**5.1. Preparing the "Manish Retractor"**

"Manish Retractor" is prepared using a 2 ml disposable plastic syringe. The hub of the syringe is divided to obtain a 4 cm length of the retractor. It is further slit along its full length with the help of a scissor and the resultant device is named "Manish Retractor" (**Figures 2** and **3**). Manish retractor replaces the use of large "S" retractor (need 12 mm skin incision) and provide the clear view of ARS through 5 mm skin incision. It retracts skin and subcutaneous fat up to the ARS. This being a cylindrical retraction device is less invasive & less traumatic. This indigenous retractor device plays the key role in accessing the PPS by 5 mm Visiport. This avoids the dependence over wide bore Hasson trocar which is must for current surgical technique [6].

**5.2. Pre-peritoneal space access by "555 Manish Technique"**

**Figure 3.** Divided syringe hub is slit along its full length to make "Manish Retractor"

Excess subcutaneous fat may be cleared by suction.

removal from the 5 mm trocar (**Figure 13**). CO2

leak.

chances of CO<sup>2</sup>

In order to reach the ARS, A 5 mm incision is made in the infra-umbilical region just lateral to midline (**Figure 4**). It is then deepened in the subcutaneous fat and the Manish retractor is inserted. The circumference of the 2 ml syringe is such that it snugly fits in the 5 mm incision. It aids in displacing the fat outwards so that the glistening ARS is clearly visible (**Figure 5**).

Next, using a No. 11 blade, a 5 mm transverse incision is made in the ARS and the underlying longitudinal muscle fibers of rectus muscle are seen (**Figures 6** and **7**). The 5 mm Visiport is mounted over a 5 mm, zero-degree telescope so as to enter into the pre-peritoneal space under vision (**Figure 8**). As the Visiport is progressed into the incision, one can appreciate the upper and the lower lip of the slit in ARS (**Figure 9**) followed by rectus muscle fibers laterally and linea alba medially (**Figure 10**). On further advancement of the trocar the arcuate line gets visible beyond which the posterior rectus sheath is deficient. Finally, after crossing the arcuate line the loose areolar tissue of the pre-peritoneal space gets visible (**Figures 11** and **12**). Then the Manish retractor is pulled out gently from the incision by sliding over the trocar. The slit in the retractor helps its easy and complete

after removing the telescope and leaving the cannula of trocar at its site. The trocar is snugly held by the skin, soft tissue and ARS without any need for anchoring sutures and

Hasson trocar insertion in current technique of TEP repair is a relatively blind step because only the insertion of Hasson trocar in to the ARS is under vision while rest of the trocar

insufflation at 14 mm pressure is achieved

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**Figure 2.** 2mL Syringe hub is divided to make "Manish Retractor".

**Figure 3.** Divided syringe hub is slit along its full length to make "Manish Retractor"

## **5.2. Pre-peritoneal space access by "555 Manish Technique"**

**5. Steps of "555 Manish Technique" for Mini TEP repair of inguinal** 

**hernia**

1. Preparing the "Manish Retractor".

**5.1. Preparing the "Manish Retractor"**

**4.** Dissection the hernia sac.

28 Hernia Surgery and Recent Developments

**2.** Pre-peritoneal space access by "555 Manish Technique."

**6.** Closure of all the infra-umbilical port site wounds.

**Figure 2.** 2mL Syringe hub is divided to make "Manish Retractor".

**3.** Dissection of pre-peritoneal space and placement of working ports.

**5.** Insertion & placement of mesh by "Tail Pull" technique through 5 mm port.

"Manish Retractor" is prepared using a 2 ml disposable plastic syringe. The hub of the syringe is divided to obtain a 4 cm length of the retractor. It is further slit along its full length with the help of a scissor and the resultant device is named "Manish Retractor" (**Figures 2** and **3**). Manish retractor replaces the use of large "S" retractor (need 12 mm skin incision) and provide the clear view of ARS through 5 mm skin incision. It retracts skin and subcutaneous fat up to the ARS. This being a cylindrical retraction device is less invasive & less traumatic. This indigenous retractor device plays the key role in accessing the PPS by 5 mm Visiport. This avoids the dependence over wide bore Hasson trocar which is must for current surgical technique [6].

In order to reach the ARS, A 5 mm incision is made in the infra-umbilical region just lateral to midline (**Figure 4**). It is then deepened in the subcutaneous fat and the Manish retractor is inserted. The circumference of the 2 ml syringe is such that it snugly fits in the 5 mm incision. It aids in displacing the fat outwards so that the glistening ARS is clearly visible (**Figure 5**). Excess subcutaneous fat may be cleared by suction.

Next, using a No. 11 blade, a 5 mm transverse incision is made in the ARS and the underlying longitudinal muscle fibers of rectus muscle are seen (**Figures 6** and **7**). The 5 mm Visiport is mounted over a 5 mm, zero-degree telescope so as to enter into the pre-peritoneal space under vision (**Figure 8**). As the Visiport is progressed into the incision, one can appreciate the upper and the lower lip of the slit in ARS (**Figure 9**) followed by rectus muscle fibers laterally and linea alba medially (**Figure 10**). On further advancement of the trocar the arcuate line gets visible beyond which the posterior rectus sheath is deficient. Finally, after crossing the arcuate line the loose areolar tissue of the pre-peritoneal space gets visible (**Figures 11** and **12**). Then the Manish retractor is pulled out gently from the incision by sliding over the trocar. The slit in the retractor helps its easy and complete removal from the 5 mm trocar (**Figure 13**). CO2 insufflation at 14 mm pressure is achieved after removing the telescope and leaving the cannula of trocar at its site. The trocar is snugly held by the skin, soft tissue and ARS without any need for anchoring sutures and chances of CO<sup>2</sup> leak.

Hasson trocar insertion in current technique of TEP repair is a relatively blind step because only the insertion of Hasson trocar in to the ARS is under vision while rest of the trocar

**Figure 4.** A 5 mm incision is made in the infra-umbilical region just lateral to midline.

**Figure 5.** "Manish Retractor" provides a clear view of anterior rectus sheath by displacing fat outwards.

advancement up to the PPS is blind which can lead to accidental injury to peritoneum. The injury to peritoneum can lead to pneumoperitoneum. Pneumoperitoneum at this stage of surgery leads to difficult dissection and also prolongs the duration of surgery [8]. This is avoidable in our technique as one can see the track of the trocar up to the PPS. It also negates the need for anchoring sutures over the anterior rectus sheath which is required to fix the large cone of the Hasson trocar [9]. The cone of the Hasson trocar further tears the fibers of ARS at the time of fixation to get a leak proof fixation of cone which needs to be repaired by absorbable sutures at the end of the procedure. Finally, the financial impact of using a Hasson's trocar is also

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**Figure 7.** Longitudinal rectus muscle fibres are visible through the slit in ARS.

**Figure 6.** No. 11 blade is used to incise ARS.

**Figure 6.** No. 11 blade is used to incise ARS.

advancement up to the PPS is blind which can lead to accidental injury to peritoneum. The injury to peritoneum can lead to pneumoperitoneum. Pneumoperitoneum at this stage of surgery leads to difficult dissection and also prolongs the duration of surgery [8]. This is avoidable in our technique as one can see the track of the trocar up to the PPS. It also negates the need for

**Figure 5.** "Manish Retractor" provides a clear view of anterior rectus sheath by displacing fat outwards.

**Figure 4.** A 5 mm incision is made in the infra-umbilical region just lateral to midline.

30 Hernia Surgery and Recent Developments

**Figure 7.** Longitudinal rectus muscle fibres are visible through the slit in ARS.

anchoring sutures over the anterior rectus sheath which is required to fix the large cone of the Hasson trocar [9]. The cone of the Hasson trocar further tears the fibers of ARS at the time of fixation to get a leak proof fixation of cone which needs to be repaired by absorbable sutures at the end of the procedure. Finally, the financial impact of using a Hasson's trocar is also

**Figure 8.** Visiport is mounted over 5 mm, zero-degree telescope and introduced through "Manish retractor" to reach PPS under vision.

**Figure 9.** Upper and lower lips of slit in ARS.

alleviated. The placement of 1st trocar by "555 Manish Technique" takes 2.5 min of surgical time which is far less than average 7–10 min of time taken in placement of Hasson trocar. This technique of accessing the PPS is time saving, less traumatic and less invasive than Hasson

insufflation at 14 mm Hg pressure and on high flow rate helps in creating the Space of Bogros & Space of Retzius. The dissection in PPS is beginning by dissecting the relatively avascular loose areolar tissue in midline till the pubic bone as the first landmark. Then the dissection is carried out laterally on the contralateral side to make the 5 mm working ports. We are trained in performing TEP repair via lateral approach. The first working port is placed just above and medial to ASIS and second one, 5 cm cranial to it. Lateral working port approach is not the part of "555 Manish Technique" and so the procedure can be done using midline working

pneumo-

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**5.3. Dissection of pre-peritoneal space and placement of working ports**

**Figure 11.** Pre-peritoneal fat becomes visible through visiport on reaching the PPS.

ports as well after insertion of 1st 5 mm infra-umbilical camera port.

Blunt dissection of loose areolar tissue is done by 5 mm, zero-degree telescope. CO2

trocar technique [5, 6].

**Figure 12.** Loose areolar tissue in pre-peritoneal space.

**Figure 10.** Linea alba is visible on the left side while rectus muscle fibre on the right side of figure.

**Figure 11.** Pre-peritoneal fat becomes visible through visiport on reaching the PPS.

**Figure 12.** Loose areolar tissue in pre-peritoneal space.

**Figure 10.** Linea alba is visible on the left side while rectus muscle fibre on the right side of figure.

**Figure 8.** Visiport is mounted over 5 mm, zero-degree telescope and introduced through "Manish retractor" to reach

PPS under vision.

32 Hernia Surgery and Recent Developments

**Figure 9.** Upper and lower lips of slit in ARS.

alleviated. The placement of 1st trocar by "555 Manish Technique" takes 2.5 min of surgical time which is far less than average 7–10 min of time taken in placement of Hasson trocar. This technique of accessing the PPS is time saving, less traumatic and less invasive than Hasson trocar technique [5, 6].

#### **5.3. Dissection of pre-peritoneal space and placement of working ports**

Blunt dissection of loose areolar tissue is done by 5 mm, zero-degree telescope. CO2 pneumoinsufflation at 14 mm Hg pressure and on high flow rate helps in creating the Space of Bogros & Space of Retzius. The dissection in PPS is beginning by dissecting the relatively avascular loose areolar tissue in midline till the pubic bone as the first landmark. Then the dissection is carried out laterally on the contralateral side to make the 5 mm working ports. We are trained in performing TEP repair via lateral approach. The first working port is placed just above and medial to ASIS and second one, 5 cm cranial to it. Lateral working port approach is not the part of "555 Manish Technique" and so the procedure can be done using midline working ports as well after insertion of 1st 5 mm infra-umbilical camera port.

vas deferens using blunt and sharp dissection. Catgut loop is then tied at the base of the sac after complete parietalization of cord structures and vas deferens. 5 mm telescope provides a

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good vision and does not cause any problem in dissection (**Figure 14**).

**Figure 15.** No. 1 silk thread is tied at one end of rolled mesh with 20 cm long tail.

**Figure 16.** Silk thread tail is inserted through 5 mm trocar in to PPS.

**Figure 13.** Slit in "Manish retractor" helps in its complete removal without taking out the 5 mm trocar.

**Figure 14.** Indirect inguinal hernia sac is dissected from cord structures.

#### **5.4. Dissection of hernia sac**

Maryland dissector and a blunt grasper are used to reach up to the hernia sac and cord structures by gentle dissection. The sac is reduced and dissected off from the cord structure and vas deferens using blunt and sharp dissection. Catgut loop is then tied at the base of the sac after complete parietalization of cord structures and vas deferens. 5 mm telescope provides a good vision and does not cause any problem in dissection (**Figure 14**).

**Figure 15.** No. 1 silk thread is tied at one end of rolled mesh with 20 cm long tail.

**Figure 16.** Silk thread tail is inserted through 5 mm trocar in to PPS.

**5.4. Dissection of hernia sac**

34 Hernia Surgery and Recent Developments

**Figure 14.** Indirect inguinal hernia sac is dissected from cord structures.

Maryland dissector and a blunt grasper are used to reach up to the hernia sac and cord structures by gentle dissection. The sac is reduced and dissected off from the cord structure and

**Figure 13.** Slit in "Manish retractor" helps in its complete removal without taking out the 5 mm trocar.

**Figure 17.** The end of long tail of silk thread is left inside the PPS.

**6. Insertion and placement of mesh by "Tail Pull" technique through** 

The "Tail Pull" technique is also innovated and used to insert the adequate size mesh. A light weight polypropylene mesh of 15 × 12 cm size is rolled to the thinnest possible thickness along its width. A No. 1 silk thread of 20 cm length is tied at one end of the rolled mesh (**Figure 15**). The long silk thread tail is grasped with Maryland dissector and then inserted through a 5 mm working port. Maryland dissector is then taken out leaving the end of the tail in the PPS (**Figures 16** and **17**). This end of tail is then grasped by inserting Maryland dissector through other working port. The tail is then pulled inside which facilitate the insertion of mesh in PPS through 5 mm port (**Figures 18** and **19**). The mesh is then unrolled inside after cutting the thread and placed over the myopectineal orifice (**Figure 20**). It is fixed with tackers over the cooper's ligament. This "Tail Pull" technique facilitate the insertion of mesh as only the mesh is traversing through the trocar cannula while conventionally the mesh is introduced along with a grasping instrument which need a bigger lumen to insert mesh, as mesh and instrument both occupy the space of lumen. The use of a lightweight mesh reduces complications of chronic

**Figure 20.** Adequate size light weight polypropylene mesh is unfolded over myopectineal orifices and fixed at cooper's

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All 5 mm trocars are taken out after deflating the space. The small 5 mm size of the infra-umbilical ports does not need any repair of ARS or subcutaneous fat. Skin is stapled as all the wounds are of 5 mm in size. The 12 mm infra-umbilical skin incision in Hasson trocar technique ultimately gets wider due to fixation of the large cone and ultimately becomes a size of 2.5–3.0 cm. Even the ARS fibers got teared because of the tight fixation of the tip of the cone and needs to be repaired along with subcutaneous fat with Vicryl. Larger incisions are always more prone for SSI and more pain [11]. All these complications are prevented in "555 Manish Technique" as it

is done by all three 5 mm ports without deviating from the principles of TEP repair.

**5 mm port**

ligament.

pain, seroma formation, etc. [10].

**7. Closure of all the infra-umbilical port site wounds**

**Figure 18.** Light weight polypropylene mesh is pulled inside through 5 mm port.

**Figure 19.** Rolled mesh is then pulled inside by holding and pulling the silk thread inside with grasper from another port.

**Figure 20.** Adequate size light weight polypropylene mesh is unfolded over myopectineal orifices and fixed at cooper's ligament.
