A short (3–5 cm) skin incision is carried out at the level of the deep inguinal orifice. The external oblique aponeurosis is incised and a self-retaining retractor (e.g., Gelpi) is placed. The ilioinguinal nerve is identified and preserved; identification of the iliohypogastric nerve and genital branch is not necessary since they are not affected by the dissection. The spermatic cord is taped. Contrary to what occurs in the Lichtenstein repair, no extensive dissection between the external oblique aponeurosis and internal oblique muscle is undertaken. The type of hernia is determined; spinal or local anesthesia can make it easier for the patient to strain and to cough.

In indirect hernias the cremaster is cut at its insertion around the deep inguinal orifice, to facilitate identification of the epigastric vessels at the medial margin, but it is not resected and it may be reinserted with a few stitches at the end of the procedure. The sac is dissected and reduced into the preperitoneal space. Blunt preperitoneal dissection is carried out through the internal orifice. It is initiated with a blunt curved clamp (e.g., Kelly clamp), just under the epigastric vessels, at the medial margin of the internal ring. Then a gauze is introduced through the deep orifice and dissection is extended with the index finger using this “dissection gauze”. Dissection starts first medially, in the space of Retzius, up to the pubic bone. Then lateral dissection is carried out in the space of Bogros, up to the iliac spine or close to it. This lateral dissection may be a little bit more difficult, due to the tougher adherence between the peritoneum and abdominal wall, but it is achieved by proceeding gently with the finger and the moist dissection gauze.

The extent of dissection must be sufficient to accommodate the patch, but more extensive dissection is neither necessary nor useful. In practice, the length of the index finger in the direction of the pubis and in the direction of iliac spine, as well as the same in width, is adequate.

At the end of the dissection, the gauze is removed before proceeding to placement of the patch. The size of the patch (medium or large) is chosen according to anatomy.

The medial half of the patch (widest side) is introduced first in the direction of the pubic bone. To do so, one angled retractor lifts the epigastric vessels, another one (blade retractor) reclines the peritoneum medially, so that the Cooper’s ligament becomes visible. The widest end of the patch, grasped with the Kelly clamp, is introduced in the direction of the pubis. Then, the clamp and retractors are removed.

To introduce the lateral part of the patch, two retractors lift the lateral edge of the internal orifice and, using a clamp in one hand and a toothless forceps in the other, the surgeon manages to gently introduce the lateral half of the patch in the lateral compartment of the preperitoneal space. Then, the retractors are removed and deployment of the patch is achieved with the finger by pushing on the memory-ring. The counter-pressure exerted by the patient straining can facilitate deployment. Asking the patient to strain helps check that the prosthetic patch has securely fixed the hernia bulge. In cases where a small protrusion still occurs this is easily corrected by readjusting the patch. For this reason, local or spinal anesthesia are good choices. Thanks to the abdominal pressure, the memory-ring and the limited dissection, no fixation of the patch is required. The external oblique aponeurosis, Scarpa’s fascia and the skin are sutured.

In direct hernias a circular incision of the transversalis fascia is performed at the base of the sac and the sac is reduced. Then, preperitoneal dissection and placement of the patch are carried out through the fascia orifice. It should be emphasized that checking for a small unapparent indirect sac is mandatory, and that the lateral dissection is extended as far as for an indirect hernia, to parietalize the cord and correctly cover the lateral compartment. The procedure is very easy in the case of large mixed hernias in which both components are evident.

The avascular preperitoneal plane of dissection is located between the deep aspect of the transversalis fascia and the preperitoneal fat, which is attached to the peritoneum. As small blood vessels are contained in the fat, they are not damaged when dissection is carried out in contact with the fascia. Therefore, for a bloodless dissection to be carried out, the finger pad or the blunt tip of the Kelly clamp must constantly face upwards and keep in contact with the fascia. This plane of dissection can be aided by infiltration of local anesthetic. As for major vessels, they are easily palpated and protected by the vascular sheath.

The “dissection gauze” is not intended to create the pocket by its volume, but it is used for blunt dissection, moved with the fingertip, like a gauze nut.

When switching from the dissection of medial to that of lateral compartment, changing hands can facilitate the gesture.

When grasping the patch with a toothless clamp to introduce it medially, it is important that: 1) the clamp does not hold the memory-ring, 2) the clamp is positioned under the patch, so that the patch is bent over the clamp and its curvature fits with the convex shape of the peritoneal sac and the concave shape of the deep aspect of the abdominal wall. Doing so facilitates patch deployment.

When introducing the patch medially, do not follow the natural tendency to push it too far, because in this case covering of the lateral compartment will not be sufficient. Only the medial half of the patch — no more — is introduced medially.

When introducing the lateral end of the patch laterally, do not follow the natural tendency to push towards the umbilicus. The correct direction is towards the iliac spine.

Correct deployment of the lateral part of the patch is essential, because in the case it is not totally flat and the tip kinks up into the muscular wall, it may induce discomfort. If this occurs, a very simple solution can relieve such symptoms. A short skin incision (1–2 cm) located over the kink is performed in local anesthesia. A small opening of the funnel containing the memory-ring is performed with the scalpel or scissors and the plastic ring is easily pulled out.

The counter-pressure exerted by straining facilitates patch deployment. Therefore, spinal or local anesthesia is very useful. It is suggested to start these repairs under spinal or epidural anesthesia in the first instance.

The TIPP repair fits well with day case surgery. In the initial series it was performed with an overnight stay in half of the cases, principally because of national regulation. However, in a recent French series the percentage of day surgery evolved with national rules and increased from 48% in 2010 to 72% in 2012 [7], and in the TULIP trial the majority of repairs were performed as day cases [8].

Postoperative pain is indeed tolerable. Pain assessed by visual analog scale was rated at 1.67/10 and 2.7/10 in two series [3, 5] and the percentage of patients who did not take analgesics was 6% and 15% [3, 9]. The time off work was around two weeks. Intraoperative events reported in one series [7] occurred in 4%. They included peritoneal tears and injury of epigastric vessels and were easily managed by peritoneum suture or vessel ligature. The percentage of postoperative complications was around 5–7%. All were benign superficial complications. There were 0.4 to 4% hematomas, but cases of severe bleeding have not been reported [4, 5, 7].