{"paper_id":"4875fd44-2779-4400-beda-9f8b0fedd69c","body_text":"Streamlining the totally extraperitoneal approach for laparoscopic inguinal hernia repair: the 3-2-1 method | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Streamlining the totally extraperitoneal approach for laparoscopic inguinal hernia repair: the 3-2-1 method Xue-Lu Zhou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3160654/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The total extraperitoneal (TEP) technique is known for its complexity compared to the transabdominal preperitoneal technique (TAPP). This study aimed to streamline the TEP procedure by introducing the 3-2-1 method, which involves creating three surgical planes, implementing two transitions, and establishing a spacious preperitoneal space. The objective was to comprehensively evaluate the safety, efficacy, and reliability of this approach. Methods A total of 358 patients with 380 inguinal hernias underwent TEP repair using the 3-2-1 method via the retromuscular approach. Patient characteristics, operative time, hospital stay, complications, and recurrence rates were assessed. Results Among the hernias, 190 were on the right side, 140 on the left side, and 50 were bilateral. The distribution of hernia types included indirect hernia (201), direct hernia (132), compound hernia (16), complex hernia (6), and femoral hernia (3). The average operative time was 58 minutes for unilateral hernias and 110 minutes for bilateral hernias. Postoperative complications occurred in 32 cases (8.9%), but no serious complications were observed. The average hospital stay was 7 days, and patients were followed up for an average of 49 months. There were no cases of chronic pain or recurrence. Conclusions The 3-2-1 method for laparoscopic TEP repair of inguinal hernias proves to be a simple, safe, effective, and reliable approach. Inguinal hernia Extraperitoneal Retromuscular Transition Repair Figures Figure 1 Figure 2 Figure 3 Introduction The totally extraperitoneal (TEP) repair is a laparoscopic surgical technique employed for the treatment of inguinal hernias. It involves the placement of a mesh in the preperitoneal space between the transversalis fascia and peritoneum. Accurate positioning of the mesh within the correct preperitoneal space is crucial for the success of the procedure [ 1 – 6 ]. However, accessing this space through the various membranous structures and surgical planes in the lower lateral abdominal wall can be complex and challenging. Therefore, a comprehensive understanding of the anatomy of the lower abdominal wall and groin region is imperative for the surgical approach. In order to simplify the TEP procedure, the 3-2-1 method has been developed. This technique involves the creation of three surgical planes utilizing different anatomical spaces, which are then connected through two transitions to establish a spacious preperitoneal space. By adopting the 3-2-1 method, the TEP procedure is streamlined, resulting in improved surgical outcomes, including precise mesh placement, reduced postoperative complications, and lower recurrence rates. Patients and Methods Patients Between October 2017 and January 2023, a retrospective analysis was conducted on a cohort of 360 patients (384 hernias) who underwent the totally extraperitoneal (TEP) approach for inguinal hernia repair at our hospital. Two patients were excluded from the study due to the presence of large peritoneal tears, which necessitated their conversion to the transabdominal preperitoneal (TAPP) technique. The analyzed patient population consisted of 340 males and 18 females, with an average age of 52 ± 2.7 years (range: 24 to 86 years) and an average body mass index (BMI) of 24.1 ± 2.2 kg/m2 (range: 19.8 to 28.1 kg/m2). All hernias were primary, with 190 on the right side, 140 on the left side, and 50 bilateral cases. The distribution of hernia types was as follows: 201 indirect hernias, 132 direct hernias, 16 combined hernias, 6 complex hernias (direct + indirect + femoral hernia and direct + indirect + Spiegel), and 3 femoral hernias. Scrotal hernias accounted for 13.9% (53/380) of all hernias. Further details regarding hernia location, classification, and type can be found in Table 1 . This study was approved by the Hospital Ethics Committee, and informed consent was obtained from all participants included in the study. Table 1 Demographics and hernia characteristics of the patients No. of patients (no. of hernias) 360 (384) Mean age (range) 52 ± 2.7 (24–86) Body mass index 24.1 ± 2.2 (19.8–28.1) Sex Male 345 (95.8%) Female 15 (4.2%) Location of hernia Right 192 (50.0%) Left 144 (37.5%) Bilateral 48 (12.5%) Type of hernia [7] II 131 (34.1) III 253 (65.9) Mean operative time (range) 58 (± 2.5) min. for unilateral hernia 110 (± 1.7) min. for bilateral hernia Mean hospital stays (range) 7 (5–10 d) Mean follow-up (range) 49 (6–70 mo) Inclusion and exclusion criteria The inclusion criteria for this study were as follows: (1) Married patients over 25 years old with primary inguinal hernia. (2) Patients who could be reliably followed up. The following were the exclusion criteria: (1) Elderly patients unable to tolerate general anesthesia. (2) Patients with severe heart, lung, 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 urological surgery. (6) Patients with incarcerated or strangulated hernia. (7) Patients with a significantly enlarged hernia sac that could not be reduced. (8) Patients who withdrew from the study midway. Surgical procedure To establish a surgical working space, a small incision is made 1.5 cm outside the linea alba and 2 cm above the umbilicus. Subsequently, the subcutaneous layer and anterior rectus sheath (ARS) are incised, allowing access to the retromuscular space by blunt dissection of the rectus abdominis muscle. An indigenous balloon is then inserted and inflated with 150 ml of air to expand the superior space located behind the rectus abdominis [ 6 ]. Following this, a 10 mm trocar is inserted, followed by a 5 mm trocar below the umbilicus. A \"tunnel\" is created through the rectus muscle to enter the retromuscular space, which serves as the first anatomical plane. Another 5 mm trocar is placed at the midpoint of a line connecting the umbilicus and pubic symphysis to complete the process. Dissection is performed along the surface of the posterior rectus sheath (PRS) until reaching the junction of the PRS and the transversalis fascia (Fig. 1 A). The transversalis fascia is incised below the PRS (or arcuate line), medially to the linea alba, and laterally in the vicinity of the anterior superior iliac spine on the side of the hernia, allowing access to the preperitoneal space, which constitutes the second surgical anatomical plane. This incision marks the completion of the first anatomical plane transition (Fig. 1 B). Dissection of the preperitoneal space continues caudally to enter the Retzius space, which serves as the second anatomical plane. The Retzius space is separated anteriorly by the pubic symphysis and posteriorly by the superficial preperitoneal fascia, with lateral separation extending to the inferior epigastric vessels (Fig. 1 C). During the dissection of the Retzius space, important landmarks such as the pubic symphysis, Cooper's ligament, and the corona mortis must be identified. The next step involves proceeding to the lateral inguinal region and dividing the Bogros space between the peritoneum and deep layers of preperitoneal fascia, constituting the third anatomical plane. Preserving sufficient preperitoneal fat tissue in this area is crucial to prevent chronic pain caused by mesh stimulation of nerves in the \"triangle of pain.\" To enhance the preperitoneal space, a visual-enhanced technique can be employed to incise the lateral arcuate line approximately 1 cm closer to the linea semilunaris [ 8 ]. Reversal of the hernia sac is necessary. In the Retzius space, femoral and direct hernias can be separated, and for direct hernias larger than 5 cm, suturing them to the pubic ramus can prevent seroma formation. Dissection of the internal spermatic cord fascia is required for reducing an indirect hernia while separating the hernia sac from the spermatic vessels. Caution should be exercised during the dissection process to avoid damage to the underlying iliac vessels situated in the \"triangle of danger.\" To create sufficient space for the mesh, the vas deferens needs to be separated from the surrounding tissue until reaching the junction of the obliterated umbilical artery. Moreover, the spermatic cord should be released at a distance of at least 6–8 cm from the indirect ring. The interfoveolar ligament is then incised to merge the Retzius space and the Bogros space, located at two distinct anatomical planes, into a single space (Fig. 1 D). This procedure results in the formation of a large enough preperitoneal space to accommodate the mesh (Fig. 1 E). A large 3D mesh (10.8 × 16 cm, Bard Davol Inc. Warwick, RI, 02886, USA) is placed in the created preperitoneal space to complete the hernia repair (Fig. 1 F). Finally, the trocars are removed under direct vision, and the skin incisions are closed with sutures. Results The study findings revealed that the average operation duration for unilateral hernias was 58 (± 2.5) minutes and for bilateral hernias was 110 (± 1.7) minutes, with a range of 46 to 140 minutes. During the surgery, 26 patients experienced small peritoneal injuries, which did not require specific treatment. However, two patients with large peritoneal tears had to undergo an early switch to transabdominal preperitoneal (TAPP) surgery and were subsequently excluded from the study analysis. Acute urinary retention occurred in 25 patients postoperatively, necessitating catheterization for several days. Among the observed postoperative complications, eight cases of hematoma were reported, with three requiring suction and one necessitating incision and drainage of the scrotum. Additionally, there were 20 cases of seroma, with six requiring multiple punctures for fluid drainage, while the remaining 14 cases resolved spontaneously. Three patients experienced subcutaneous emphysema, which did not require treatment. One patient reported a foreign body sensation in the groin, which resolved after six months. Due to the social insurance system in our country, ambulatory surgery is not currently performed, resulting in an average hospital stay of seven days (range: 7–10 days). The follow-up period for the majority of patients (333 out of 358) ranged from six to 70 months, with an average duration of 49 months. During this follow-up period, no cases of chronic pain or recurrence were reported. A summary of the study results can be found in Table 2 . Table 2 Intraoperative and postoperative complications Intraoperative Peritoneal tear 28 (7.8%) Inferior epigastric vessels injury 0 (0%) Bladder injury 0 (0%) Postoperative Subcutaneous emphysema 3 (0.8%) Hematoma 8 (2.2%) Seroma 20 (5.5%) Wound infection 0 (0%) Foreign body sensation 1(0.3%) Chronic pain 0 (0%) Urinary retention 25 (6.9%) Recurrence 0 (0%) Discussion The preperitoneal space, situated between the transversalis fascia and the peritoneum, serves as the location for the placement of a large mesh in inguinal hernia preperitoneal repair [ 1 – 6 ]. However, there is currently no consensus regarding the optimal technique for incising the transversalis fascia [ 9 – 11 ]. In our study, we utilized the concept of \"three anatomical planes, two-plane transition, and one space\" to create an adequately spacious preperitoneal space for mesh placement. Through this approach, we achieved positive clinical outcomes in the context of totally extraperitoneal (TEP) inguinal hernia repair. The surgical anatomy for TEP is classified into three planes: the first surgical plane, located in the anterior wall of the lower abdomen, is a potential space between the rectus abdominis muscle (or rectus fascia if present) and the PRS, which is replaced by the transversalis fascia located below the arcuate line. To access this initial working space, we selected a supraumbilical incision. This approach offers several benefits, including the ability to directly observe the separation of the first plane, a reduced risk of damaging blood vessels and the peritoneum, and a clear view of the surgical area. Furthermore, by preserving the integrity of the PRS, the surgeon can evaluate the morphology, position, and quantity of the arcuate line [ 5 , 6 ]. When performing an anatomical separation of the first plane, several factors must be taken into account. Firstly, it is essential to avoid damaging the costal nerves, which are situated outside the posterior space of the rectus abdominis. Secondly, the inferior epigastric artery can be anatomically divided into three segments. The first segment of the artery originates from the external iliac artery and passes through the transversalis fascia, entering t the PRS. This segment is referred to as the extrinsic segment. The second segment of the artery travels within the PRS, and it is known as the intrathecal segment. The third segment of the artery extends upward into the rectus abdominis muscle and forms an anastomosis with the epigastric artery. This segment is referred to as the intramuscular segment [ 12 , 13 ]. As the course of the intrathecal segment (and its branches) can vary due to variations in the PRS, care must be taken to avoid damaging the artery or its branches, which could result in hemorrhage, unclear vision, and potentially fatal postoperative hemorrhage [ 6 ]. Thirdly, each patient's body shape and abdominal wall thickness is unique, so the depth of the separation layer must be tailored accordingly. If the separation layer is too deep, it could lead to peritoneal tear and pneumoperitoneum, which could negatively impact the operation. The seconded anatomical plane consists of the preperitoneal space between the superficial layer of preperitoneum (the membranous layer of the extraperitoneal fascia) [ 14 ] and the peritoneum, and the Retzius space, which extends downward from the preperitoneal space. The Retzius space is a potential retropubic space situated between the bladder and the pubic bone. Its boundaries include the transversalis fascia anteriorly, the preperitoneal fascia (or superficial umbilical bladder fascia) posteriorly [ 4 , 6 , 14 , 15 ], and the inferior epigastric vessels laterally. The identification of the second plane is based on the presence of avascular connective tissue that resembles a white spider web, which is considered significant and often referred to as the “holy planes” [ 5 ]. Dissecting the second plane requires several important considerations. First, separation must occur between the preperitoneal fascia and the transversalis fascia, which delineates two important surgical planes between the rectus and the peritoneum. The retromuscular plane (or the first plane), between the rectus and the transversalis fascia, contains the inferior epigastric vessels, while the preperitoneal plane (or the second plane), between the transversalis fascia and the superficial layer of the preperitoneal fascia, contains the median and medial umbilical ligaments enveloped by the visceral fascia of the bladder [ 6 ]. It is essential to minimize iatrogenic trauma to the pelvic fascia during this separation. Second, when separating the Retzius space, care must be taken to avoid excessive depth, as it may damage the retropubic venous plexus or blood vessels on the bladder’s surface, leading to bleeding. Finally, special attention should be paid to the abnormal obturator blood vessels and the “corona mortis” on the Cooper’s ligament to prevent damage to the blood vessels in these areas. The third plane, also known as the Bogros space or posterior inguinal space, is a potential space located behind the groin area. It is an extension of the preperitoneal space in the groin but is separate from the Retzius space. The Bogros space is situated between the deep preperitoneal fascia, or the inner fatty layer of the extraperitoneal fascia [ 4 , 6 , 14 ], anteriorly and the peritoneum posteriorly, with the fascia iliaca on the outer aspect and the interfoveolar ligament (the inferior epigastric vessels) on the inner aspect. Similar to the second plane, the Bogros space is also free of blood vessels. When dissecting this plane, it is essential to proceed between the peritoneum and the deep preperitoneal fascia while minimizing any harm to the peritoneum. Caution must be exercised as the peritoneum becomes thinner cephalad. Preserving the extraperitoneal fat tissue in the iliac fossa region is critical, and the nerves in the pain triangle should be safeguarded to avoid postoperative pain. Visual-enhanced techniques can be used to enlarge the Bogros space if required [ 8 ]. The surgical procedure can be divided into two distinct transitions. The first transition involves the movement from the retromuscular space to the preperitoneal space, which can be visualized as two stacked floors without direct connection (Fig. 2 A, B). To access the second plane, an incision must be made in the transversalis fascia at the arcuate line, creating an opening resembling a gap in the \"floor ceiling\" (Fig. 2 C, D). This opening provides entry into the second plane, which extends downwards towards the Retzius space beneath the first plane. During this operation, several important considerations should be considered. If a classic arcuate line is present, the transversalis fascia can be incised below it to access the second level. However, if the arcuate line is low or absent, an artificial incision over the appropriate posterior sheath is necessary [ 5 , 6 , 16 ]. Care must be exercised not to incise the arcuate line too deeply, as it may cause peritoneal damage and lead to pneumoperitoneum. In the event of a small peritoneal tear during surgery, the procedure can continue, but a larger tear would require suturing to prevent significant pneumoperitoneum from interfering with the operation. The second transition involves the movement from the Retzius space behind the pubic bone to the Bogros space behind the lateral groin. The Retzius space contains organs such as the bladder, prostate, spermatic cord, and ureter, enclosed by superficial and deep layers of preperitoneal fascia. This fascia originates from the mesoderm and lies between the ectoderm (transversalis fascia) and endoderm (peritoneum). The preperitoneal fascia extends upwards and backwards, forming the retrorenal and prerenal fascia, collectively known as the urogenital fascia (UGF), which encloses the kidneys and adrenal glands [ 17 , 18 ]. In contrast, the Bogros space does not contain any organs and is separated from the Retzius space by a “partition wall” formed by the interfoveolar ligament (Fig. 3 A, B). To access the Bogros space, the interfoveolar ligament needs to be removed (Fig. 3 C, D). However, the anatomy of the interfoveolar ligament can vary, requiring caution to avoid damage to the inferior epigastric and iliac vessels, as well as the vas deferens. Additionally, the vas deferens needs to be divided up to the intersection of the obliterated umbilical artery to achieve an adequate preperitoneal space during surgery. Upon separating the lower abdominal wall and inguinal region, the preperitoneal space is created, encompassing the preperitoneal space of the lower abdominal wall, the caudally extending Retzius space, and the laterally located Bogros space. While considered as a single unit, this space can be further divided into two compartments: the medial and lateral compartments. The medial compartment contains vasculature, including the femoral artery and vein. The lateral compartment allows for the passage of the iliopsoas, attaching to the femur, along with the femoral nerve. Proper positioning of the mesh within the preperitoneal space is crucial for effective inguinal hernia repair. The mesh should be placed with half in the Retzius space, between the superficial preperitoneal fascia and the retropubic transversalis fascia, and half in the Bogros space, between the deep preperitoneal fascia and the peritoneum [ 15 ]. This placement ensures complete coverage of the hernia defect and minimizes the risk of recurrence. The incidence of postoperative complications associated with hernia repair in this study population was relatively low, and no cases of serious complications were reported. Among the observed complications, twenty-eight cases of peritoneal laceration were noted, with two cases requiring an early transition to TAPP due to the size of the tear. Acute urinary retention following general anesthesia was observed in twenty-five elderly patients, necessitating catheterization for several days. Eight cases of hematoma, potentially associated with scrotal hernia, were reported, and one case required surgical drainage of the scrotum, while the remaining two cases were managed with puncture and aspiration. Twenty cases of seroma were also reported, with six requiring drainages via puncture and the others resolving spontaneously. Notably, no cases of chronic pain were reported in this cohort. The authors suggest that the presence of preperitoneal adipose tissue in the Bogros space offers protection against nerve stimulation within the \"triangle of pain\" by the mesh. Furthermore, non-fixation of the mesh may also contribute to the prevention of chronic pain. During the follow-up period, one patient reported experiencing a foreign body sensation in the groin; however, these symptoms resolved after six months and were likely attributed to the patient's low body weight. Although no recurrences were observed during the long-term follow-up, it remains important to continue monitoring for potential complications and the possibility of recurrence. Conclusion In conclusion, the \"3-2-1\" technique for totally extraperitoneal inguinal hernia repair, involving three dissection planes, two plane transitions, and one preperitoneal space, proves to be a straightforward and comprehensible approach. The results of follow-up assessments indicate its safety and effectiveness, with no notable complications reported. Furthermore, the technique lends itself well to adoption by surgeons who are new to the procedure, as it is easily learnable and implementable. Declarations Acknowledgements Not applicable. Author contributions This work was done by ZXL and there is no contribution of any other authors. Funding This study was funded by Dongguan Science and Technology Bureau (2023507 15009200). Availability of data and materials The datasets used and analyzed during the current study are available from the corresponding author on reasonable request Ethics approval and consent to participate All procedures performed in studies involving human participants were in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was approved by the Ethics Committee of Chashan Hospital of Guangdong Medical University. All patients obtained informed consent. Consent for publication Not applicable. Competing interests The author declares that he has no competing interest. References Kingsnorth AN, Skandalakis PN, Colborn GL, Weidman TA, Skandalakis LJ, Skandalakis JE. Embryology, anatomy, and surgical applications of the preperitoneal space. Surg Clin North Am. 2000;80(1):1–24. Arregui ME. Surgical anatomy of the preperitoneal fasciae and posterior transversalis fasciae in the inguinal region. Hernia. 1997;1(2):101–10. 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The applied surgical anatomy of the peritoneal fascia of the groin and the \"secondary\" internal inguinal ring. Aust N Z J Surg. 1975;45(1):8–14. Ohuchi M, Fukunaga M, Nagakari K, Azuma D, Kohama S, Nomoto J, Sakamoto K. Surgical technique and outcomes of transabdominal preperitoneal inguinal hernia repair after radical prostatectomy: dissection between the transversalis fascia and superficial layers of preperitoneal fascia. Hernia. 2019;23(1):167–74. Ansari MM. Artificial Arcuate line: surgical creation during TEPP hernioplasty. Clin Surg. 2017;2:1698. Asakage N. Paradigm shift regarding the transversalis fascia, preperitoneal space, and Retzius' space. Hernia. 2018;22(3):499–506. Li Y, Qin C, Yan L, Tong C, Qiu J, Zhao Y, Xiao Y, et al. Urogenital fascia anatomy study in the inguinal region of 10 formalin-fixed cadavers: new understanding for laparoscopic inguinal hernia repair. BMC Surg. 2021;21(1):295. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-3160654\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":223495488,\"identity\":\"ee65a08a-07b3-4b47-80cf-79e1e4a2573c\",\"order_by\":0,\"name\":\"Xue-Lu Zhou\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyElEQVRIiWNgGAWjYDACCQglw8DOwPiAwYAELTwMzAzMBiRrYZMgyl3ys5uPSfO22fAYHOYxq/xRcEeegf3w0Q34tDDOOZYmObMtDazlNo/BM8MGnrS0G/i0MEvkmEl8bDsM0cJgcJixQYLHDK8WNpCWxLb/YC2FPwwO2xPUwgOx5QBYCwOQTCSoRUIiLdlyxrlkHsnDbMXSQC3JbYT8Ij8j+eBtnjI7Ob7jzRs//vhz2Laf/fAxvFqw+I405aNgFIyCUTAKsAEAxGBAfrMrf6EAAAAASUVORK5CYII=\",\"orcid\":\"\",\"institution\":\"Chashan Hospital of Guangdong Medical University\",\"correspondingAuthor\":true,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Xue-Lu\",\"middleName\":\"\",\"lastName\":\"Zhou\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2023-07-11 14:29:26\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-3160654/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-3160654/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":41245411,\"identity\":\"63e76a6a-2b89-46b7-840f-3418f895d4c0\",\"added_by\":\"auto\",\"created_at\":\"2023-08-08 14:31:17\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":66764441,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eThe figure illustrates the sequence of steps involved in the laparoscopic total extraperitoneal inguinal hernia repair, with a specific focus on the 3-2-1 method. \\u003cstrong\\u003e1A\\u003c/strong\\u003e Separation of the first plane (retromuscular space), \\u003cstrong\\u003e1B \\u003c/strong\\u003eA transverse incision is made on the transversalis fascia (arcuate line) below the PRS, completing the first transition from the first plane to the second plane (preperitoneal space) indicated by the green arrow, \\u003cstrong\\u003e1C\\u003c/strong\\u003e The dissection of the Retzius space, which extends from the preperitoneal space, is carried out thoroughly, \\u003cstrong\\u003e1D\\u003c/strong\\u003e After the Bogros space is dissected, the interfoveolar ligament is incised to complete the second transition from the second to the third surgical plane (green arrow), \\u003cstrong\\u003e1E \\u003c/strong\\u003eA sufficiently large preperitoneal space is created, \\u003cstrong\\u003e1F\\u003c/strong\\u003e A mesh of large size (10.8 × 16 cm) is utilized to repair indirect, direct, and femoral hernias simultaneously, in order to minimize the risk of inguinal hernia recurrence\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-3160654/v1/beee055ae4669be8e88360d1.png\"},{\"id\":41245408,\"identity\":\"5561de58-9cf5-437b-b26a-69e4d69e6340\",\"added_by\":\"auto\",\"created_at\":\"2023-08-08 14:31:16\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":6157217,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eThe figure shows a schematic diagram of the anatomical relationship between the first and second planes, as well as the first transition between them in the sagittal plane. \\u003cstrong\\u003e2A, B\\u003c/strong\\u003e The first surgical plane, known as the retromuscular space, and the second surgical plane, called the preperitoneal space, can be analogized as \\\"upper and lower floors\\\" that are not directly connected anatomically, \\u003cstrong\\u003e2C, D\\u003c/strong\\u003e Following the incision of the transversalis fascia (or the arcuate line), the surgical plane proceeds through its first transition (red dotted arrow), facilitating access from the first plane to the second plane and extending downward into the Retzius space\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-3160654/v1/afcc59806f39e5794fdd40d7.png\"},{\"id\":41245410,\"identity\":\"ac06d764-e82a-4683-9591-713173876b49\",\"added_by\":\"auto\",\"created_at\":\"2023-08-08 14:31:16\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":5792899,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eThe figure shows a schematic diagram the anatomical relationship between the second plane and the third plane, as well as the second transition between them in the axial plane. \\u003cstrong\\u003e3A, B\\u003c/strong\\u003e The anatomical relationship between the second plane (the Retzius space) and the third plane (the Bogros space) can be compared to a \\\"partition wall\\\" between two rooms, where the two planes are not connected to each other, \\u003cstrong\\u003e3C, D \\u003c/strong\\u003eTo finalize the second surgical plane transition (red dotted arrow), it is necessary to cut the interfoveolar ligament that separates the second plane (the Retzius space) from the third plane (the Bogros space), merging these two spaces into a single preperitoneal space. A large mesh can be inserted into this newly created space to complete the surgery\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-3160654/v1/94dbd2c7613f87121b98d27f.png\"},{\"id\":43014895,\"identity\":\"04ac055a-857b-4cf3-bbf9-8bdc548a5148\",\"added_by\":\"auto\",\"created_at\":\"2023-09-12 15:07:23\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":745762,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-3160654/v1/0b42710a-c709-4dcf-a4e0-6f2f2555b38c.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Streamlining the totally extraperitoneal approach for laparoscopic inguinal hernia repair: the 3-2-1 method\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eThe totally extraperitoneal (TEP) repair is a laparoscopic surgical technique employed for the treatment of inguinal hernias. It involves the placement of a mesh in the preperitoneal space between the transversalis fascia and peritoneum. Accurate positioning of the mesh within the correct preperitoneal space is crucial for the success of the procedure [\\u003cspan additionalcitationids=\\\"CR2 CR3 CR4 CR5\\\" citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. However, accessing this space through the various membranous structures and surgical planes in the lower lateral abdominal wall can be complex and challenging. Therefore, a comprehensive understanding of the anatomy of the lower abdominal wall and groin region is imperative for the surgical approach. In order to simplify the TEP procedure, the 3-2-1 method has been developed. This technique involves the creation of three surgical planes utilizing different anatomical spaces, which are then connected through two transitions to establish a spacious preperitoneal space. By adopting the 3-2-1 method, the TEP procedure is streamlined, resulting in improved surgical outcomes, including precise mesh placement, reduced postoperative complications, and lower recurrence rates.\\u003c/p\\u003e\"},{\"header\":\"Patients and Methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ePatients\\u003c/h2\\u003e \\u003cp\\u003eBetween October 2017 and January 2023, a retrospective analysis was conducted on a cohort of 360 patients (384 hernias) who underwent the totally extraperitoneal (TEP) approach for inguinal hernia repair at our hospital. Two patients were excluded from the study due to the presence of large peritoneal tears, which necessitated their conversion to the transabdominal preperitoneal (TAPP) technique. The analyzed patient population consisted of 340 males and 18 females, with an average age of 52\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.7 years (range: 24 to 86 years) and an average body mass index (BMI) of 24.1\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.2 kg/m2 (range: 19.8 to 28.1 kg/m2). All hernias were primary, with 190 on the right side, 140 on the left side, and 50 bilateral cases. The distribution of hernia types was as follows: 201 indirect hernias, 132 direct hernias, 16 combined hernias, 6 complex hernias (direct\\u0026thinsp;+\\u0026thinsp;indirect\\u0026thinsp;+\\u0026thinsp;femoral hernia and direct\\u0026thinsp;+\\u0026thinsp;indirect\\u0026thinsp;+\\u0026thinsp;Spiegel), and 3 femoral hernias. Scrotal hernias accounted for 13.9% (53/380) of all hernias. Further details regarding hernia location, classification, and type can be found in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e. This study was approved by the Hospital Ethics Committee, and informed consent was obtained from all participants included in the study.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eDemographics and hernia characteristics of the patients\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"2\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNo. of patients (no. of hernias)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e360 (384)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMean age (range)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e52\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.7 (24\\u0026ndash;86)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBody mass index\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e24.1\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.2 (19.8\\u0026ndash;28.1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSex\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMale\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e345 (95.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFemale\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e15 (4.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLocation of hernia\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRight\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e192 (50.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLeft\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e144 (37.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBilateral\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e48 (12.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eType of hernia\\u003csup\\u003e[7]\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eII\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e131 (34.1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eIII\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e253 (65.9)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMean operative time (range)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e58 (\\u0026plusmn;\\u0026thinsp;2.5) min. for unilateral hernia 110 (\\u0026plusmn;\\u0026thinsp;1.7) min. for bilateral hernia\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMean hospital stays (range)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e7 (5\\u0026ndash;10 d)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMean follow-up (range)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e49 (6\\u0026ndash;70 mo)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec4\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eInclusion and exclusion criteria\\u003c/h2\\u003e \\u003cp\\u003eThe inclusion criteria for this study were as follows: (1) Married patients over 25 years old with primary inguinal hernia. (2) Patients who could be reliably followed up. The following were the exclusion criteria: (1) Elderly patients unable to tolerate general anesthesia. (2) Patients with severe heart, lung, 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 urological surgery. (6) Patients with incarcerated or strangulated hernia. (7) Patients with a significantly enlarged hernia sac that could not be reduced. (8) Patients who withdrew from the study midway.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec5\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eSurgical procedure\\u003c/h2\\u003e \\u003cp\\u003eTo establish a surgical working space, a small incision is made 1.5 cm outside the linea alba and 2 cm above the umbilicus. Subsequently, the subcutaneous layer and anterior rectus sheath (ARS) are incised, allowing access to the retromuscular space by blunt dissection of the rectus abdominis muscle. An indigenous balloon is then inserted and inflated with 150 ml of air to expand the superior space located behind the rectus abdominis [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. Following this, a 10 mm trocar is inserted, followed by a 5 mm trocar below the umbilicus. A \\\"tunnel\\\" is created through the rectus muscle to enter the retromuscular space, which serves as the first anatomical plane. Another 5 mm trocar is placed at the midpoint of a line connecting the umbilicus and pubic symphysis to complete the process. Dissection is performed along the surface of the posterior rectus sheath (PRS) until reaching the junction of the PRS and the transversalis fascia (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eA). The transversalis fascia is incised below the PRS (or arcuate line), medially to the linea alba, and laterally in the vicinity of the anterior superior iliac spine on the side of the hernia, allowing access to the preperitoneal space, which constitutes the second surgical anatomical plane. This incision marks the completion of the first anatomical plane transition (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eB). Dissection of the preperitoneal space continues caudally to enter the Retzius space, which serves as the second anatomical plane. The Retzius space is separated anteriorly by the pubic symphysis and posteriorly by the superficial preperitoneal fascia, with lateral separation extending to the inferior epigastric vessels (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eC). During the dissection of the Retzius space, important landmarks such as the pubic symphysis, Cooper's ligament, and the corona mortis must be identified. The next step involves proceeding to the lateral inguinal region and dividing the Bogros space between the peritoneum and deep layers of preperitoneal fascia, constituting the third anatomical plane. Preserving sufficient preperitoneal fat tissue in this area is crucial to prevent chronic pain caused by mesh stimulation of nerves in the \\\"triangle of pain.\\\" To enhance the preperitoneal space, a visual-enhanced technique can be employed to incise the lateral arcuate line approximately 1 cm closer to the linea semilunaris [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. Reversal of the hernia sac is necessary. In the Retzius space, femoral and direct hernias can be separated, and for direct hernias larger than 5 cm, suturing them to the pubic ramus can prevent seroma formation. Dissection of the internal spermatic cord fascia is required for reducing an indirect hernia while separating the hernia sac from the spermatic vessels. Caution should be exercised during the dissection process to avoid damage to the underlying iliac vessels situated in the \\\"triangle of danger.\\\" To create sufficient space for the mesh, the vas deferens needs to be separated from the surrounding tissue until reaching the junction of the obliterated umbilical artery. Moreover, the spermatic cord should be released at a distance of at least 6\\u0026ndash;8 cm from the indirect ring. The interfoveolar ligament is then incised to merge the Retzius space and the Bogros space, located at two distinct anatomical planes, into a single space (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eD). This procedure results in the formation of a large enough preperitoneal space to accommodate the mesh (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eE). A large 3D mesh (10.8 \\u0026times; 16 cm, Bard Davol Inc. Warwick, RI, 02886, USA) is placed in the created preperitoneal space to complete the hernia repair (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eF). Finally, the trocars are removed under direct vision, and the skin incisions are closed with sutures.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eThe study findings revealed that the average operation duration for unilateral hernias was 58 (\\u0026plusmn;\\u0026thinsp;2.5) minutes and for bilateral hernias was 110 (\\u0026plusmn;\\u0026thinsp;1.7) minutes, with a range of 46 to 140 minutes. During the surgery, 26 patients experienced small peritoneal injuries, which did not require specific treatment. However, two patients with large peritoneal tears had to undergo an early switch to transabdominal preperitoneal (TAPP) surgery and were subsequently excluded from the study analysis. Acute urinary retention occurred in 25 patients postoperatively, necessitating catheterization for several days. Among the observed postoperative complications, eight cases of hematoma were reported, with three requiring suction and one necessitating incision and drainage of the scrotum. Additionally, there were 20 cases of seroma, with six requiring multiple punctures for fluid drainage, while the remaining 14 cases resolved spontaneously. Three patients experienced subcutaneous emphysema, which did not require treatment. One patient reported a foreign body sensation in the groin, which resolved after six months. Due to the social insurance system in our country, ambulatory surgery is not currently performed, resulting in an average hospital stay of seven days (range: 7\\u0026ndash;10 days). The follow-up period for the majority of patients (333 out of 358) ranged from six to 70 months, with an average duration of 49 months. During this follow-up period, no cases of chronic pain or recurrence were reported. A summary of the study results can be found in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eIntraoperative and postoperative complications\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"2\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eIntraoperative\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePeritoneal tear\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e28 (7.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eInferior epigastric vessels injury\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0 (0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBladder injury\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0 (0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePostoperative\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSubcutaneous emphysema\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3 (0.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHematoma\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8 (2.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSeroma\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e20 (5.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eWound infection\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0 (0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eForeign body sensation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1(0.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eChronic pain\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0 (0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUrinary retention\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e25 (6.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRecurrence\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0 (0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThe preperitoneal space, situated between the transversalis fascia and the peritoneum, serves as the location for the placement of a large mesh in inguinal hernia preperitoneal repair [\\u003cspan additionalcitationids=\\\"CR2 CR3 CR4 CR5\\\" citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. However, there is currently no consensus regarding the optimal technique for incising the transversalis fascia [\\u003cspan additionalcitationids=\\\"CR10\\\" citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]. In our study, we utilized the concept of \\\"three anatomical planes, two-plane transition, and one space\\\" to create an adequately spacious preperitoneal space for mesh placement. Through this approach, we achieved positive clinical outcomes in the context of totally extraperitoneal (TEP) inguinal hernia repair.\\u003c/p\\u003e \\u003cp\\u003eThe surgical anatomy for TEP is classified into three planes: the first surgical plane, located in the anterior wall of the lower abdomen, is a potential space between the rectus abdominis muscle (or rectus fascia if present) and the PRS, which is replaced by the transversalis fascia located below the arcuate line. To access this initial working space, we selected a supraumbilical incision. This approach offers several benefits, including the ability to directly observe the separation of the first plane, a reduced risk of damaging blood vessels and the peritoneum, and a clear view of the surgical area. Furthermore, by preserving the integrity of the PRS, the surgeon can evaluate the morphology, position, and quantity of the arcuate line [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. When performing an anatomical separation of the first plane, several factors must be taken into account. Firstly, it is essential to avoid damaging the costal nerves, which are situated outside the posterior space of the rectus abdominis. Secondly, the inferior epigastric artery can be anatomically divided into three segments. The first segment of the artery originates from the external iliac artery and passes through the transversalis fascia, entering t the PRS. This segment is referred to as the extrinsic segment. The second segment of the artery travels within the PRS, and it is known as the intrathecal segment. The third segment of the artery extends upward into the rectus abdominis muscle and forms an anastomosis with the epigastric artery. This segment is referred to as the intramuscular segment [\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]. As the course of the intrathecal segment (and its branches) can vary due to variations in the PRS, care must be taken to avoid damaging the artery or its branches, which could result in hemorrhage, unclear vision, and potentially fatal postoperative hemorrhage [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. Thirdly, each patient's body shape and abdominal wall thickness is unique, so the depth of the separation layer must be tailored accordingly. If the separation layer is too deep, it could lead to peritoneal tear and pneumoperitoneum, which could negatively impact the operation.\\u003c/p\\u003e \\u003cp\\u003eThe seconded anatomical plane consists of the preperitoneal space between the superficial layer of preperitoneum (the membranous layer of the extraperitoneal fascia) [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e] and the peritoneum, and the Retzius space, which extends downward from the preperitoneal space. The Retzius space is a potential retropubic space situated between the bladder and the pubic bone. Its boundaries include the transversalis fascia anteriorly, the preperitoneal fascia (or superficial umbilical bladder fascia) posteriorly [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e], and the inferior epigastric vessels laterally. The identification of the second plane is based on the presence of avascular connective tissue that resembles a white spider web, which is considered significant and often referred to as the \\u0026ldquo;holy planes\\u0026rdquo; [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]. Dissecting the second plane requires several important considerations. First, separation must occur between the preperitoneal fascia and the transversalis fascia, which delineates two important surgical planes between the rectus and the peritoneum. The retromuscular plane (or the first plane), between the rectus and the transversalis fascia, contains the inferior epigastric vessels, while the preperitoneal plane (or the second plane), between the transversalis fascia and the superficial layer of the preperitoneal fascia, contains the median and medial umbilical ligaments enveloped by the visceral fascia of the bladder [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. It is essential to minimize iatrogenic trauma to the pelvic fascia during this separation. Second, when separating the Retzius space, care must be taken to avoid excessive depth, as it may damage the retropubic venous plexus or blood vessels on the bladder\\u0026rsquo;s surface, leading to bleeding. Finally, special attention should be paid to the abnormal obturator blood vessels and the \\u0026ldquo;corona mortis\\u0026rdquo; on the Cooper\\u0026rsquo;s ligament to prevent damage to the blood vessels in these areas.\\u003c/p\\u003e \\u003cp\\u003eThe third plane, also known as the Bogros space or posterior inguinal space, is a potential space located behind the groin area. It is an extension of the preperitoneal space in the groin but is separate from the Retzius space. The Bogros space is situated between the deep preperitoneal fascia, or the inner fatty layer of the extraperitoneal fascia [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e], anteriorly and the peritoneum posteriorly, with the fascia iliaca on the outer aspect and the interfoveolar ligament (the inferior epigastric vessels) on the inner aspect. Similar to the second plane, the Bogros space is also free of blood vessels. When dissecting this plane, it is essential to proceed between the peritoneum and the deep preperitoneal fascia while minimizing any harm to the peritoneum. Caution must be exercised as the peritoneum becomes thinner cephalad. Preserving the extraperitoneal fat tissue in the iliac fossa region is critical, and the nerves in the pain triangle should be safeguarded to avoid postoperative pain. Visual-enhanced techniques can be used to enlarge the Bogros space if required [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThe surgical procedure can be divided into two distinct transitions. The first transition involves the movement from the retromuscular space to the preperitoneal space, which can be visualized as two stacked floors without direct connection (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003eA, B). To access the second plane, an incision must be made in the transversalis fascia at the arcuate line, creating an opening resembling a gap in the \\\"floor ceiling\\\" (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003eC, D). This opening provides entry into the second plane, which extends downwards towards the Retzius space beneath the first plane. During this operation, several important considerations should be considered. If a classic arcuate line is present, the transversalis fascia can be incised below it to access the second level. However, if the arcuate line is low or absent, an artificial incision over the appropriate posterior sheath is necessary [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e]. Care must be exercised not to incise the arcuate line too deeply, as it may cause peritoneal damage and lead to pneumoperitoneum. In the event of a small peritoneal tear during surgery, the procedure can continue, but a larger tear would require suturing to prevent significant pneumoperitoneum from interfering with the operation.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe second transition involves the movement from the Retzius space behind the pubic bone to the Bogros space behind the lateral groin. The Retzius space contains organs such as the bladder, prostate, spermatic cord, and ureter, enclosed by superficial and deep layers of preperitoneal fascia. This fascia originates from the mesoderm and lies between the ectoderm (transversalis fascia) and endoderm (peritoneum). The preperitoneal fascia extends upwards and backwards, forming the retrorenal and prerenal fascia, collectively known as the urogenital fascia (UGF), which encloses the kidneys and adrenal glands [\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e]. In contrast, the Bogros space does not contain any organs and is separated from the Retzius space by a \\u0026ldquo;partition wall\\u0026rdquo; formed by the interfoveolar ligament (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003eA, B). To access the Bogros space, the interfoveolar ligament needs to be removed (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003eC, D). However, the anatomy of the interfoveolar ligament can vary, requiring caution to avoid damage to the inferior epigastric and iliac vessels, as well as the vas deferens. Additionally, the vas deferens needs to be divided up to the intersection of the obliterated umbilical artery to achieve an adequate preperitoneal space during surgery.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eUpon separating the lower abdominal wall and inguinal region, the preperitoneal space is created, encompassing the preperitoneal space of the lower abdominal wall, the caudally extending Retzius space, and the laterally located Bogros space. While considered as a single unit, this space can be further divided into two compartments: the medial and lateral compartments. The medial compartment contains vasculature, including the femoral artery and vein. The lateral compartment allows for the passage of the iliopsoas, attaching to the femur, along with the femoral nerve. Proper positioning of the mesh within the preperitoneal space is crucial for effective inguinal hernia repair. The mesh should be placed with half in the Retzius space, between the superficial preperitoneal fascia and the retropubic transversalis fascia, and half in the Bogros space, between the deep preperitoneal fascia and the peritoneum [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. This placement ensures complete coverage of the hernia defect and minimizes the risk of recurrence.\\u003c/p\\u003e \\u003cp\\u003eThe incidence of postoperative complications associated with hernia repair in this study population was relatively low, and no cases of serious complications were reported. Among the observed complications, twenty-eight cases of peritoneal laceration were noted, with two cases requiring an early transition to TAPP due to the size of the tear. Acute urinary retention following general anesthesia was observed in twenty-five elderly patients, necessitating catheterization for several days. Eight cases of hematoma, potentially associated with scrotal hernia, were reported, and one case required surgical drainage of the scrotum, while the remaining two cases were managed with puncture and aspiration. Twenty cases of seroma were also reported, with six requiring drainages via puncture and the others resolving spontaneously. Notably, no cases of chronic pain were reported in this cohort. The authors suggest that the presence of preperitoneal adipose tissue in the Bogros space offers protection against nerve stimulation within the \\\"triangle of pain\\\" by the mesh. Furthermore, non-fixation of the mesh may also contribute to the prevention of chronic pain. During the follow-up period, one patient reported experiencing a foreign body sensation in the groin; however, these symptoms resolved after six months and were likely attributed to the patient's low body weight. Although no recurrences were observed during the long-term follow-up, it remains important to continue monitoring for potential complications and the possibility of recurrence.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eIn conclusion, the \\\"3-2-1\\\" technique for totally extraperitoneal inguinal hernia repair, involving three dissection planes, two plane transitions, and one preperitoneal space, proves to be a straightforward and comprehensible approach. The results of follow-up assessments indicate its safety and effectiveness, with no notable complications reported. Furthermore, the technique lends itself well to adoption by surgeons who are new to the procedure, as it is easily learnable and implementable.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthor contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis work was done by ZXL and there is no contribution of any other authors.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study was funded by Dongguan Science and Technology Bureau (2023507 15009200).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAll procedures performed in studies involving human participants were in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was approved by the Ethics Committee of Chashan Hospital of Guangdong Medical University. All patients obtained informed consent.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe author declares that he has no competing interest.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eKingsnorth AN, Skandalakis PN, Colborn GL, Weidman TA, Skandalakis LJ, Skandalakis JE. Embryology, anatomy, and surgical applications of the preperitoneal space. Surg Clin North Am. 2000;80(1):1\\u0026ndash;24.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eArregui ME. Surgical anatomy of the preperitoneal fasciae and posterior transversalis fasciae in the inguinal region. Hernia. 1997;1(2):101\\u0026ndash;10.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMirilas P, Mentessidou A. The secondary external inguinal ring and associated fascial planes: surgical anatomy, embryology, applications. Hernia. 2013;17(3):379\\u0026ndash;89.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNagahisa Y, Homma S, Chen K, Sakurai R, Hattori N, Kawamoto Y, Hashida K, et al. Feasibility of a new approach for creating a preperitoneal space in transabdominal preperitoneal repair inguinal hernia repair: using a sandwich approach. Surg Today. 2017;47(5):595\\u0026ndash;600.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAnsari MM. Surgical preperitoneal space: holy plane of dissection between transversalis fascia and preperitoneal fascia for TEPP inguinal hernioplasty. MOJ Surg. 2018;6(1):26\\u0026ndash;33.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eZhou XL, Luo JH, Huang H, Wang YH, Zhang HB. Totally extraperitoneal herniorrhaphy (TEP): lessons learned from anatomical observations. Minim Invasive Surg. 2021; 2021:5524986.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNyhus LM, Klein MS, Roger FB. Inguinal hernia. Curr Probl Surg. 1991;28(6):401\\u0026ndash;50.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDaes J. Reparo laparosc\\u0026oacute;pico de la hernia inguinal: presentaci\\u0026ograve;n de la t\\u0026eacute;cnica totalmente extraperitoneal con vista extendida. Revista Colombiana de Cirug\\u0026iacute;a. 2011;26(2):89\\u0026ndash;92.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLorenz A, Augustin C, Konschake M, Gehwolf P, Henninger B, Augustin F, \\u0026Ouml;fner D. The Preperitoneal space in hernia repair. Front Surg. 2022;9:869731.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAsakage N. Paradigm shift regarding the transversalis fascia, preperitoneal space, and Retzius' space. Hernia. 2018;22(3):499\\u0026ndash;506.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAnsari MM. Posterior rectus canal: not a single anatomical entity \\u0026amp; morphology \\u0026ndash; a laparoscopic study during TEP hernioplasty. Turk J Surg. 2019;35(4):299\\u0026ndash;308.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRao MP, Swamy V, Arole V, Mishra P. Study of the course of inferior epigastric artery with reference to laparoscopic portal. J Minim Access Surg. 2013;9(4):154\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWang YH, Huang H, Luo JH, Zhang HB, Zheng FQ, Liang SC, Zhou XL. Anatomical observation and clinical significance of the arcuate line in totally extraperitoneal preperitoneal (TEP) herniorrhaphy. Chin J Clin Anat. 2021;39(1):16\\u0026ndash;21.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eFowler R. The applied surgical anatomy of the peritoneal fascia of the groin and the \\\"secondary\\\" internal inguinal ring. Aust N Z J Surg. 1975;45(1):8\\u0026ndash;14.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eOhuchi M, Fukunaga M, Nagakari K, Azuma D, Kohama S, Nomoto J, Sakamoto K. Surgical technique and outcomes of transabdominal preperitoneal inguinal hernia repair after radical prostatectomy: dissection between the transversalis fascia and superficial layers of preperitoneal fascia. Hernia. 2019;23(1):167\\u0026ndash;74.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAnsari MM. Artificial Arcuate line: surgical creation during TEPP hernioplasty. Clin Surg. 2017;2:1698.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAsakage N. Paradigm shift regarding the transversalis fascia, preperitoneal space, and Retzius' space. Hernia. 2018;22(3):499\\u0026ndash;506.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLi Y, Qin C, Yan L, Tong C, Qiu J, Zhao Y, Xiao Y, et al. Urogenital fascia anatomy study in the inguinal region of 10 formalin-fixed cadavers: new understanding for laparoscopic inguinal hernia repair. BMC Surg. 2021;21(1):295.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Inguinal hernia, Extraperitoneal, Retromuscular, Transition, Repair\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-3160654/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-3160654/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground \\u003c/strong\\u003eThe total extraperitoneal (TEP) technique is known for its complexity compared to the transabdominal preperitoneal technique (TAPP). This study aimed to streamline the TEP procedure by introducing the 3-2-1 method, which involves creating three surgical planes, implementing two transitions, and establishing a spacious preperitoneal space. The objective was to comprehensively evaluate the safety, efficacy, and reliability of this approach.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods \\u003c/strong\\u003eA total of 358 patients with 380 inguinal hernias underwent TEP repair using the 3-2-1 method via the retromuscular approach. Patient characteristics, operative time, hospital stay, complications, and recurrence rates were assessed.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults\\u003c/strong\\u003e Among the hernias, 190 were on the right side, 140 on the left side, and 50 were bilateral. The distribution of hernia types included indirect hernia (201), direct hernia (132), compound hernia (16), complex hernia (6), and femoral hernia (3). The average operative time was 58 minutes for unilateral hernias and 110 minutes for bilateral hernias. Postoperative complications occurred in 32 cases (8.9%), but no serious complications were observed. The average hospital stay was 7 days, and patients were followed up for an average of 49 months. There were no cases of chronic pain or recurrence.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusions\\u003c/strong\\u003e The 3-2-1 method for laparoscopic TEP repair of inguinal hernias proves to be a simple, safe, effective, and reliable approach.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Streamlining the totally extraperitoneal approach for laparoscopic inguinal hernia repair: the 3-2-1 method\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2023-08-08 14:31:11\",\"doi\":\"10.21203/rs.3.rs-3160654/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"4d5f11ac-7024-4d89-9a24-7c94ab8b0ece\",\"owner\":[],\"postedDate\":\"August 8th, 2023\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2023-09-12T14:59:16+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2023-08-08 14:31:11\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-3160654\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-3160654\",\"identity\":\"rs-3160654\",\"version\":[\"v1\"]},\"buildId\":\"cBFmMYwuxLRRLfASyISRj\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}