triangle of