The enhanced view-totally extraperitoneal technique for repair of inguinal hernia

Abstract

To the Editor, We read with much interest the publication by Jorge Daes on his modified totally extraperitoneal (TEP) technique. In this article the author states that part of the difficulty with the TEP technique is the limited space it provides for dissection. This is especially evident in obese patients, in patients with large hernias, and in the deployment, spreading out, and fixation of large meshes [1]. In his modification the author introduces the balloon dissection via a 12 mm incision high on the upper lateral quadrant of the abdomen on the same side of the hernia or on either side in the bilateral case [1], creates the space, and then removes it to place a blunt-tip trocar and insufflate the space. Two additional 5 mm trocars are inserted in the midline. Through the lowest trocar port he introduces a scissors and cuts the Douglas’ line (arcuate line, linea semicircularis) just at the level of the camera, thus providing ample view of the surgical area [1]. In the Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia of the International Endohernia Society [2], with respect to trocar placement for TEP, on page 2,792 we point out that, as an alternative to placement of two working trocars in the midline, one trocar can be placed in the midline and the second trocar laterally, 2 cm above the superior anterior iliac spine. This port placement gives better trocar triangulation and makes complete dissection of large lateral hernia sacs easier. To ensure adequate exposure of the lateral abdominal wall up to 2 cm above the superior anterior iliac spine, it is often necessary to cut the Douglas’ line (arcuate line, linea semicircularis) with scissors via the trocar placed in the midline [3]. Cutting the Douglas’ line (arcuate line, linea semicircularis) for this trocar placement confers essentially greater space for dissection as well as optimal mesh placement. Hence, the positive effect of cutting the Douglas’ line (arcuate line, linea semicircularis) as described by Daes [1] is also ensured by this approach. However, the advantage compared with the technique described by Daes [1] is manifested, in particular, for bilateral inguinal hernias, since when placing the optic trocar in the upper abdomen, the optic becomes trapped in the canal of the rectus sheath, thus hampering dissection on the other side. For bilateral inguinal hernia, Daes therefore describes placement of the optic trocar in addition on the other side [1]. Such an approach is not needed when using the technique described in the guidelines [2], since the contralateral inguinal hernia can be easily dissected via the trocars already placed. Likewise, bilateral mesh placement is easily accomplished [3]. For cosmetic reasons, preference should definitely be given to umbilical placement of the optic trocar. Thanks to Daes it can be pointed out that incision of the Douglas’ line (arcuate line, linea semicircularis) with F. Kockerling D. A. Jacob (&) Department of Surgery and Center of Minimally Invasive Surgery, Vivantes Hospital, Neue Bergstr. 6, 13585 Berlin, Germany e-mail: dietmar.jacob@vivantes.de