Usefulness of a Long Forceps Technique in Single-Incision Laparoscopic Surgery for Totally Extraperitoneal Repair of Inguinal Hernia Open Access

S-TEP operations were performed for 34 inguinal hernias in 27 patients from November 2013 to February 2015. Among them, unilateral inguinal hernia repair was performed in 20 patients. Among these 20 patients, a straight long (43 cm) dissection and grasping forceps (Karl Storz, Tuttlingen, Germany; Fig. 1) was used for 5 patients in conjunction with the HARMONIC ACE (Ethicon Endo-Surgery, Cincinnati, Ohio). The characteristics of these patients were summarized in Table 1.

A 1-cm umbilical incision was made, followed by a linear alba incision, and a 5-mm port was inserted. Next, a 5-mm flexible laparoscope was moved into the peritoneal cavity through this port, and the type of inguinal hernia was diagnosed. We also examined whether the opposing side indicated the presence of an inguinal hernia. A drainage tube was then inserted from the linear alba into the peritoneal cavity and tightened to exhaust any excess carbon dioxide (CO₂) gas. A 1-cm incision over the anterior rectus sheath allowed us to retract the rectus muscle laterally and a preperitoneal space was made by blunt dissection using a finger or gauze. The single-port device was then inserted and insufflation was initiated with CO₂ gas at 8 mmHg. A 5-mm flexible scope was used for better visualization. By using a long, straight forceps and the HARMONIC ACE, the preperitoneal space was created using the landmarks for proper dissection, such as the pubic bone inferiorly and the psoas muscle laterally, so that the whole myopectineal orifice was visualized. The hernia sac was then freed from the spermatic cord using a long, straight forceps, and a 14 × 10 cm mesh was rolled, inserted, and deployed. Absorbable spiral tackers were used for fixation over the Cooper's ligament, lateral to the inferior epigastric vessels.

A long forceps was used in 5 cases (median age: 71 years; range: 40–88 years). The instances of collision between the forceps and the laparoscope were found to dramatically decrease with the use of long forceps because it is capable of widely separating the distance between the bilateral forceps and between the forceps and the laparoscope (Figs. 2, 3). All patients underwent successful S-TEP repair. No complications were detected in the use of long forceps. No cases of recurrence or major complications were observed.

Laparoscopic hernia repair has been reported to be superior to conventional inguinal hernia repair because the procedure reduces postoperative pain, enables an earlier return to work and is associated with a better cosmetic outcome.^4,5  The 2 common laparoscopic techniques used in the treatment of inguinal hernia are transabdominal preperitoneal repair (TAPP) and TEP repair. No significant differences have been reported between the 2 procedures regarding postoperative complications, recurrence rates, or chronic groin pain. However, the TAPP approach carries the potential risks of visceral injury, intestinal obstruction due to intraabdominal adhesion, and port-site hernia.^5–9  One study reported that the risk of intestinal obstruction following the TAPP procedure was 1.14 per 1,000 person-years, while that after the TEP procedure was reported to be 0.28.¹⁰  As laparoscopic incisions or trocars present risks for hemorrhage, organ injury, incisional hernia, and poor cosmetic outcomes, SILS has increasingly been used to treat a variety of conditions. The first case of S-TEP was reported in 2009.³  A relatively small number of reports compare conventional TEP and S-TEP.^11–14  These reports have indicated that S-TEP is safe and feasible procedure, and have noted that an umbilical incision provides excellent cosmetic outcomes. For these reasons, S-TEP has been used as standard procedure in our institution since December 2013.

However, the collision of the forceps and a laparoscope remains a specific problem that is associated with SILS. While a curved forceps is considered to be effective for avoiding this problem, the difficulties involved with its use have prevented it from becoming widespread. In contrast, the use of a long forceps does not change the sense of position. We thus think that it would be easier to use a long forceps than a curved forceps. It is capable of widely separating the distance between the bilateral forceps and between the forceps and the laparoscope (Figs. 2, 3).

Although the accumulation of more cases is necessary, we believe that the present technique enable the ability to reduce the difficulty of S-TEP in using a long forceps.

In conclusion, the use of a long forceps during S-TEP repair may decrease the difficulty for dissection.

The authors have no conflicts of interest to declare.