Teaching the transrectus sheath preperiotneal mesh repair: TREPP in 9 steps

• 30.000 inguinal hernias in the Netherlands are operated, as 750.000 inguinal hernias in the USA are operated annually.
• Chronic pain is a problem after Lichtenstein repair in 15–40% of the reports.
• Evolution of inguinal surgery lead to endoscopic approaches.
• An easy open technique without need of general anesthesia is needed to reduce costs.
• TREPP is gaining popularity and many surgeons in training for TREPP request a step by step description.

BackgroundThe preperitoneal mesh position seems preferable to reduce the number of patients with postoperative chronic pain after inguinal hernia surgery. The transrectus sheath preperitoneal mesh repair (TREPP) is gaining popularity. Teaching a new technique requires a standardized approach to achieve an optimal learning curve. The aim of this paper was to provide a step-by-step teaching module for hernia surgeons learning the TREPP.MethodsLiterature was critically reviewed and the forthcoming nine surgical steps of the new TREPP technique and its rationale are described in this article. The TREPP hernia repair technique is illustrated with an online education video and three photos of the anatomical landmarks and the proposed mesh position of TREPP.ResultsThe nine steps of TREPP are described extensively and the critical steps are presented in a standardized way for surgical educational purposes. Also the rationale and technical considerations of inguinal hernia experts are presented.DiscussionTREPP may be a promising technique for groin hernia surgery. To date there have been no major complications with the TREPP repair which is currently the subject of a RCT. The learning curve of TREPP is being investigated and teaching of this technique requires standardization for trainee surgeons.ConclusionTREPP potentially merges the advantages of a preperitoneal positioned mesh with an open technique. Initial results are promising and TREPP seems to be applicable in different hospitals in the Netherlands. Since the start of an active teaching program, TREPP has been introduced and accepted well by dedicated hernia surgeons in other hospitals in the Netherlands and Europe.