An Innovative “555 Technique” for Totally Extra-Peritoneal Repair of Inguinal Hernia Using All 5 mm Ports

Introduction:

Three ports (one 10 mm Hasson trocar and two 5 mm ports) technique for total extra-peritoneal (TEP) repair of inguinal hernia is standard nowadays. ¹ We all have dependence on 10 mm Hasson trocar to create preperitoneal space (PPS) and mesh insertion. Hasson trocar leads to a large defect in the anterior rectus sheath and a large wound. It causes increased morbidity in terms of pain, high incidence of surgical site infection (SSI), high chances of incisional hernia, and suboptimal cosmetic outcome in comparison with 5 mm port wound. ^2,3 Dependence and necessity of having a costly Hasson trocar exclusively for TEP repair are reflected in surgical cost. Morbidity management of a larger port site wound also has financial impact on the patients. ⁴ We have devised an innovative “555 Technique” by using all three 5 mm ports (Endopath XCEL Bladeless Trocar) to create PPS, dissection of sac, and insertion and placement of mesh without any difficulty. A 5 mm infra-umbilical incision is made to create PPS under vision. A 2 mL plastic syringe hub is cut and used as a retractor to make an incision in the anterior rectus sheath. The other two 5 mm working ports are used for dissection of sac and mesh placement. Our technique avoids the use of the costly Hasson trocar to create PPS.

Materials and Methods:

From October 21, 2014 to July 30, 2015, 30 consecutive TEP repairs were done using our new “555 Technique.”

Results:

Thirty patients (28 males, 2 females) were operated using the “555 Technique.” The mean age of the patients was 43 years, ranging from 23 to 76 years. Of the 30 patients, 13 patients had indirect inguinal hernia (11 unilateral and 2 bilateral) and 17 patients had direct inguinal hernia (7 unilateral and 10 bilateral). Two unilateral indirect inguinal hernias were irreducible. Both the females were having indirect inguinal hernia. The average time for insertion of the 5 mm trocar in PPS using our technique was 170 seconds, which is less than the insertion time of the conventional Hasson trocar placement. Pneumoperitoneum occurred in four cases, which was managed by putting Veress needle into the peritoneal cavity. All 30 cases were effectively operated using the “555 Technique.” During the postoperative period, analgesic requirement was less because of all the 5 mm ports. There was no incidence of SSI, hernia recurrence, or incisional hernia formation. Small infraumbilical scar is cosmetically more acceptable to patients.

Conclusion:

The “555 Technique” is a feasible option without compromising the principles of TEP repair for inguinal hernia. It is cost effective as it avoids dependence on the costly Hasson trocar and gives less morbidity and better cosmetic results.

No competing financial interests exist.

Runtime of video: 7 mins 13 secs