By: Dr Manish Kumar Gupta
In this era of innovations, even Indian surgeons are playing their active role in coming up with less invasive, more advanced, safer surgeries with innovative tools. Till date, laparoscopic inguinal hernia operations were done using old technique of Hasson Trocar placement. Use of three ports (12mm Hasson trocar & two 5mm ports) for total extra-peritoneal (TEP) repair of inguinal hernia is a standard laparoscopic technique followed worldwide.
Laparoscopic surgeons have dependence over wide bore 12mm Hasson trocar to create pre-peritoneal space (PPS) & mesh insertion. Placing and fixing a large bore Hasson trocar to the anterior rectus sheath (ARS) with its 3 cm large cone in the anterior abdominal needs a bigger skin incision in the infra-umbilical region and also leads to a bigger defect in ARS. Hasson trocar insertion in PPS is a relatively blind step, as only the insertion is under vision but tracking the trocar to PPS is blind, which can injure peritoneum accidently leading to difficult dissection and prolongation of operative time. Placement of Hasson trocar takes 7-10 minutes of operative time. ARS and subcutaneous fat need to be repaired with absorbable sutures at the end of surgery. However, to ease matters, an Indian surgeon has developed a new technique for groin hernia operation. This new technique involves less tissue dissection and enables the patient to get back to his normal life faster due to smallest possible 5mm incisions and almost invisible scars.
Dr. Manish K. Gupta, Laparoscopic Surgeon at Sir Ganga Ram Hospital, Delhi, had developed an innovative procedure for groin hernia repair in the year 2014. With this innovative and less invasive technique he has successfully operated more than two hundred fifty groin hernias till now. Marking it as a safe technique for others to start following as well.
Ease of procedure for clinicians & patients, both
Morbidity management in terms of more pain and increased chances of surgical site infection of a larger port site wound also have financial impact on the patients. Large skin incisions not only leave scars on the body, but also on mind and soul. Big scar below the belly button is not acceptable especially to female patients. In developing countries like India, the cost of surgical treatment is always a matter of concern. Dependence and necessity of using a costly Hasson trocar exclusively for TEP repair ultimately reflect in overall surgical cost.
Dr. Gupta has innovated an Optiview ‘555 Manish Technique’ for Mini TEP repair of inguinal hernia by all 5 mm ports.He has indigenously made Manish Retractor for precisely inserting a 5mm Optiview trocar to PPS in between the anterior and posterior rectus sheath, which was not possible earlier. Insertion of 5 mm trocar placement without Manish Retractor is not possible as it can lead to accidental injury of posterior rectus sheath leading to pneumoperitoneum.
This technique avoids large incision in the infra-umbilical region and dependence over costly Hasson trocar. Insertion of Optiview trocar has an added advantage of tracking the path of trocar up to PPS and avoid accidental injury to peritoneum. We have also innovated a Tail Pull technique to insert an adequate size synthetic mesh through 5 mm port to cover the hernial orifices. There is no need to repair the anterior rectus sheath and subcutaneous fat at the end of the procedure as the defects are only 5 mm in size; this size of skin wound needs a single stitch, which leaves almost an invisible scar.
Since October 2014, 250 groin hernias were operated successfully by this technique. Out of these, 220 groin hernias, 3 femoral and 1 obturator hernia were also operated, which are rare types of groin hernia than inguinal hernia. The average duration of 1st 5mm Optiview trocar placement to PPS takes 2.1 minutes of operative time. Pain is less because of smaller 5 mm infra umbilical incision. Three cases were converted to transabdominal preperitoneal (TAPP) repair because of adhesions due to previous surgery and difficult dissection. There was no recurrence or major complications other than persistence of seroma in 4 patients on 6 months follow up. Smaller, almost invisible scar, below the umbilicus is usually cosmetically acceptable to the patients.
Optiview “555 Manish Technique” is easy, less invasive, less morbid, time saving, cost effective and reproducible without changing the principles of TEP repair of groin hernias.
About the author
Dr. Manish K. Gupta is a Laparoscopic Surgeon at Sir Ganga Ram Hospital, New Delhi. With his innovation, he has successfully operated more than 250 groin hernias till now. The video of his surgery technique was also accepted and published by the Journal of Laparoendoscopic and Advanced Surgical Technique, Videoscopy Part B, New York, USA.