Total Extraperitoneal Endoscopic Inguinal Hernioplasty (Tep). Dealing With the Round Ligament

Background International guidelines recommend the laparoendoscopic approach to treat inguinal hernia in women. When performing this technique we have to deal with the round ligament of the uterus and the doubt arises: to divide or not to divide. The peritoneum may be intensely attached to the round ligament and its dissection may be technically challenging. There is no specific statement or consensus on this matter included in the guidelines. Method Video presentation: three different options to manage the round ligament during TEP inguinal hernioplasty. Results Management options regarding the round ligament of the uterus: Division: the round ligament is dissected proximally to avoid injuring the genital branch of the genitofemoral nerve. Place 5 mm endoclips close to the peritoneum before dividing it. Dissection: The round ligament is usually difficult to liberate from the peritoneal sac. Care must be taken to preserve the peritoneal sac integrity. Open the peritoneum: To save the round ligament, the peritoneal sac can be cut to obtain a flap followed by closure of the defect with 5 mm endoclips. Conclusion There is no consensus regarding the round ligament of the uterus’ preservation in TEP surgery, this matter needs further evaluation. We describe three valid management options, but we recommend preservation over division. Nevertheless, sometimes the ligament needs dividing in order to perform a proper repair with mesh placement. If this is the case, the surgeon must have the genital branch of the genitofemoral nerve in mind to avoid chronical postoperative pain.