Ten Surgical Commandments of Totally Extraperitoneal Inguinal Hernia Repair: A Stepwise Technical Roadmap for Safe and Reproducible Surgery

Abstract

Background: Totally extraperitoneal (TEP) inguinal hernia repair is an established laparo-endoscopic technique that applies the principles of posterior preperitoneal mesh reinforcement without entering the peritoneal cavity. Despite well-recognised advantages in selected patients, the technique is limited by a narrow working space, unfamiliar posterior groin anatomy, and a learning curve that may predispose to technical errors.
Objective: To present a structured, anatomy-based set of ten operative commandments for TEP repair that can be used as a practical roadmap for training, intraoperative standardisation, and quality assurance.
Technique: The operative sequence is organised around safe retrorectus access, stable pneumo-extraperitoneum, medial Retzius dissection, lateral Bogros dissection, identification of all potential hernia sites, careful parietalisation of cord structures, achievement of the critical view of the myopectineal orifice, adequate mesh deployment, selective fixation, and desufflation under direct vision.
Conclusion: A reproducible TEP operation depends less on isolated manoeuvres and more on consistent exposure of the entire myopectineal orifice. The proposed commandments translate key anatomic concepts into a stepwise checklist that may reduce missed hernias, inadequate mesh overlap, neurovascular injury, and mesh displacement.