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Totally extraperitoneal (TEP) repair involves creating a preperitoneal space. The preperitoneal space can be created by telescopic dissection (TD) or plane dissection (PD). Nevertheless, these techniques may have some complications. This study aims to assess the impact and comprehensively compare the TD and PD methods in patients undergoing laparoscopic TEP inguinal hernia repair.
Methods
A retrospective analysis was conducted on 156 patients who underwent PD at the Hospital from January 2017 to December 2023. Using propensity score matching (PSM), 312 TD patients were matched at a 1:2 ratio. The primary outcomes included peritoneal injury, vascular injury, clarity of the surgical field, operation time, and intraoperative blood loss. Secondary outcomes included length of hospital stay, postoperative pain, and recurrence rate.
Results
After matching, no significant differences in clinical characteristics were observed between the two groups. The PD group showed better the surgical field clarity, reduced intraoperative blood loss, and shorter operation time compared to the TD group. Additionally, the TD group had higher hospitalization costs. There were no statistically significant differences in hospital stay and follow-up duration between the two groups. There was a significant difference in the overall complication rate between the PD and TD groups, mainly in terms of peritoneal and vascular injuries. There was no statistical difference in severe complications (Clavien–Dindo classification) between the two groups. There was also no significant difference between the two groups in terms of incision infection, seroma, hematoma, chronic pain, and recurrence rate between the groups.
Conclusion
Both plane dissection and telescopic dissection demonstrate efficacy and reliability in TEP surgery. The PD group showed superior performance in terms of clarity of the surgical field, reduction of peritoneal and vascular injuries, and could shorten hospital stays and reduce costs. Therefore, plane dissection has considerable potential for application in TEP surgery.
Shang-Jun Zhou and Hai Huang are co-first authors of the article.
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The totally extraperitoneal (TEP) laparoscopic inguinal hernia repair is a minimally invasive technique that hinges on the precise creation of the preperitoneal space, encompassing the Retzius and Bogros spaces [1, 2]. Central to this procedure are three dissection methods: telescopic dissection (TD), balloon dissection (BD), and anatomical plane dissection (PD), each with distinct advantages and limitations [3‐7]. While balloon dissection facilitates rapid space creation, its high cost and associated risks—such as vascular injury, peritoneal tear, or bladder trauma—limit its widespread adoption [5, 8]. TD remains the most commonly utilized technique in current clinical practice [3]; however, emerging evidence suggests it may heighten the risk of peritoneal or vascular injuries, potentially compromising procedural safety [9]. In contrast, PD, grounded in membrane anatomy principles, offers a refined approach characterized by improved intraoperative visualization and reduced tissue trauma [6, 9]. Despite these innovations, robust comparative studies evaluating PD versus TD in TEP procedures—particularly regarding safety, efficacy, and visualization quality—remain scarce. This study aims to address this critical knowledge gap by systematically analyzing the perioperative outcomes and laparoscopic field clarity associated with these two techniques, thereby informing evidence-based surgical decision-making.
Materials and methods
Study population and data selection
A retrospective analysis was conducted on the clinical data of patients undergoing TEP surgery at the department of surgery in our hospital. The study included two groups: the plane dissection group (PD group) and the telescopic dissection group (TD group). Inclusion Criteria: (1) Married patients older than 25 years; (2) Able to participate in reliable follow-up. Exclusion Criteria: (1) Old and frail patients unable to withstand general anesthesia; (2) Patients with severe cardiopulmonary, liver, or kidney dysfunction. (3) Patients with severe coagulation disorders; (4) Patients with a history of lower abdominal surgery; (5) Patients with a history of urinary system surgery; (6) Patients with incarcerated or strangulated hernia; (7) Patients with a large hernia sac that cannot be reduced; (8) Patients who withdraw from the study midway. Based on these criteria, a total of 519 cases were collected, including 156 in the PD group and 363 in the TD group. After 1:2 propensity score matching, 156 cases were successfully included in the PD group and 312 in the TD group (Fig. 1). Before matching, the PD group had a higher proportion of indirect hernias, while fewer direct hernias and type II hernias were observed. In contrast, the TD group had an older age. After matching, there were no statistically significant differences in clinical characteristics between the two groups (Table 1). The study was approved by the Ethics Committee of our Hospital, and all patients provided written informed consent before surgery.
Fig. 1
Flowchart of inclusions and exclusions of all participants in the study
A small incision is made 2 cm above the umbilicus and then 1.5 cm laterally, through which the skin, subcutaneous tissue, and anterior rectus sheath (ARS) are excised to access the retromuscular space. (Fig. 2a). A 10 mm trocar is inserted through this incision to access the first surgical plane located between the rectus and posterior rectus sheath (PRS), establishing the initial working space. A 5 mm trocar is placed below the umbilicus, and another 5 mm trocar is positioned at the midpoint between the umbilicus and the pubic symphysis. Dissection continues along the surface of the PRS until it reaches the intersection with the transversalis fascia (i.e., the arcuate line). It then incised to enter the preperitoneal space, thus completing the first anatomical plane transition. The dissection is extended caudally into the same layer of the Retzius space, which constitutes the second surgical plane. Subsequently, the dissection is redirected laterally towards the groin area, freeing the Bogros space situated between the peritoneum and the deep layer of the preperitoneal fascia. This establishes the third surgical plane. Care must be taken to preserve the preperitoneal fatty tissue in order to avoid chronic pain caused by nerve irritation within the "pain triangle" due to the mesh. The hernia sac is then reduced. Femoral and direct hernias can be separated in the Retzius space, while direct hernias larger than 5 cm are sutured to the pubic ramus to prevent seroma formation. The reduction of an indirect hernia necessitates the incision of the internal spermatic fascia and meticulous dissection of the hernia sac from the spermatic vessels. These vessels should be stripped cranially at least 6 cm from the internal ring, and the vas deferens should be dissected until the obliterated umbilical artery is encountered. Finally, the interfoveolar ligament is incised to complete the second anatomical plane transition. This integrates the two distinct planes of the Retzius and Bogros spaces into a single large preperitoneal space, which accommodates the mesh effectively. A 3D mesh measuring 10.8 cm × 16 cm (Bard Davol Inc. Warwick, RI, 02886, USA) is placed without fixation in the created preperitoneal space to complete the preperitoneal hernia repair [11, 12]. The trocars are removed under direct vision, and the skin incisions are then sutured (see the Supplementary Video).
Fig. 2
Comparison of preperitoneal space dissection between the PD and TD groups. a Plane dissection: The retromuscular space was meticulously identified between the rectus and the PRS, followed by careful dissection along the PRS up to the arcuate line, where an incision was made to access the preperitoneal space. b Telescopic dissection: Blunt rod separation was performed forward, backward, and laterally along the PRS. Multiple “cellular” separation holes were observed, with some penetrating through the PRS into the preperitoneal space while others remained within the retromuscular space, resulting in minor bleeding from small blood vessels
A small incision of approximately 1.0 cm is made below or beside the umbilicus, cutting through the linea alba or ARS. The rectus muscle is retracted to expose the space behind it. The telescope is then advanced along the PRS, breaking through the peritoneal fascia, and entering the preperitoneal space (Fig. 2b). The telescope is moved forward, backward, and laterally to separate and expand the preperitoneal working space. A 10 mm trocar is placed at the umbilical incision site, and two 5 mm trocars are inserted approximately one-third above and one-third below the midpoint between the umbilicus and the pubic symphysis. Like the PD group, dissection begins in the medial compartment (Retzius space), where direct and femoral hernias are easily identified and reduced. Subsequently, the lateral compartment (Bogros space) is separated, where an indirect hernia is often dissected and reduced. The remaining steps are essentially the same as those in the PD group described above.
Observation indicators
The main outcomes of the study were peritoneal injury, vascular injury, surgical visual field clarity, operative time, intraoperative blood loss, and postoperative complication rate. Secondary outcomes included length of stay, postoperative pain, and recurrence rate.
Assessment of complications
In our study, the intraoperative and postoperative complications were collected and reported according to the guidelines presented in the literatures [13, 14]. Chronic postherniorrhaphy groin pain is defined as pain lasting > 6 months after surgery. The statistical analysis was conducted utilizing the Clavien–Dindo classification system [15], with special attention paid to situations in which multiple complications were encountered by a single patient. Grade I complications were categorized according to the highest observed Clavien–Dindo grade within each patient.
Postoperative care
TEP is usually performed under general anesthesia, requiring postoperative monitoring for 3–5 h. Postoperative management included sandbag compression on the groin area for eight hours and analgesics tailored to renal function as needed: paracetamol for those with compromised renal capabilities and ibuprofen or paracetamol for other patients. Patients were encouraged to adhere to a diet characterized by low-fat and high-protein content to support their recovery. More strenuous activity, such as running or contact sports, should be avoided for three months. Follow-up data were collected through telephone questionnaires that covered various aspects such as incision sites, pain management strategies, dietary habits, and bowel function. The Visual Analogue Scale (VAS) was utilized to evaluate the participants’ chronic pain levels. Recurrence was identified by the presence of a bulge in the inguinal region. Instances where completed questionnaires were not received from patients or repeated contact attempts proved unsuccessful, they were classified as non-respondents. The completion rates for the TD group and the PD group were 94.8% (296 out of 312) and 94.2% (147 out of 156), respectively.
Statistical analysis
The data were analyzed using SPSS 28 software. Propensity score matching (PMS) was performed on the baseline data of patients at a ratio of 1:2, with the caliper value set to 0.1. Descriptive statistics were used to analyze baseline characteristics, while T-tests or Chi-square tests were employed to compare primary and secondary outcomes between the two groups. Measurement data were expressed as mean ± standard deviation (x ± s), and comparisons between groups were made using T-tests. Categorical data were presented as cases (%). The χ2 test was used for comparisons among groups, and P < 0.05 indicated a statistically significant difference.
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Results
After matching with propensity score 1:2, 156 patients were included in PD group and 312 patients in TD group, respectively, and there was no statistical difference in the basic clinical data, hernia classification, type and hernia site of the two groups, showing comparability (Table 1). Figure 3 shows the covariates of PD and TD groups before and after matching.
Fig. 3
The covariate balance in the two groups before and after the propensity score matching. Red dots and blue dots indicated the absolute standardize mean differences (Color figure online)
There were no perioperative deaths in either group. The results showed that the clarity of visual field in PD group was better than that in TD group (Z = 5.425, P = 0.02), mainly due to the significant difference between grade II and IV visual field (χ2 = 4.300, P = 0.038 and χ2 = 4.544, P = 0.033, respectively) (Fig. 4a–d). The intraoperative blood loss in PD group was less than TD (t = − 2.964, P = 0.003), and the operative time was shorter (t = − 4.670, P < 0.001). The hospitalization cost in TD group was higher than that in PD group (t = − 7.182, P < 0.001). There was no significant difference in length of stay and follow-up between the two groups (t = − 1.661, P = 0.097 and t = − 1.663, P = 0.245). There were no statistically significant differences between the two groups in terms of, seroma, hematoma, urinary retention, or recurrence rates. Additionally, there were no incisional infections or chronic pain in either group. (Table 2).
Fig. 4
Semiquantitative grading system of the bloodstain. a Grade I: Less than a quarter of the tissue in the screen stained with blood, b Grade II: Less than half of the tissue stained, c Grade III: Less than three quarters of the tissue stained, d Grade IV: More than three quarters of tissue stained
Intraoperative and postoperative outcomes of the patients
TD group 312 (n, %)
PD group 156 (n, %)
t/Z/χ2
P Value
Degree of bloodstain
Z = 5.425
0.0200
I
245 (78.5)
133 (85.3)
χ2 = 2.477
0.1160
II
52 (16.7)
19 (12.2)
χ2 = 4.300
0.0380
III
9 (2.9)
4 (2.5)
χ2 = 0.044
0.8340
IV
6 (1.9)
0 (0)
χ2 = 4.544
0.0330
Operation time (min)
92.34 ± 34.084
78.33 ± 22.026
t = − 4.670
< 0.001
Loss of blood (ml)
11.29 ± 29.980
4.09 ± 6.279
t = − 2.964
0.0030
Hospital stay (day)
7.15 ± 2.695
6.74 ± 2.060
t = − 1.661
0.0970
Expenses (Yen)
19,460.24 ± 5506.3623
16,080.45 ± 2899.1610
t = − 7.182
< 0.001
Follow-up (mon)
27.52 ± 12.453
26.01 ± 14.757
t = − 1.163
0.2450
Recurrence
1
0
χ2 = 0.501
0.4790
A significant difference was observed in the total complication rate between the PD group and the TD group (χ2 = 4.424, P = 0.035), mainly in terms of peritoneal injury and vascular injury, with the difference between the two groups being statistically significant (χ2 = 7.145, P = 0.008 and χ2 = 3.956, P = 0.047, respectively). Among the vascular injuries in TD group, two cases had bleeding of more than 500 ml. According to the Clavien–Dindo grading system, there were no statistically significant differences between two groups in complications of grade III or higher, including severe vascular injury, hematoma, seroma, chronic pain, urinary retention, and recurrence rates (χ2 = 0.501, P = 0.479). The incidence of postoperative complications and Clavien–Dindo grading are detailed in Table 3.
Table 3
Intraoperative and postoperative complications graded according the Clavien–Dindo classification (n, %)
Group
Total complications (n, %)
Severe complication (IIIa ~ V)
Type of complication (n, %)
Peritoneum tear
Vascular injury
Incision infection
Hematoma
Seroma
Chronic pain
Urinary retention
TD group = 312
113 (36.2)
2 (0.6)
60 (19.2)
12 (3.8)
0 (0)
6 (1.9)
13 (4.2)
0 (0)
22 (7.1)
PD group = 156
37 (23.7)
0 (0)
15 (9.6)
1 (0.6)
0 (0)
3 (1.9)
5 (3.2)
0 (0)
13 (8.3)
χ2
χ2 = 4.424
χ2 = 0.501
χ2 = 7.145
χ2 = 3.956
χ2 = 0.000
χ2 = 0.260
χ2 = 0.247
P Value
0.035
0.479
0.008
0.047
1.000
0.601
0.619
Group
Clavien–Dindo classification total
Clavien–Dindo classification grade (n, %)
0
I
II
IIIa
IIIb
IVa
IVb
V
TD group = 312
199 (63.8)
108 (34.6)
3 (1.0)
0 (0)
2 (0.6)
0 (0)
0 (0)
0 (0)
PD Group = 156
119 (76.3)
35 (22.4)
2 (1.3)
0 (0)
0 (0)
0 (0)
0 (0)
00 (0)
Z/χ2
Z = − 2.703
χ2 = 7.462
χ2 = 7.270
χ2 = 0.101
χ2 = 0.501
P Value
0.007
0.006
0.007
0.751
0.479
Discussion
The success of laparoscopic inguinal hernia repair, whether using the transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) approach, relies on precise mesh placement within the preperitoneal space to reinforce the myopectineal orifice (MPO). To achieve this, meticulous dissection is required to establish an optimal surgical field. In the TAPP procedure, an incision is made on the peritoneum to enter the preperitoneal space through the abdominal cavity. This approach involves dissecting from posterior to anterior across a single anatomical plane. In contrast, the TEP procedure involves navigating through multiple layers from the skin to the preperitoneal space, moving from anterior to posterior. The complexity of these multiple layers, intricate anatomy, limited workspace, and technical challenges have historically restricted the widespread adoption of the TEP procedure.
Since Dulucq first introduced the TEP technique in 1992 [16], telescopic dissection has remained the predominant method for preperitoneal space creation. Although this method offers intuitive surgical maneuverability, it comes with technical demands such as precise layer separation, restricted visual field optimization, and elevated complication rates reported in the literature, which have persisted as barriers to consistent success. To objectively evaluate these trade-offs, we compared telescopic dissection (TD) with plane dissection (PD), a method emphasizing anatomical layer-by-layer separation under direct visualization, to assess differences in perioperative outcomes, including safety profiles, procedural efficacy, and surgical field clarity.
Our study found a significant increase in overall complication rates and severity, particularly concerning vascular and peritoneal injuries, in patients undergoing TD compared to PD (60 [19.2%] vs 15 [9.6%], P = 0.008; 12 [3.8%] vs 1 [0.6%], P = 0.047, respectively). These findings highlight the critical role of dissection technique in optimizing safety and outcomes. These disparities stem from anatomical and technical factors: 1. Layer Navigation Challenges: TD relies on blind advancement through tissue planes, increasing the likelihood of inadvertent peritoneal tear or vascular injury (e.g., inferior epigastric artery [IEA] laceration in 12 TD cases vs. 1 PD case). TD images reveal multiple “cellular” separation holes, some of which puncture into the preperitoneal space while others remain in the retromuscular space (Fig. 2b). In contrast, PD’s direct visualization of landmarks such as the arcuate line–transversalis fascia junction enables precise dissection (Fig. 1a), minimizing collateral damage. 2. Arcuate Line Variability: Textbook descriptions of arcuate line location (4–6 cm below umbilicus) apply to only about 30% of cases [17‐20]. Low or absent arcuate lines, present in most patients, create thicker posterior rectus sheaths (PRS), making TD dissection hazardous. PD allows intentional PRS incision under direct vision, facilitating safe entry into the preperitoneal space. 3. Vascular Vulnerability: The IEA’s retromuscular course (particularly in patients without arcuate lines) increases its vulnerability during TD [20, 21], as observed in two TD cases with > 500 ml blood loss. In addition, excessive dissection depth further may risk iliac or obturator vessel injury. Patients undergoing TD experienced greater blood-stained surgical fields (P < 0.001), prolonged hospital stays, and higher costs, likely due to minor vessel tears during repetitive TD maneuvers. However, no significant differences in hematoma/seroma rates or chronic pain were observed, attributable to standardized mesh placement and postoperative compression protocols. Additionally, although one case had relapse in TD group, there was no significant difference between the two groups.
While PD demonstrates clear advantages in reducing complications, its adoption hinges on three interdependent factors: 1. Training Infrastructure: High-volume surgical centers with simulation labs and proctorship programs are critical for overcoming PD’s learning curve. Simulation training allows surgeons to practice PD in a risk-free environment, mastering its anatomical precision before live application. Proctorship programs further accelerate skill acquisition by pairing novice surgeons with experienced mentors. Operative times decrease significantly with procedural familiarity, highlighting the value of structured training. Institutions lacking these resources risk delayed adoption due to technical barriers. 2. Patient Selection: PD is particularly advantageous in anatomically complex cases. In complex hernias, TD’s blunt dissection risks causing iatrogenic injury to displaced structures, such as the peritoneum, vessels, and bladder. Arcuate line anomalies complicate TD by thickening the posterior rectus sheath, whereas PD enables direct visualization for safe entry. 3. Resource Availability: Centers lacking advanced visualization systems or hemostatic equipment may prioritize PD to reduce complication risks. This framework balances patient safety, surgeon skill, and resource availability, emphasizing PD as the preferred approach in optimized settings.
This study has several limitations. First, its retrospective design introduces potential selection bias, though propensity score matching mitigated confounding. Second, surgeon skill variability—a critical factor in TEP outcomes—was not quantified. Third, the evolving learning curve for PD may have influenced later-case outcomes. Fourth, while our telephone follow-up achieved a 95% response rate, potential recall bias in patient-reported outcomes and the inability to perform physical examinations represent notable constraints. Multi-center prospective trials with long-term follow-up are necessary to validate these findings.
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Conclusion
PD offers a safer, more controlled approach to TEP dissection, particularly in anatomically complex cases. By integrating structured training, patient-specific decision-making, and institutional support, surgeons can mitigate TD’s risks while advancing minimally invasive hernia repair.
Declarations
Disclosures
Shang-Jun Zhou, Hai Huang, Ping Zhan, Rui-Bin Deng, Yan-Qing Deng, Pei-Jie Zhang, Huan-Bin Zhang, Hong-Shuai Li, You-Hua Wang, Jian-Hua Luo and Xue-Lu Zhou have no conflicts of interest or financial ties to disclose.
Conflict of interest
The authors have no conflict of interest or financial ties to disclose.
Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
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