DECOMPRESSION OF ACCIDENTAL PNEUMOPERITONEUM IN TEP AND eTEP HERNIA SURGERIES USING VERESS NEEDLE AND 5 mm TROCAR - A COMPARATIVE STUDY

Abstract

Background: An unintended peritoneal breach leading to accidental pneumoperitoneum ranks among the most frequent intraoperative challenges during totally extraperitoneal (TEP) and extended totally extraperitoneal (eTEP) hernia repair. As carbon dioxide tracks into the peritoneal cavity, the preperitoneal working space collapses, visualisation deteriorates, and conversion to an alternative approach may become necessary. Several strategies have been proposed to address this problem, but deliberately decompressing the pneumoperitoneum remains the most direct and effective solution. This study evaluates and compares the safety and effectiveness of two decompression techniques, the Veress needle and the 5 mm trocar, in both TEP and eTEP repairs. Methods: Operative records of 550 consecutive extraperitoneal hernia repairs (250 TEP, 300 eTEP) carried out at Saveetha Medical College and Hospital between January 2017 and June 2024 were reviewed retrospectively. Accidental pneumoperitoneum was noted in 80 patients (14.5 %): 50 of 250 TEP repairs (20.0 %) and 30 of 300 eTEP repairs (10.0 %), and these 80 patients constituted the study cohort. Group A (n = 38; 27 TEP, 11 eTEP) was decompressed using a Veress needle, while Group B (n = 42; 23 TEP, 19 eTEP) was decompressed using a 5 mm trocar, both introduced at Palmer’s point following nasogastric decompression and exclusion of splenomegaly. Demographic characteristics, operative duration, ease of decompression, intraoperative and postoperative complications, and VAS pain scores were analysed and compared between groups using the Chi-square test and Student’s t-test, with statistical significance set at p < 0.05. Results: TEP repairs were complicated by accidental pneumoperitoneum twice as often as eTEP repairs (20.0 % vs 10.0 %; χ² = 10.97, p < 0.001). Baseline age, BMI, sex, and hernia type did not differ significantly between the two decompression groups (p = 0.721, 0.746, 0.133, and 0.838, respectively). The 5 mm trocar group had a significantly shorter mean operative time (94.1 ± 35.9 vs 119.5 ± 38.0 min; p = 0.003) and shorter hospital stay (2.4 ± 0.5 vs 2.7 ± 0.6 days; p = 0.018) compared with the Veress needle group. Complications were infrequent and comparable: seroma 2 vs 1, haematoma 2 vs 1, paralytic ileus 3 vs 0 (p = 0.103) and surgical emphysema 1 vs 0. There were no bowel, vascular or splenic injuries and no mesh infections in either group. VAS pain scores were similar at 24 h (4.8 ± 0.7 vs 4.6 ± 0.6; p = 0.176) and at 48 h (3.5 ± 0.5 vs 3.7 ± 0.6; p = 0.108), with no clinically or statistically significant difference at either time point. Conclusion: Both techniques of decompression are safe and feasible in TEP as well as eTEP repair. The 5 mm trocar provided faster and more sustained decompression, shortening operative time without added morbidity. Incorporating trocar decompression as a standardised step may improve workflow during extraperitoneal repairs, particularly when the peritoneal rent occurs early in the dissection.