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CLINICAL TECHNIQUE
            Laparoscopic Mesh Hernioplasty: A Novel Method of

            Extraperitoneal Space Creation


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            Manash Ranjan Sahoo , Leesa Misra , Sibabrata Kar , Jyotirmaya Nayak , Soumya Bharati Rout , Amiya Ranjan Parida ,
            Pradeep Kumar Pradhan 7
             AbstrAct
             Introduction: In the era of laparoscopic surgery, total extraperitoneal (TEP) hernia repair has become the standard procedure for treatment of
             inguinal hernias. While balloon is used to create extraperitoneal space in most Western countries, the financial burden of buying a balloon in
             a developing country like India is overwhelming. So, we present a case series of extraperitoneal space creation using a zero-degree telescope
             to reduce the cost of the surgery to a few thousand rupees (less than 100 dollars).
             Context: Laparoscopic total extraperitoneal inguinal hernia repair.
             Aims: To study the feasibility of creation of extraperitoneal space using a zero-degree telescope in laparoscopic total extraperitoneal hernia repair.
             Materials and methods: It is a case series of 500 patients from June 2011 to July 2021. Furthermore, it is a single-surgeon experience.
             Results: A Total of 500 laparoscopic TEP hernia surgeries were performed over a period of 10 years. Out of these, 485 patients were male and 15
             patients were female. The age of patients ranged from 5 years to 85 years. Out of these, 50 patients (10%) were converted to transabdominal
             preperitoneal (TAPP) hernia repair. During the follow-up period, no hernia recurrence was found. No major complication was noted in any
             patients during this period. Seroma formation was noted in 25 patients (5%). Retention of urine was noted in 25 patients (5%). All patients
             returned to normal routine work within 2 weeks.
             Conclusion: Zero-degree telescope is a feasible method of creating extraperitoneal space in laparoscopic total extraperitoneal repair.
             Key messages: Slight changes in advanced laparoscopic methods can make these costly procedures accessible to a vast population of poor
             people in the world.
             Keywords: Extraperitoneal space creation, Laparoscopic, Laparoscopic hernioplasty, Mesh hernioplasty, Total extraperitoneal repair.
             World Journal of Laparoscopic Surgery (2022): 10.5005/jp-journals-10033-1516


            IntroductIon
                                                               1 Department of General Surgery, All India Institute of Medical Sciences,
            Inguinal hernioplasty has progressed from tissue-based repair   Bhubaneswar, Odisha, India
            of Bassini and mesh repair of Lichtenstein to laparoscopic hernia   2–7 Department of General Surgery, SCB Medical College and Hospital,
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            repair today which was reportedly first performed by Ger.  Initially,   Cuttack, Odisha, India
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            surgeons used the TAPP method for hernia repair.  But it was soon
            found out that entering peritoneal cavity for hernia repair has its   Corresponding  Author: Jyotirmaya Nayak, Department of Surgery,
                                                               SCB Medical College and Hospital, Cuttack, Odisha, India, Phone: +91
            own disadvantages such as inadequate closure of the peritoneum   9438037714, e-mail: drjmnayak@gmail.com
            and injury to viscera from trocars and needles. To overcome these   How to cite this article: Sahoo MR, Misra L, Kar S, et al. Laparoscopic
            complications, total extraperitoneal (TEP) approach was developed.   Mesh Hernioplasty: A Novel Method of Extraperitoneal Space Creation.
            Total extraperitoneal approach eliminates complications related   World J Lap Surg 2022;15(2):185–187.
            to entry into the peritoneal cavity and reduces operative time in   Source of support: Nil
            bilateral hernias. 2,3
               Extraperitoneal space creation is most commonly done by   Conflict of interest: None
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            balloon dissector as it simplifies the process.  The space creation can
            also be done without using balloon dissector. In this case, a zero-  experience which has been done in a premiere Government
            degree telescope (10 mm) is used to create the space by sweeping   Institute in Eastern India.
            down fibrofatty tissues to the sides. But this may be difficult   All patients had to undergo pre-anesthesia checkup and fit
            and time-consuming for inexperienced surgeons. Moreover,   patients were taken up for surgery. All patients were catheterized
            the surgeon may tear the peritoneum inadvertently leading to   during the procedure, and the catheter was removed within few
            conversion of TEP to TAPP. So here we present a case series of TEP   hours after surgery. A 10 mm incision was given just below the
            approach of laparoscopic hernia repair in which extraperitoneal   umbilicus. Anterior rectus sheath was identified and incised to
            space creation is done using a zero-degree telescope, thus reducing   expose rectus muscle. Two right-angled retractors were used to
            the cost of hernia surgery.                        retract rectus muscle laterally to expose the posterior rectus sheath.
                                                               A 10 mm trocar is pushed through the posterior rectus sheath to
                                                               enter the extraperitoneal space. A zero-degree telescope is then
            MAterIAls And Methods                              introduced, and the space creation is done with gentle vertical
            This is a case series of 500 patients from June 2011 to July 2021 with   and horizontal motion and plane achieved by identification of
            a follow-up period of atleast 1 year. This study is a single surgeon   Cooper’s ligament. Two 5 mm ports are created under vision, one

            © The Author(s). 2022 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.
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