**4.1. Instruments used in "555" technique**

Three 5 mm Visiport (Endopath XCEL bladders trocar: Ethicon) (**Figure 1**).

Two milliliters plastic syringe to make "Manish Retractor".

Five millimeters 0 or 30-degree telescope.

Laparoscopic instruments (Maryland dissector, Grasper, scissors).

Silk thread No 1-0 on needle.

15 × 10 cm size, light weight polypropylene mesh (Ultrapro Mesh; Ethicon).

Tacker for mesh fixation.

inguinal hernia repair in 1992. Laparoscopic inguinal hernia repair can be done either by trans abdominal pre-peritoneal (TAPP) or totally extra-peritoneal (TEP) approach. Laparoscopic inguinal hernia shows advantage over tension-free Liechtenstein repair in terms of less pain, early return to work, smaller scars and low recurrence rates. TEP repair of inguinal hernia has gained popularity in last two decades since 1st introduced by Dulucq in 1992 [2]. TEP repair of inguinal hernia is now a standard surgical technique [3]. It also avoids the chances of missing femoral, obturator and contralateral inguinal hernia and simultaneously give the operating surgeon an opportunity to repair at the same time [2, 4]. Fixing a mesh over the myopectineal orifice at the time of TEP or TAPP repair prophylactically prevents femoral or

This technique requires specialized anatomical knowledge and good two hand dexterity for dissecting hernia sac and placement of mesh. Therefore, the acceptance and implementation of TEP have been slow in comparison to other laparoscopic procedures such as cholecystectomy. Laparoscopic inguinal hernia repair has steep learning curve especially in TEP repair and due to limited working space [5, 6]. Increased operative time and complication rates during the early learning curve are other drawbacks. Creating a preperitoneal space without injuring the peritoneum is again a challenging task in the initial part of surgery. Accidental pneumoperitoneum can further compromise the pre-peritoneal space which leads to difficult dissection and prolongation of surgical time [6]. The current Hasson trocar approach is the only way to create pre-peritoneal space and the only technique known among laparoscopic surgeons. There is always dependence over the wide Hasson trocar and its broader cone to create pre-peritoneal space. A larger infra-umbilical incision is required for dissecting up to the anterior rectus sheath with the help of "S Retractor" to fix the Hasson trocar with the anchoring sutures. The insertion of Hasson trocar is a relatively blind surgical step of TEP repair of inguinal hernia [7]. Cases of port site incisional hernia were also reported at the site of 12 mm port site used for insertion of mesh [2]. Exclusive use of Hasson trocar for TEP repair in current scenario ultimately reflects in surgical cost. Management of morbidities due to larger port site wound also adds to the financial burden over the patient. Large scar below the belly button is cosmetically suboptimal especially to females. Bigger wound not only leave scar on the body but

**3. Innovative approach of Mini TEP by "555 Manish Technique"**

We have innovated a "555 Manish Technique" which addresses the shortcomings of the conventional TEP repair of inguinal hernia. In our technique, we complete Mini TEP repair by all three 5 mm ports. We do not use Hasson trocar to create pre-peritoneal space and innovated

obturator hernia formation.

26 Hernia Surgery and Recent Developments

**2. Current scenario of TEP repair**

over the mind & soul as well [6, 7].

**Figure 1.** Instruments used in "555 Manish Technique".
