Closure of peritoneal rents during total extraperitoneal inguinal hernia repair using nonabsorbable polymer ligating clips “Hem-o-Lok®”

In the modern era, laparoscopic repair of inguinal hernia has become increasingly common worldwide, with the total extraperitoneal (TEP) approach being widely utilised. Peritoneal injury during TEP repair is a recognised complication, with some studies reporting an incidence of up to 47%. Although practice and proper technique can minimise the risk, peritoneal injury remains a challenging issue. Peritoneal rents [Figure 1] can lead to the creation of pneumoperitoneum, complicating the surgical procedure. If these defects are not adequately repaired, complications such as bowel herniation, adhesion of bowel loops to the polypropylene mesh and even fistulisation may occur. In addition, herniation through unrepaired defects can result in bowel obstruction.Figure 1: Peritoneal rent with pouting of small bowelVarious techniques have been described for closing these rents, including the use of pre-tied Endoloop sutures, direct suturing or surgical staplers. However, these methods have limitations. Endoloop sutures can be challenging to place on larger defects, especially when working with only two ports. Similarly, suturing through midline ports is technically demanding and time-consuming. We describe an alternative technique for closing peritoneal rents using 5 mm non-absorbable polymer ligating clips “Hem-o-Lok®”. These interlocking clips can be deployed through 5-mm ports. The technique involves grasping the edge of the rent with a laparoscopic grasper and gently pulling it laterally and outwards. This manoeuvre aligns the edges of the defect while ensuring no intraperitoneal contents are trapped between them. The edges are then approximated and secured using Hem-o-Lok clips, effectively closing the defect [Figures 2-5]. Use of Hem-o-Lok has been previously described by Nitta et al. in their case series, which showed that it is a safe technique with shorter operative time as compared to endoscopic suturing.[1]Figure 2: Defining the peritoneal rentFigure 3: Traction on the rent from one corner to align its edgesFigure 4: Using the small Hem-o-Lok clip for closureFigure 5: Watertight closure of the rentWe have employed this technique in 25 patients with peritoneal rents ranging from 1 cm to 4 cm in size. The outcomes were favourable, with no reported complications. In addition, this method did not significantly extend the overall operative time. The limitation of this technique is that it is difficult to apply over wider peritoneal defects and difficult to close and approximate with these clips. Availability of data and material (data transparency) Available with the corresponding author. Authors’ contributions Anmol Ahuja–Involved in describing the technique Tarun Mittal–reading and editing the manuscript Shresth Manglik–reading and editing the manuscript Vinod K Malik–reading and editing the manuscript Ashish Dey–reading and editing the manuscript. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.