Surgical Endoscopy

, Volume 27, Issue 11, pp 4360–4363

Suction test to demonstrate the peritoneal edge during laparoscopic extraperitoneal inguinal hernia repair


    • Upper Gastrointestinal Surgical Unit, Royal North Shore HospitalUniversity of Sydney
  • Jason Free
    • Upper Gastrointestinal Surgical Unit, Royal North Shore HospitalUniversity of Sydney
  • Sivakumar Gananadha
    • Upper Gastrointestinal Surgical Unit, Royal North Shore HospitalUniversity of Sydney
  • Thomas J. Hugh
    • Upper Gastrointestinal Surgical Unit, Royal North Shore HospitalUniversity of Sydney
  • Jaswinder S. Samra
    • Upper Gastrointestinal Surgical Unit, Royal North Shore HospitalUniversity of Sydney
Dynamic Manuscript

DOI: 10.1007/s00464-013-3031-3

Cite this article as:
Nahm, C., Free, J., Gananadha, S. et al. Surg Endosc (2013) 27: 4360. doi:10.1007/s00464-013-3031-3



Inadequate peritoneal dissection from retroperitoneal structures may account for a large number of hernia recurrences amongst surgeons and trainees who are new to totally extraperitoneal (TEP) laparoscopic inguinal hernia repair. In this paper, we describe a simple dynamic test that allows surgeons to better appreciate the peritoneal edge during the initial dissection phase of TEP inguinal hernia repair, allowing for more adequate dissection of the peritoneum from retroperitoneal structures before placement of mesh.


Data from a single surgeon was collected on 113 consecutive patients who underwent laparoscopic TEP inguinal hernia repair at the Royal North Shore Hospital in Sydney. The data was retrospectively reviewed to determine the number of cases in which the suction test led to further peritoneal dissection prior to mesh placement.

Operative Technique

After balloon dissection of the pre-peritoneal space and initial dissection of peritoneum and sac from retroperitoneal structures, a laparoscopic suction device is used to aspirate the insufflated gas from the pre-peritoneal space to cause the peritoneum to bulge anteriorly, thus demonstrating the edge of the peritoneal reflection. Further dissection is performed if deemed necessary at this point, and the mesh is placed over the hernia defect.


136 TEP hernia repairs were performed in 113 patients. In 26 (23 %) of patients, the abovementioned technique was of particular value resulting in further dissection of peritoneum prior to mesh placement. There were no complications as a direct result of the test.


This dynamic suction test is a risk-free and useful operative tool for surgeons and trainees who are new to TEP inguinal hernia repair, and provides a definitive way of identifying the peritoneal reflection to ensure the peritoneum has been dissected adequately prior to mesh placement.


LaparoscopicHerniaTotal extraperitonealPeritoneumSuction

The landscape of inguinal hernia repair has changed dramatically over the last two decades. Laparoscopic total extraperitoneal (TEP) repair of inguinal hernia, as originally described by McKernan and Laws [1], has become a popular technique among many surgeons. It is purported to result in less postoperative pain [2, 3], earlier return to daily activities [3], and reduced chronic groin pain compared with a tension-free open repair [4]. However, TEP is associated with an increased risk of intraoperative and postoperative complications compared with an open approach [2, 3]. Some studies also suggest that the TEP repair results in higher recurrence rates compared with other techniques [5, 6], but this might be explained in part by the long learning curve for the TEP technique [7, 8]. Failure to fully cover the defect with mesh as a result of insufficient peritoneal dissection might also explain these findings.

A key aspect of TEP repair is extensive peritoneal mobilization from the retroperitoneal structures in order to create adequate space for optimal mesh placement [9]. Inexperienced surgeons may fail to perform the full dissection of the edge of the peritoneal reflection for fear of breaching it. We present a simple method to demonstrate the peritoneum and its associated reflection from the retroperitoneal structures during the dissection phase of the operation. This method is valuable in cases where the demarcation between the retroperitoneum and peritoneal lining becomes obscured.



Data were collected on all patients undergoing laparoscopic TEP hernia repair at the Royal North Shore Hospital by a single surgeon (JS) between March 2009 and April 2012. Patients with a previous hernia repair, giant inguinoscrotal hernias, a previous laparotomy, or pelvic fractures were excluded from the study.

A standard TEP technique was used as previously described by Bittner et al. [9]. Identification and isolation of the hernial sac were followed by dissection between the peritoneum and the retroperitoneal structures. The peritoneum was separated from the retroperitoneal structures including the vas deferens, testicular vessels, iliac vessels, iliacus, and the psoas muscle. Most authors recommend that the peritoneum should be reflected back until the vas deferens can be seen entering medially into the pelvic cavity [9]. The peritoneum can then be separated from the underlying structures by a combination of blunt stripping and sharp scissors dissection. Any bleeding or bruising of the areolar tissue at this stage can result in failure to clearly appreciate the edge of the peritoneum, and a simple test to assist with this identification might be helpful.

Operative technique

Appreciating the position of the peritoneum and its reflection from the retroperitoneal structures is a prerequisite for adequate dissection. When this view is obscured, aspiration of the extraperitoneal space with a suction device can demonstrate the edge of the peritoneum. Suction of the extraperitoneal space decreases the extraperitoneal pressure resulting in lifting of the peritoneum. The peritoneum bulges anteriorly (Fig. 1), and in the laparoscopic view, the peritoneum rolls over the cord structures. When aspiration is stopped, the extraperitoneal space refills with gas from the insufflator. Restoration of pressure within the extraperitoneal space allows the peritoneum to fall back from the cord structures on to the retroperitoneum (Fig. 2). It is this repeated action of aspiration and insufflation that provides the basis of dynamic testing to accurately assess the site where the peritoneum is most caudally adherent to the retroperitoneum. This test enables the surgeon to ensure that there is ample space for placement of the mesh over the hernial defects and that the peritoneum will not be trapped between the mesh and the retroperitoneum at the end of the operation. The latter event may lead to a higher risk of hernia recurrence. The deflation/insufflation test can be repeated after placement of the mesh to assess the adequacy of the dissection as well as the mesh placement.
Fig. 1

A suction device (in the most inferior port) is used to aspirate the gas from the extraperitoneal space, causing the peritoneum bulge anteriorly
Fig. 2

After ceasing aspiration, the extraperitoneal space is reinsufflated with gas and the peritoneum falls back into its original position. Repeated aspiration and insufflation demonstrates the peritoneal reflection, enabling the surgeon to gauge the adequacy of retroperitoneal dissection for optimal mesh placement


A total of 136 TEP hernia repairs were performed during the study period in a total of 113 patients. One hundred six patients were men; the median age of the whole cohort was 55 years (range, 19–86 years). Ninety (79.6 %) patients had a unilateral hernia repair, and the remainder had bilateral hernia repairs. Eighty-seven hernias were indirect and 49 were direct. None of the patients required conversion to either transabdominal preperitoneal or open hernia repair. The dynamic aspiration test was used in all patients. Notably, in 26 (23 %) patients the peritoneum was densely adherent to the retroperitoneal structures, and in these cases the technique proved to be of particular value resulting in further dissection of the peritoneum before mesh placement.

Postoperative complications occurred in five (4 %) patients. Two patients developed a hematoma around the spermatic cord. Both of these patients had a long-standing indirect inguinal hernia. One of these patients also developed urinary retention requiring bladder catheterization for 24 h. Two patients developed a superficial wound infection at the umbilical port site requiring oral antibiotics on discharge. One elderly patient developed a recurrence after 24 months. Diagnostic laparoscopy revealed a recurrence at the cephalad margin of the mesh. This was repaired using an open mesh technique.


The original TEP repair as described by McKernan and Laws [1] has undergone numerous modifications. The modern TEP repair can be called a work in progress. These modifications include balloon dissection [10], 3-D mesh [11], lightweight mesh [12], endoloop closure of the hernia sac [13], glue fixation of mesh [14], or no fixation of mesh [15].

The learning curve for TEP repair is relatively long, estimated to be 80 cases before becoming proficient [8]. The higher recurrence rate associated with TEP hernia repair is thought mainly to occur during this learning curve, as the risk of recurrence in experienced hands is similar to open hernia repair [9]. The majority of recurrences occur because of a failure to adequately dissect the peritoneum from the retroperitoneal structures. In inexperienced hands, this can result in placement of the mesh over the peritoneal edge.

The above technique allows accurate visualization of the peritoneal reflection from the retroperitoneal structures. The test can be repeated as many times as required without any adverse outcome. We have not witnessed any complications in this series as result of this test. This test might be useful for surgeons performing laparoscopic groin surgery, particularly if there has been a previous pelvic dissection.


We thank Levent Efe, CMI, for his illustrations.


Christopher Nahm, Jason Free, Sivakumar Gananadha, Thomas J. Hugh, and Jaswinder S. Samra have no conflicts of interest or financial ties to disclose.

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© Springer Science+Business Media New York 2013