Bucher, P.

Morel, P.

Pugin, F.

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Hernia (2009) 13:667–668DOI 10.1007/s10029-009-0564-4LETTER TO THE EDITORSingle port totally extraperitoneal laparoscopic inguinal hernia repairRe: Single incision total extraperitoneal (one SITE) laparoscopic inguinal hernia repair using a single access port device, B. P. Jacob et al. (2009) Hernia, June 27 (Epub ahead of print)P. Bucher · F. Pugin · P. Morel Received: 30 July 2009 / Accepted: 18 September 2009 / Published online: 4 October 2009©  Springer-Verlag 2009Dear Editor,We read with interest the letter by Jacob et al. [1] report-ing a series of three cases of single incision totally extra-peritoneal (TEP) laparoscopic inguinal hernia repair. Thisletter deserves comments regarding the potential of devel-opment for single incision or port laparoscopic inguinalhernia repair.We Wrst want to congratulate Jacob et al. [1] for theirreport of single incision TEP laparoscopic inguinal herniarepair, although previous authors have reported single inci-sion TEP inguinal repair [2]. As these authors, we have alsotried to approach inguinal hernia through single port accessTEP laparoscopic repair and have completed four cases [3].However, our experience with single port access laparo-scopic TEP inguinal hernia repair made us draw diVerentconclusions compared to Jacob et al.We have completed four cases of inguinal hernia (twounilateral indirect, one bilateral indirect, and one unilateraldirect hernias) repair through single port access (SPA) lapa-roscopic TEP using Parietex ADP2™ meshes (Covidien)without parietal Wxation. A single 12-mm port was insertedinside the inferior umbilical skin on the midline. To con-duct SPA TEP inguinal hernia repair, a working channelendoscope (Richard Wolf GmbH) was used with a standardstraight 5-mm instrument. Dissection was achieved withouta dissecting balloon. After hernia reduction and spermaticcord and vessel isolation, the mesh was placed. The anteriorfacial incision was closed with 2/0 Maxon under vision.The median operative time was 60 (range 52–64) min. Oneintra-operative complication was recorded (bleeding fromthe corona mortis vein), which was controlled by elec-tro-coagulation, but necessitated the adjunction of anadditional 5-mm midline port. No post-operative com-plications were recorded and no recurrences have beenrecorded to the present with a median follow-up of 14(range 16–13 months).First, we found that, using a single-incision multiporttrocar, such as those available for clinical practice, man-dates a too large an incision compared to those needed forconventional TEP laparoscopic repair. Conventional TEPlaparoscopic repair could be achieved easily with two lapa-roscopic ports (one umbilical and one midline) by surgeonsexperienced in TEP laparoscopic repair. Using thisapproach, the median operative time is, in our experience,34 (range 13–54) min [4]. Large umbilical incisions may,as noted by Jacob et al., be associated with a higher rate ofincisional hernia and may not oVer a major cosmetic advan-tage. However, they may be associated with a decrease inthe analgesia needed compared to the two-port approach.For this reason, we tried to perform single port TEP laparo-scopic repair using a single 12-mm access to furtherdecrease parietal trauma. While single port access TEPrepair is feasible, as we experienced, it is probably too diY-cult and does not oVer suYcient safety, even for surgeonsexperienced with single access surgery and TEP repair.We, thus, think that other inguinal hernia repair approachesand instrumental development should be investigated inorder to improve the feasibility, safety, and cosmeticresults of single access inguinal cure before diVusing thistechnique for this indication. According to this question,we have now undergone investigation of trans-abdominalpre-peritoneal (TAPP) inguinal repair, using a multiporttrocar (TriPort™, ASC) with a deXectable-tip endoscope andXexible or curved instrumentation. Preliminary experienceP. Bucher (&) · F. Pugin · P. MorelVisceral Surgery, Department of Surgery, University Hospital Geneva, 4, Rue Gabrielle-Perret-Gentile, 1211 Geneva 14, Switzerlande-mail: pascal.bucher@hcuge.ch123668 Hernia (2009) 13:667–668with laparoendoscopic single-site TAPP, in our hands, wasassociated with subjective surgeon improved feasibility andsafety, while allowing improved cosmetic results.In conclusion, we think that improvement in cosmesis,which can be associated with a decrease in parietal trauma,for inguinal repair have investigated in more detail. Thedevelopment of a two-port technique may be a Wrst step,but single access surgery is the approach that we shouldexamine more closely. Instrumental development and theevaluation of diVerent approaches, especially the TAPPapproach, may be the way forwards. However, we shouldkeep in mind that our Wrst mission is patients’ cure andsurgical safety while developing these new techniques.References1. Jacob BP, Tong W, Reiner M, Vine A, Katz LB (2009) Single inci-sion total extraperitoneal (one SITE) laparoscopic inguinal herniarepair using a single access port device. Hernia [Epub ahead ofprint]2. Cugura JF, Kirac I, Kulis T, JankoviT J, Beslin MB (2008) First caseof single incision laparoscopic surgery for totally extraperitonealinguinal hernia repair. Acta Clin Croat 47:249–2523. Bucher P, Pugin F, Morel P (2009) Scarless surgery: reality throughumbilical laparoendoscopic single site surgery (LESS)? Rev MedSuisse 5:1412–14154. Bucher P, Pugin F, Inan I, Ris F, Morel P (2008) Single midlineworking port for TEP inguinal and crural hernia repair. Swiss KnifeSuppl 1:50123

Single port totally extraperitoneal laparoscopic inguinal hernia repair: Re: Single incision total extraperitoneal (one SITE) laparoscopic inguinal hernia repair using a single access port device, B. P. Jacob et al. (2009) Hernia, June 27 (Epub ahead of print)

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Single port totally extraperitoneal laparoscopic inguinal hernia repair: Re: Single incision total extraperitoneal (one SITE) laparoscopic inguinal hernia repair using a single access port device, B. P. Jacob et al. (2009) Hernia, June 27 (Epub ahead of print)

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