title: Liquid-injection for preperitoneal dissection of transabdominal preperitoneal (TAPP) inguinal [corrected] hernia repair.
abstract: BACKGROUND
  The creation of an adequate peritoneal flap during laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair, while avoiding injuring surrounding structures can be technically challenging. Liquid infiltration of the preperitoneal space can help facilitate dissection and avoid inadvertent injuries. We describe a novel technique for TAPP inguinal hernia repair using liquid-injection for preperitoneal [corrected] dissection and report our initial experience.
  
  
  METHODS
  TAPP inguinal hernia repair using a liquid-injection technique during preperitoneal dissection was performed by a single surgical resident without prior TAPP repair experience from July 2013 to January 2014. After trocar placement, 60 mL of 0.3 % lidocaine with 1:300,000 dilution of epinephrine was injected percutaneously using a blunt needle under laparoscopic visualization into the preperitoneal space to assist with the dissection and parietalization of the vas deferens, spermatic vessels, and epigastric vessels. The initial peritoneal incision is performed at the lateral side of the inguinal canal, followed by blunt dissection of the preperitoneal space.
  
  
  RESULTS
  Eleven patients (median age: 69; 8 male) with a total of 12 inguinal hernias underwent a TAPP repair using a liquid-injection preperitoneal dissection technique. Ten patients had unilateral hernias (4 indirect, 6 direct), and one patient had bilateral direct hernias. The median operative time, median injection time, and median dissection time were 116, 3.5, and 42 min, respectively. Estimated blood loss was less than 10 mL for all cases. No intraoperative injuries, conversions to open repair, or 30-day postoperative complications occurred. There were no hernia recurrences after a median follow-up of 143 days.
  
  
  CONCLUSIONS
  Our preliminary experience suggests that liquid-injection to assist preperitoneal dissection during TAPP inguinal hernia repair appears to be safe and feasible. This novel method facilitates the dissection of spermatic cord structures, and can be used to minimize trauma to surrounding structures, especially when performed by trainees with limited operative experience.
authors.affiliation: NTT East Sapporo Hospital, Sapporo, Hokkaido, Japan, tmizota@huhp.hokudai.ac.jp.
authors.forename: Tomoko
authors.initials: T
authors.lastname: Mizota
authors.forename: Yusuke
authors.initials: Y
authors.lastname: Watanabe
authors.forename: Amin
authors.initials: A
authors.lastname: Madani
authors.forename: Norihiro
authors.initials: N
authors.lastname: Takemoto
authors.forename: Hidehisa
authors.initials: H
authors.lastname: Yamada
authors.forename: Saseem
authors.initials: S
authors.lastname: Poudel
authors.forename: Yuji
authors.initials: Y
authors.lastname: Miyasaka
authors.forename: Yo
authors.initials: Y
authors.lastname: Kurashima
mesh_terms: D000368:Aged; D000779:Anesthetics, Local / Q000008:administration & dosage; D004210:Dissection / Q000379:methods*; D004338:Drug Combinations; D004837:Epinephrine / Q000008:administration & dosage*; D005260:Female; D006552:Hernia, Inguinal / Q000601:surgery*; D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D007264:Inguinal Canal / Q000601:surgery*; D007267:Injections; D010535:Laparoscopy / Q000379:methods; D008012:Lidocaine / Q000008:administration & dosage*; D008297:Male; D010537:Peritoneum / Q000601:surgery*; D014662:Vasoconstrictor Agents / Q000008:administration & dosage
chemical_list: D000779:Anesthetics, Local; D004338:Drug Combinations; D014662:Vasoconstrictor Agents; D008012:Lidocaine; D004837:Epinephrine