Laparoscopic Access to the Preperitoneal Space

Laparoscopic herniorrhaphy has become an important procedure for the laparoscopic surgeon. Although in some situations controversial, it is a procedure that is here to stay. The two most common types of laparascopic herniorrhaphy have been previously described. Trans-abdominal preperitoneal (TAPP) necessitates entering the abdominal cavity. This puts the patient at risk for laparoscopic misadventures with needles and trocars and requires closure of the peritoneum. If mesh is exposed to the abdominal contents there is a risk of adhesive bowel obstruction. Total extra-peritoneal (TEP) hernia repair is a more difficult procedure, with a steeper learning curve. The advantage of the extra-peritoneal approach is that there is less risk of needle or trocar injury to the intra-abdominal contents. Also, the peritoneum is not incised so the mesh is not exposed to bowel. For these reasons the TEP hernia repair is, in our opinion, the laparoscopic procedure of choice. One of the difficulties in the TEP herniorrhaphy is gaining access to the preperitoneal space. This is typically done in an open method using various retractors and right-angle scopes. In this report we describe a technique using the visi-port trocar system (US Surgical Inc.) to access the preperitoneal space.