Trocar insertion in enhanced-view totally extra-peritoneal (eTEP) repair of inguinal hernias

The enhanced view totally extra-peritoneal (eTEP) repair is a useful modification of the classic TEP operation which offers a more panoramic view of the operative field with greater flexibility in port positioning. It can offer greater ease of surgery in large, irreducible or bilateral inguinal hernias due to its improved ergonomics. Misunderstanding the myo-fascial anatomy, incorrect positioning or sequence of trocar insertion can lead to inadvertent peritoneal injury with pneumoperitoneum, impeding the operating surgeon.

We describe our method for the surface marking of the semilunar and arcuate lines which guides the site of initial optic access. After blunt/balloon dissection of the pelvic extra-peritoneal space, the lateral trocar is inserted first to clear the peritoneum off the posterior aspect of arcuate line, allowing us to divide it near its medial attachment. The second working trocar is inserted at the umbilicus after visually confirming the extent of dissection. Additional trocars are inserted depending on bilaterality or size of the hernia.

We have operated 124 cases of bilateral inguinal hernia between April 2017 and February 2020, where we suffered peritoneal injury in only four cases, without leading to the conversion of the procedure. The widely dissected space with the division of the arcuate line further increased the ease of laying down a large prosthetic mesh.

The exact sequence of trocar insertion and their positioning described by us improves ergonomics and ensures a safe division of the arcuate line with minimal risk of damage to underlying peritoneum.