Laparoscopic totally extraperitoneal (TEP) hernioplasty using two trocars: anatomical landmarks and surgical technique

Abstract

BackgroundAmong endoscopic hernioplasties, totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) approach are widely accepted alternatives to open surgery, both providing less postoperative pain, hospital length of stay and early return to work. Classical TEP technique requires three skin incisions for placement of three trocars in the midline or in triangulation.AimTo describe a technique using only two trocars for laparoscopic total extraperitoneal for inguinal hernia repair.MethodExtraperitoneal access: place two regular trocars on the midline. The 10 mm is inserted into the subcutaneous in horizontal direction after a transverse infra-umbilical incision and then elevated at 60º angle. The 5 mm trocar is inserted at the same level of the pubis with direct vision. Preperitoneal space dissection: introduction 0º optical laparoscope through the infra-umbilical incision for visualization and preperitoneal dissection; insufflation pressure must be below 12 mmHg. Dissection of some anatomical landmarks: pubic bone, arcuate line and inferior epigastric vessels. Exposure of "triangle of pain" and "triangle of doom". Insertion through the 10 mm trocar polypropylene mesh of 10x15 cm to cover the hernia sites. Peritoneal sac and the dorsal edge of the mesh are repositioned in order to avoid bending or mesh displacement. It is also important to remember that the drainage is not necessary.ResultsThe 2-port TEP required less financial costs than usual because it is not necessary an auxiliary surgeon to perform the technique. Trocars, suturing material and wound dressing were spared in comparison to the classical technique. Besides, there were only two incisions, which provides a better plastic result and less postoperative pain.ConclusionThe TEP technique using two trocars is an alternative technique which improves cosmetic and financial outcomes.

Comparative Study of Postoperative Pain Between the Lichtenstein and Laparoscopy Surgical Techniques for the Treatment of Unilateral Primary Inguinal Hernia

“…In Brazil, from 2015 to 2016 the National Health System (Sistema Único de Saúde - SUS) treated more than 117.090 cases of unilateral inguinal hernia through the open technique and 901 cases through laparoscopic techniques 19 . Nowadays, several surgical techniques are available for the treatment of inguinal hernia 5 , 10 , 15 . However, two techniques are generally accepted as the best treatment options for inguinal hernia repair: the tension-free open Lichtenstein and the laparoscopic procedures 4 .…”

Tensiometric Analysis of Meshes Used in Abdominal Ventral Wall Defects in Rats

“…The standard procedure for the surgical correction of the incisional hernia is performed with the use of meshes 3 , 7 , 12 . The most widely used material is polypropylene which causes rapid acute inflammatory response followed by chronic foreign body reaction that persists for months and years after the surgical procedure.…”

Interspinous Line: Relations with Other Landmarks (Xiphisternum, Umbilicus, Pubic Symphysis and Arcuate Line of Douglas) and Importance for Surgeons

“…During the laparoscopic total extraperitoneal (TEPP) hernioplasty, the arcuate line is one of the three essential important surgical landmarks during the early phase of medial dissection in the posterior rectus canal [51][52][53][54][55][56], because the preperitoneal space is created just below the traditional arcuate line. The anterior interspinous line is one of the important landmarks to ascertain the average position of the Arcuate line for the preoperative planning and port placement, especially the middle port at or below the level of the arcuate line in the 3-port-in-midline technique for TEPP hernioplasty.…”