title: Laparoscopic totally extraperitoneal (TEP) hernioplasty using two trocars: anatomical landmarks and surgical technique.
abstract: BACKGROUND
  Among endoscopic hernioplasties, totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) approach are widely accepted alternatives to open surgery, both providing less postoperative pain, hospital length of stay and early return to work. Classical TEP technique requires three skin incisions for placement of three trocars in the midline or in triangulation.
  
  
  OBJECTIVE
  To describe a technique using only two trocars for laparoscopic total extraperitoneal for inguinal hernia repair.
  
  
  METHODS
  Extraperitoneal access: place two regular trocars on the midline. The 10 mm is inserted into the subcutaneous in horizontal direction after a transverse infra-umbilical incision and then elevated at 60º angle. The 5 mm trocar is inserted at the same level of the pubis with direct vision. Preperitoneal space dissection: introduction 0º optical laparoscope through the infra-umbilical incision for visualization and preperitoneal dissection; insufflation pressure must be below 12 mmHg. Dissection of some anatomical landmarks: pubic bone, arcuate line and inferior epigastric vessels. Exposure of "triangle of pain" and "triangle of doom". Insertion through the 10 mm trocar polypropylene mesh of 10x15 cm to cover the hernia sites. Peritoneal sac and the dorsal edge of the mesh are repositioned in order to avoid bending or mesh displacement. It is also important to remember that the drainage is not necessary.
  
  
  RESULTS
  The 2-port TEP required less financial costs than usual because it is not necessary an auxiliary surgeon to perform the technique. Trocars, suturing material and wound dressing were spared in comparison to the classical technique. Besides, there were only two incisions, which provides a better plastic result and less postoperative pain.
  
  
  CONCLUSIONS
  The TEP technique using two trocars is an alternative technique which improves cosmetic and financial outcomes.
authors.affiliation: Medical School, University of São Paulo, São Paulo, Brazil.
authors.forename: Leandro Ryuchi
authors.initials: LR
authors.lastname: Iuamoto
authors.affiliation: Medical School, University of São Paulo, São Paulo, Brazil.
authors.forename: Juliana Mika
authors.initials: JM
authors.lastname: Kato
authors.affiliation: Abdominal Wall Repair Center, Samaritano Hospital, São Paulo, Brazil.
authors.forename: Alberto
authors.initials: A
authors.lastname: Meyer
authors.affiliation: Department of Digestive Surgery, Clinique Chirurgicale Mutualiste, Saint-Étienne, France.
authors.forename: Pierre
authors.initials: P
authors.lastname: Blanc
mesh_terms: D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy; D013525:Surgical Instruments