At which layer in the human anatomy is the mesh placed during Laparoscopic TEP inguinal hernia repair?

Question

I am told that one of the benefits of TEP hernia repair is that it avoids penetrating the abdominal cavity. This implies that the surgeon does not cut into the Transversales Facia or the Peritoneum Thus my confusion arrives from where the mesh is actually placed.

• Does the mesh get sandwiched in between the Transversales Fascia and the abdominal muscles or does it go below (ie deep) to that Facia?
• Is an inguinal hernia usually just a bulge, rather than an actual tear, through the Peritoneum/Trasverales Facia and/or abdominal muscles ?
• If the hernia is an actual 'tear' does the surgeon need to stitch 2 edges of what tore back together or does the mesh provide enough rigidity to make the tear ineffective

Answer 1

I am told that one of the benefits of TEP hernia repair is that it avoids penetrating the abdominal cavity. This implies that the surgeon does not cut into the Transversales Facia or the Peritoneum

Transversalis fascia is a part of the abdominal wall, not the abdominal cavity. So penetration of the transversalis fascia is done but not into the peritoneal cavity.

_{[Source:Wikipedia]}

Does the mesh get sandwiched in between the Transversales Fascia and the abdominal muscles or does it go below (ie deep) to that Facia?

In TEP, the dissection is done in the preperitoneal space to place the mesh in that space.

_{[Source:Ref3]}

The preperitoneal space is commonly described as the space between the peritoneum and transversalis fascia (TF).[Ref1]

Therefore, it is placed between TF and peritoneum. The mesh is secured to the posterior aspect of rectus abdominis, Cooper's ligament, Lacunar ligament, transversus abdominis aponeurotic arch and laterally to the iliopubic tract.

Is an inguinal hernia usually just a bulge, rather than an actual tear, through the Peritoneum/Trasverales Facia and/or abdominal muscles ?

It is usually just a bulge, but stretching of the TF do occur in large hernias.

If the hernia is an actual 'tear' does the surgeon need to stitch 2 edges of what tore back together or does the mesh provide enough rigidity to make the tear ineffective?

In laparoscopic hernioplasty, it is recommended to be done in large hernias to prevent complications.

Defect closure in laparoscopic mesh hernioplasty for large indirect hernias is safe and feasible and can significantly reduce postoperative seroma formation and relative complications. This approach is recommended in large indirect or scrotal hernia repair.[Ref2]

---

References

1. Lorenz A, Augustin C, Konschake M, Gehwolf P, Henninger B, Augustin F and Öfner D (2022) The Preperitoneal Space in Hernia Repair. Front. Surg. 9:869731. doi: 10.3389/fsurg.2022.869731

2. Li B, Shi S, Qin C, Yu J, Gong D, Nie X, Miao J, Lai Z, Cui W and Li G (2022) Internal Ring Defect Closure Technique in Laparoscopic Mesh Hernioplasty for Indirect Inguinal Hernia. Front. Surg. 9:794420. doi: 10.3389/fsurg.2022.794420

3. Ansari MM. Surgical preperitoneal space: holy plane of dissection between transversalis fascia and preperitoneal fascia for TEPP inguinal hernioplasty. MOJ Surg. 2018;6(2):26-33 DOI: 10.15406/mojs.2018.06.00119