title: Suction test to demonstrate the peritoneal edge during laparoscopic extraperitoneal inguinal hernia repair.
abstract: BACKGROUND
  Inadequate peritoneal dissection from retroperitoneal structures may account for a large number of hernia recurrences amongst surgeons and trainees who are new to totally extraperitoneal (TEP) laparoscopic inguinal hernia repair. In this paper, we describe a simple dynamic test that allows surgeons to better appreciate the peritoneal edge during the initial dissection phase of TEP inguinal hernia repair, allowing for more adequate dissection of the peritoneum from retroperitoneal structures before placement of mesh.
  
  
  METHODS
  Data from a single surgeon was collected on 113 consecutive patients who underwent laparoscopic TEP inguinal hernia repair at the Royal North Shore Hospital in Sydney. The data was retrospectively reviewed to determine the number of cases in which the suction test led to further peritoneal dissection prior to mesh placement.
  
  
  METHODS
  After balloon dissection of the pre-peritoneal space and initial dissection of peritoneum and sac from retroperitoneal structures, a laparoscopic suction device is used to aspirate the insufflated gas from the pre-peritoneal space to cause the peritoneum to bulge anteriorly, thus demonstrating the edge of the peritoneal reflection. Further dissection is performed if deemed necessary at this point, and the mesh is placed over the hernia defect.
  
  
  RESULTS
  136 TEP hernia repairs were performed in 113 patients. In 26 (23 %) of patients, the abovementioned technique was of particular value resulting in further dissection of peritoneum prior to mesh placement. There were no complications as a direct result of the test.
  
  
  CONCLUSIONS
  This dynamic suction test is a risk-free and useful operative tool for surgeons and trainees who are new to TEP inguinal hernia repair, and provides a definitive way of identifying the peritoneal reflection to ensure the peritoneum has been dissected adequately prior to mesh placement.
authors.affiliation: Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, University of Sydney, St Leonards, NSW, 2065, Australia, chrisnahm@gmail.com.
authors.forename: Christopher
authors.initials: C
authors.lastname: Nahm
authors.forename: Jason
authors.initials: J
authors.lastname: Free
authors.forename: Sivakumar
authors.initials: S
authors.lastname: Gananadha
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Hugh
authors.forename: Jaswinder S
authors.initials: JS
authors.lastname: Samra
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004210:Dissection / Q000009:adverse effects / Q000379:methods; D004867:Equipment Design; D005260:Female; D006406:Hematoma / Q000209:etiology; D006552:Hernia, Inguinal / Q000601:surgery*; D059685:Herniorrhaphy / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D007327:Insufflation; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013396:Suction / Q000295:instrumentation / Q000379:methods*; D013526:Surgical Mesh; D016896:Treatment Outcome; D016055:Urinary Retention / Q000209:etiology; D055815:Young Adult