Totally Extraperitoneal Herniorrhaphy (TEP): Lessons Learned from Anatomical Observations

Figure 2

Totally extraperitoneal herniorrhaphy (TEP). (a) Dissecting the retromuscular space caudally. (b) Percutaneous needle confirmation for measuring the length of the arcuate line. Classical AL: single sharp well-defined arcuate line (4.5 cm below the umbilicus) (black arrow). (c) Low AL: multiple and low AL in the incomplete PRS (11 cm below the umbilicus) (black arrow). (d) Absent AL in the complete PRS. (e) Artificial AL was surgically created by incising PRS and the transversalis fascia beneath. (f) Retromuscular space (ventrally) and preperitoneal space (dorsally) were seen clearly. (g) The vas deferens was freed to obliterated umbilical artery. (h) Weakness of MPO was covered by a large mesh. RAM = rectus abdominis muscle, PRS = posterior rectus sheath, IEV = inferior epigastric vessels, R = right, M = middle. AL = arcuate line, SP = symphysis pubis, CL = Cooper’s ligament, VD = vas deferens, OUA = obliterated umbilical artery, and HS = hernia sac.

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