Single incision total extraperitoneal (one SITE) laparoscopic inguinal hernia repair using a single access port device.

To the Editors, Performing laparoscopic operations through one single skin incision has recently emerged as a possible alternative to conventional laparoscopy in a variety of surgical cases. To date, however, other than cosmesis, there is no evidence yet to suggest any signiWcant patient advantages for singleincision laparoscopic surgery. Nonetheless, single-incision cases were reported as early as in 1998 [1, 2], and, recently, the term “single incision laparoscopic surgery” (SILSTM) has been described for a large number of urologic, gynecologic, bariatric, and general surgical procedures, and its use seems to be rapidly growing. Annually in the United States, there are about 800,000 inguinal hernias performed, of which approximately 140,000 are performed laparoscopically by either the transabdominal (TAPP) or total extraperitoneal (TEP) approaches. While the indications and contraindications have yet to be described, the use of SILSTM techniques to perform laparoscopic inguinal hernia repairs is already being described [3]. SILSTM techniques are currently being performed using one of two entry methods. On the one hand, a single skin incision can be made, followed by the insertion of multiple trocars through separate points of the fascia. Alternatively, through a single skin and fascial incision, a single-port access device can be inserted and multiple trocars can be inserted through these devices. We began using single-incision techniques for TEP hernia repairs in December of 2008, and we would like to report our group’s initial experience with SILSTM inguinal hernia repairs using a singleaccess port device. The technical steps of a single incision TEP inguinal hernia are very similar to that of a traditional laparoscopic TEP inguinal hernia, and no special instruments are required. We begin by making an infraumbilical skin incision measuring 25 mm in length. The incision is made partially over the midline and is extended to over the anterior fascia of the left rectus muscle. The anterior fascia is held with two stay sutures and divided longitudinally for approximately 25 mm. The current size of the available single-incision port devices mandate this size incision. The posterior fascia at this level is identiWed and the rectus muscle is retracted laterally, allowing us to create a plane deep to the rectus muscle down to the level of the pubic bone using a dilating balloon trocar. The balloon dilator is then removed and replaced with a single-access port device (Covidien, Norwalk, CT, USA). Through this device, we insert a 12-mm trocar and two 5-mm trocars. Using a 45° 10-mm laparoscope, we then performed a routine TEP inguinal hernia repair. Standard laparoscopic instruments and mesh are then utilized for the operation. We have completed a total SILSTM inguinal hernia repair using this single-port access device in three patients. In our Wrst case, a direct inguinal and a femoral defect were discovered on the right. When the left groin was explored, a small direct defect was found. A 4 £ 6-in polypropylene mesh was inserted through the 12-mm port and secured on each side using four to Wve spiral tacks, as is our routine. The operation was straightforward and took 73 min. The patient was discharged home the same day and the postoperative course was uneventful. At the 2-week follow-up appointment, there was no evidence of recurrence and no obvious wound complications, including no evidence of an incisional hernia. The next two cases were performed in males with bilateral indirect inguinal hernias. One of these patients had B. P. Jacob (&) · W. Tong · M. Reiner · A. Vine · L. B. Katz Laparoscopic Surgical Center of New York, Mount Sinai Medical Center, New York, NY 10028, USA e-mail: bpjacob@gmail.com