title: The preperitoneal tissue dilemma in totally extraperitoneal (TEP) laparoscopic hernia repair: an anatomo-surgical study.
abstract: BACKGROUND
  One of the a main reasons for the long learning curve associated with totally extraperitoneal (TEP) laparoscopic hernia repair is an insufficient understanding of the dissection of the proper preperitoneal space. In this study, we investigated the conditions required for the correct anatomical approach to the preperitoneal space.
  
  
  METHODS
  The anatomo-surgical conditions for dissection of the correct preperitoneal space were evaluated in 10 video studies of TEP repairs. In addition, we also investigated the preperitoneal tissue layers in 10 embalmed human bodies.
  
  
  RESULTS
  The proper preperitoneal space can only be approached after cleavage of the ventral component of a bilaminar preperitoneal fascia complex, also known as the posterior lamina of the transversalis fascia. The cleavage can be accomplished spontaneously by a fully expanded balloon correctly introduced into the plane between the rectus muscle and the posterior lamina of the transversalis fascia.
  
  
  CONCLUSIONS
  The anatomy of the preperitoneal tissues in the inguinal region is complex. To gain expertise in laparoscopic totally extraperitoneal (TEP) hernia repair, the presence of a bilaminar fascia complex and the importance of the cleavage of the posterior lamina of transversalis fascia must be appreciated.
authors.affiliation: Department of Anatomy, The Lowlands Institute of Surgical and Applied Anatomy, Faculty of Medicin and Health Sciences, Erasmus University Rotterdam, Dr. Molewaterplein 50, 3015 GE Rotterdam, TheNetherlands. lange4@planet.nl
authors.forename: J F
authors.initials: JF
authors.lastname: Lange
authors.forename: P P G M
authors.initials: PP
authors.lastname: Rooijens
authors.forename: S
authors.initials: S
authors.lastname: Koppert
authors.forename: G J
authors.initials: GJ
authors.lastname: Kleinrensink
mesh_terms: D002102:Cadaver; D005205:Fascia / Q000033:anatomy & histology / Q000473:pathology; D006547:Hernia / Q000473:pathology; D006552:Hernia, Inguinal / Q000473:pathology / Q000601:surgery; D059685:Herniorrhaphy; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D010537:Peritoneum / Q000033:anatomy & histology / Q000473:pathology