First case of single incision laparoscopic surgery for totally extraperitoneal inguinal hernia repair

Laparoscopic approach to inguinal hernia repair is indicated for recurrent and bilateral hernias or as patient choice in unilateral primary hernias. Totally extraperitoneal (TEP) approach has some advantages over transabdominal preperitoneal (TAPP) approach, but has proved to be more technically demanding. It cannot be emphasized enough that every incision and trocar placement poses a risk of bleeding, organ damage, incisional hernia and less favorable cosmetic effect. Single incision laparoscopic (SILS) TEP hernia repair has reduced the number of incisions to minimum. A 60-year-old male patient presented with unilateral right sided primary indirect inguinal hernia. Laparoscopic SILS TEP repair was performed: a single 2.5-cm infraumbilical incision was made, the anterior rectus sheath was incised and a balloon dissection device was inserted over the posterior rectus sheath, guided to the pubic symphysis and inflated, resulting in separation of the peritoneum from the rectus muscle. This creation of the extraperitoneal space allowed for laparoscopic dissection to take place. We used a 10-mm optical trocar and two 5-mm trocars placed 1 cm laterally from the optical port. The operation was free from complications and the operative time was 90 minutes. Postoperative recovery was uneventful. We report on, to our knowledge, the first case of SILS TEP hernia repair. Based on this experience, we believe that SILS TEP is feasible. Adjacent placement of trocars in SILS reduces triangulation which, along with frequent crossing of instruments, renders this approach more demanding. Cosmetic benefit is clear; however, it remains to evaluate patient recovery, postoperative pain and complications in comparison to standard TEP.