Single Incision Transumbilical Laparoscopic Bilateral Inguinal Hernia Repair (TEP)

Giovanni Dapri, MD, PhD, FACS, Leonardo Gerard, MD, Viola Zulian, MD, Maria Bortes, MD, Jean Bruyns, MD, Guy-Bernard Cadiere, MD, PhD. European School of Laparoscopic Surgery, Brussels, Belgium.

Background: Laparoscopic repair of inguinal hernia by totally extra-peritoneal mesh placement (TEP) has been popularized. Recently, with the advent of single-incision transumbilical laparoscopy, this procedure has to be considered because it allows to place a big mesh with a very small final scar, which is also cosmetically acceptable.

Video: A 48-year-old male was admitted to the hospital for right direct and indirect and left direct inguinal hernia. A single-incision transumbilical laparoscopic bilateral TEP was proposed. The patient was placed in supine position with the legs straight. The surgeon stood first on patient’s left and later on the patient’s right. The natural umbilical scar was incised and the rectus fascia on the left side was open. A purse-string suture using Vicryl 1 was placed starting at 9 o’clock position. An 11-mm reusable metallic trocar was introduced behind the left rectus muscle, into the pre-peritoneal space. A 0-degree, normal length and rigid scope was advanced into the 11-mm trocar and the pre-peritoneal space was insufflated. This space was dissected using the optical system, first on the right side and then on the left side. At the time of the hernia sac retraction, a monocurved reusable grasping forceps (Karl Storz-Endoskope, Tuttlingen, Germany) was introduced inside the purse-string suture, at 9 o’clock position, parallel to the 11-mm trocar. The bilateral hernia sac was reduced, the peritoneal sheet was retracted and the spermatic elements skeletonized. Two 15 (latero-lateral) x 10 (medial cranio-caudal) x 8 (lateral cranio-caudal) cm polypropilene meshes (Bard Davol Inc., Warwick RI, US) were introduced through the 11-mm trocar. Both meshes were adequately positioned using the monocurved grasping forceps, placing the lateral corner anteriorly to the peritoneal sheet and the medial corner under 1 cm the pubic bone. The meshes were not fixed and the space was desufflated under view.

Results: Operative time was 67 minutes and the final incision length was 12 mm. Postoperative pain was controlled by paracetamol (4 g/day) and the patient was discharged after 24 hours.

Conclusions: Single-incision transumbilical bilateral TEP makes sense because it allows to place two big meshes uisng a very small final scar. This treatment permits to increase the reduction of the abdominal trauma, already obtained thanks to the conventional multitrocar laparoscopy.

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