If during laparoscopy no obvious internal hernia orifice (e.g. deep inguinal ring) is visible despite preoperative clinical/imaging suspicion, it is recommended to perform a preperitoneal exploration in search for other causes - including a lipoma of the cord/round ligament (or preperitoneal/femoral lipoma) or an occult femoral hernia. These can mimic hernia or cause a bulge/complaint even without a true hernia sac. Overlooking such lipomas is considered a known cause of “recurrence” or persistent symptoms. Therefore, during TAPP, a thorough dissection of the preperitoneal space and “parietalization” of the cord structures (i.e. mobilizing them, reflecting peritoneum, exploring the internal ring region) is essential not only for placing the mesh correctly, but also to detect occult lipomas or small hernias.
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