Eight-fold path to attain laparoscopic totally extraperitoneal (TEP) hernia repair Nirvana - a standardized technique to reduce the learning curve of surgical residents.
Laparoscopic totally extraperitoneal (TEP) hernia repair remains technically challenging due to the steep learning curve and unfamiliar territory. This paper describes an eight-step standardized technique of laparoscopic TEP hernia repair that is easily reproducible, thus reducing the learning curve. The eight steps are as follows: (a) creation of the pneumo pre-peritoneal space; (b) identify the pubis symphysis; (c) identify the inferior epigastric vessels; (d) lateral to medial dissection of the hernia sac; (e) identification of cord structures and triangle of doom/pain; (f) herniotomy; (g) parietalization of the hernia sac; (h) placement and fixation of the mesh. The learning curve of laparoscopic TEP can be decreased by proctoring, standardization of the procedure and having a formal set of operative steps that residents can follow and easily repeat.