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Laparoscopic Mesh Hernioplasty: A Novel Method of Extraperitoneal Space Creation 
























            Fig. 1: 10 mm trocar being placed behind the rectus muscle  Fig. 3: Extraperitoneal space creation being done with zero-degree
                                                               telescope























            Fig. 2: Zero-degree telescope being used           Fig. 4: Mesh being sutured to Cooper’s ligament

            4–5 cm above the pubis and another in the middle. Hernial sac is   laparoscopically with no conversion. Out of these, 50 patients (10%)
            identified, separated from cord structures, and pushed cephalad.   were converted to TAPP due to either the inability to create a space
            The edge of the peritoneum is freed from vas deferens and testicular   due to previous surgery or due to inadvertent creation of bigger-
            vessels and pushed downward. Now, a 15 × 15 cm prolene mesh is   size rent in the peritoneum. During the follow-up period, no hernia
            introduced through the 10 mm port and is positioned medially to   recurrence was found. No major complication was noted in any
            overlap the pubic bone and laterally 2 cm beyond the deep ring.   patients during this period. Few minor complications were noted.
            The mesh is fixed using prolene suture to the Cooper’s ligament   Seroma formation was noted in 25 patients (5%), which got resolved
            using single intracorporeal prolene suture. The abdomen is deflated   within 6 months with conservative treatment. Retention of urine
            under vision, so as to ensure no wrinkling of the mesh. All ports   was noted in 25 patients (5%). In these patients, recatheterization
            are closed and pressure bandage is given over the deep ring. All   was done. No other complications were noted. All patients returned
            patients were given intravenous antibiotics for 1 day and analgesics   to normal routine work within 2 weeks.
            for 2 days. Patients were discharged on the third day and follow-up
            was done after 1 month. Subsequent follow-up was done on yearly   dIscussIon
            basis (Figs 1 to 4).
                                                               This single-surgeon experience supports extraperitoneal space
                                                               creation using a zero-degree telescope to reduce the cost of
            results                                            laparoscopic hernia surgery in developing countries like India.
            A total of 500 laparoscopic TEP hernia  surgeries were performed   Most commonly, balloons are used to create the extraperitoneal
            over a period of 10 years. The follow-up period was minimum of   space. The cost of a balloon in India is around 20,000 rupees (~300
            1 year. Out of these, 485 patients (97%) were male and 15 patients   dollars), which is almost five times the total cost of hernia surgery.
            (3%) were female. All patients had undergone pre-anesthetic   Also, intracorporeal suturing eliminates the need of tacker, which
            checkup, and only fit patients were included in the study. Age of   saves another 25,000 rupees (~400 dollars). The incidence of
                                                                                                         5
            patients ranged from 5 years to 85 years. All patients were operated   seroma formation in TEP is reported to be around 7%  in other

            186   World Journal of Laparoscopic Surgery, Volume 15 Issue 2 (May–August 2022)
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