Reply to: Invited comment "Chronic pain and qualit

Dear Editors,

We would like to thank D.C. Chen and P. Amid for their kind comments about our paper entitled Chronic pain and quality of life (QoL) after transinguinal pre-peritoneal (TIPP) inguinal hernia repair using a totally extraperitoneal, parietalized, Polysoft memory ring patch [1].

We are deeply honored that they found such a great interest [2] in reading our manuscript.

We would like to add some further details to answer the remaining technical concerns, which they could have about our TIPP technique.

Many of these concerns arise from the lack of available demonstrative pictures on this minimal invasive technique, which is not easy to film. Fortunately, a few days ago we completed such a video for the EHS school, and then we extracted four pictures from it, presented here.

Without a direct vision, it is indeed difficult to imagine how much this minimal approach can provide a sufficient exposure onto the pre-peritoneal structures. This approach allows a complete dissection, under a permanent visual control, of the peritoneum (Fig. 1), the vas deferens, and the anterior aspect of the internal spermatic vessels (Fig. 2).

The vas deferens and the internal spermatic vessels are ensheathed in the urogenital fascia, easily seen here in between them (Fig. 3), sheath or fascia described by Stoppa et al. [3, 4] and others. They are both gently sep- arated from the peritoneum as far as needed. The dissec- tion, close to the peritoneum (Fig. 1), is conducted in the visceral compartment at the inner aspect of the sheath, exactly like in TEP and not in the parietal compartment where the nerves run, in particular the genito-femoral, and caudally its femoral branch.

Its genital branch enters the inguinal canal laterally, at the extreme external edge of the deep inguinal ring and joins the external spermatic vein, the so-called ‘blue line’ landmark [5].

Finally, the mesh is positioned exactly as is done in TEP (Fig. 4) between the peritoneum inside and outside the couple vas deferens-internal spermatic vessels ensheathed.

In case of lateral hernia (see the epigastric vessels not divided), the transversalis fascia is not cut open. The inguinal floor is preserved. The entire dissection and positioning of the mesh are completed through the deep inguinal ring, which, often, finally retracts entirely cover- ing the pre-peritoneal mesh.

In our experience TIPP was as painless as that of lapa- roscopic TEP, which we had been performing before. With regards to EBM, only one RCT comparing TIPP and Lichtenstein has been published yet [6, 7], this RCT favors TIPP. Further results from RCT and registries are clearly needed.


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