555 Manish Technique
Innovative “555 Manish Technique” for MINI TEP repair of Inguinal Hernia
The extent of damage done by the surgeon to anterior abdominal wall in open surgery era has shifted the surgeons and patients towards laparoscopic surgery. Lesser invasive surgeries which cause least damage to the normal tissues are being innovated.Worldwide laparoscopic inguinal hernia repair (TEP- Totally extra-peritoneal repair) is being done by infra-umbilical placement of 12mm large Hasson trocar and two other 5 mm working ports. Hasson trocar is a costly trocar and exclusively used for TEP repair of inguinal hernia.
Challenges: Hasson trocar technique is the only technique known among laparoscopic surgeons to enter in to the pre-peritoneal space. The insertion of Hasson trocar in pre-peritoneal space is a relatively blind procedure and can accidently injure the peritoneum during insertion, which lead to difficult dissection and prolongation of operating time. This Hasson trocar ultimately leaves a 20mm wound at the end of surgery because of its large cone which is required to fix this trocar with abdominal wall. Bigger wound causes more pain in comparison to 5 mm port wound.
Key Wins: I have innovated a “555 Manish Technique” in which the TEP repair is done by all three 5 mm ports. In place of 12mm infra-umbilical incision (as in Hasson trocar technique) only 5mm incision is made in the infra-umbilical region in my technique. This technique avoids the dependence over costly, large bore Hasson trocar. I’ve made an indigenous, cost effective “Manish Retractor”. This “Manish Retractor” plays a key role in inserting the 5mm trocar with minimal dissection in place of wide bore Hasson trocar. This retractor helps in dissecting up to the anterior rectus sheath and placing the 5mm trocar in pre-peritoneal space. The advantage of inserting 5mm visiport in pre-peritoneal space is that the operating surgeon can see the complete path of insertion up to the pre-peritoneal space and avoid accidental injury to peritoneum which could occur with Hasson trocar technique. I have also innovated a technique to insert light weight polypropylene mesh through 5 mm trocar which helps in completing the surgery with all 5 mm ports. There are several benefits of this Indian, unique, breakthrough “555 Manish Technique”. It is simple, safe, less painful, cost effective and having better cosmetic results in terms of smaller scar below the umbilicus.
In my technique, the 12 mm infra-umbilical incision is reduced to 5 mm size. There is no dependence over wide bore costly Hasson trocar in my technique, which reduces the cost of surgery. Very cost effective “Manish Retractor” is devised by 2 mL plastic syringe, which plays a key role in placement of 5 mm routine trocar in pre-peritoneal space. Placement of 5 mm trocar in pre-peritoneal space through my technique take an average time of 151 second (2minutes 31 seconds), which is well below the average time of Hasson trocar placement which takes an average of 7 to 10 minutes. There is no need to close the 5mm defect which again saves the cost of absorbable suture material. Pain in 5 mm wound (evaluated by VAS Score), chances of surgical site infection and smaller scar decreases the morbidity and financial burden to the patient. Being operative innovative technique it directly affects and benefits patient in terms of smaller wound, less pain, less morbidity, cost effective instrumentation, early return to work and cosmetically better scar than the current technique. This technique will decrease the financial burden over the hospitals to purchase costly Hasson trocar which is being used exclusively for inguinal hernia repair only. It will save the operating time and can lead to better utilisation of operating rooms.