many different surgical procedures have been described , and tension - free repair using a prosthetic mesh became the mainstay of herniorrhaphy .
therefore , laparoscopic transabdominal preperitoneal ( tapp ) and totally extraperitoneal ( tep ) techniques are frequently preferred .
when comparing the two techniques , tapp is easier to learn and may be associated with a shorter learning curve .
recent studies have been focused to minimise further the invasiveness of laparoscopy by reducing the number of incisions and the port size . in this way , pain and complications associated with incisions
single - incision laparoscopic surgery ( sils ) was developed with the aim of reducing the invasiveness of conventional laparoscopy , and has been successfully performed by many surgeons .
the aim of this retrospective study was to evaluate the safety and feasibility of a single - incision approach for laparoscopic tapp repair of the inguinal hernia .
patients older than 18 years of age who underwent tapp or sils - tapp between december 2012 and january 2015 in the department of surgery of a university research hospital were included in this retrospective study .
the study has been performed in accordance with the ethical standards laid down in the declaration of helsinki .
after the patients were informed about the surgical procedure and potential complications of the surgery , written informed consents were obtained from all the participants .
the data included age , gender , body mass index ( bmi ) , operative time ( placement of ports to skin closure ) , american society of anesthesiologists ( asa ) classification score , length of hospital stay ( defined as operation day to discharge day from the hospital ) , visual analogue scale ( vas ) score 24 h after the surgery , operative complications , and short - term and long - term outcomes that were obtained from hospital charts and office records .
patients with complicating diseases resulting in asa classification score iv , contraindications to laparoscopic surgery such as previous laparotomy or huge chronic scrotal hernia were also excluded from the study .
all operations were performed by the same surgeon ( h.y . ) who had experience in single - port surgery .
after standard preoperative preparation , a single intravenous dose of antibiotic prophylaxis ( cefazolin 1 g ) was administered before induction , and all the patients underwent surgery under general anaesthesia .
a similar surgical technique through a single umbilical port with conventional instruments was followed to perform sils - tapp repair .
a standard postoperative analgesic protocol was followed with intravenous petidine hydrochloride 50 mg after operation , intravenous paracetamol 500 mg every 6 h and tenoxicam 20 mg twice a day .
patients were asked to rate their pain in the range of 0 ( no pain ) to 10 ( most pain ) that most closely expressed their level of postoperative pain .
the patient was placed in a supine position on the operating table and the surgeon stood on the opposite side of the hernia .
the first 10-mm trocar ( versaport plus , covidien , mansfield , ma , usa ) was introduced through the umbilicus with open technique .
additionally , two 10-mm and 5-mm ports were placed on the right and left sides of the camera port .
the 10-mm port was used to introduce the mesh and a 30-mm curved needle for peritoneal suturing .
the peritoneal cavity was insufflated with co2 to a pressure of 12 mmhg , and a 30 laparoscope ( karl storz , germany ) was inserted .
the patient was placed in a trendelenburg position with the hernia site rotated up to allow slipping of the bowel .
the peritoneum was incised using hook electrocautery from the upper edge of the inguinal floor toward the median umblical ligament , and the preperitoneal plane was developed with sharp and blunt dissections .
a 10  15 cm - sized polypropylene mesh ( surgipro mesh , covidien , ma , usa ) was introduced through the 10-mm trocar , placed over the inguinal floor .
all potential hernia areas were covered with meshes such as hesselbach 's triangle , inguinal ring , and femoral ring .
the mesh was tacked to the transversus abdominis , iliopubic tract , and cooper ligament using absorbable tackers ( absorbatack , covidien , usa ) .
sils - tapp was performed with a similar technique to the standard tapp repair through a single umbilical port .
the sils - port ( covidien corp , mansfield , ma , usa ) was introduced through a single 2.0 - 3.0 cm transverse transumbilical skin and facial incision [ figure 1 ] .
after creation of pneumoperitoneum at pressure of 12 mmhg , two 5-mm working ports and a 10-mm camera port was inserted [ figure 2a ] .
a mesh was placed , and the peritoneum was closed with standard laparoscopic instruments or tackers . after releasing the pneumoperitoneum ,
the umbilical fascia was routinely closed with polypropylene loop suture ( surgipro ii , tyco , usa ) and the skin was sutured with 4 - 0 absorbable intradermic sutures ( monocryl , ethicon , usa ) .
a 3-cm skin and facial incision was performed ( a ) to insert the sils port ( b ) two working ports and a camera port were inserted to the abdomen ( a ) , the peritoneum incised from the upper edge of the inguinal floor ( b ) the peritoneum was separated from epigastric vessels and the vas deferens the evaluation of patient data was performed by using statistical package for the social sciences ( spss ) version 18.0 program ( ssps , inc . , chicago , il , usa ) .
continuous variables were presented as mean  standard deviation and categorical variables as the number ( % ) .
categorical variables were compared using the chi - square test and fisher 's exact test . a p level of < 0.05 was accepted as statistically significant .
the patient was placed in a supine position on the operating table and the surgeon stood on the opposite side of the hernia .
the first 10-mm trocar ( versaport plus , covidien , mansfield , ma , usa ) was introduced through the umbilicus with open technique .
additionally , two 10-mm and 5-mm ports were placed on the right and left sides of the camera port .
the 10-mm port was used to introduce the mesh and a 30-mm curved needle for peritoneal suturing .
the peritoneal cavity was insufflated with co2 to a pressure of 12 mmhg , and a 30 laparoscope ( karl storz , germany ) was inserted .
the patient was placed in a trendelenburg position with the hernia site rotated up to allow slipping of the bowel .
the peritoneum was incised using hook electrocautery from the upper edge of the inguinal floor toward the median umblical ligament , and the preperitoneal plane was developed with sharp and blunt dissections .
a 10  15 cm - sized polypropylene mesh ( surgipro mesh , covidien , ma , usa ) was introduced through the 10-mm trocar , placed over the inguinal floor .
all potential hernia areas were covered with meshes such as hesselbach 's triangle , inguinal ring , and femoral ring .
the mesh was tacked to the transversus abdominis , iliopubic tract , and cooper ligament using absorbable tackers ( absorbatack , covidien , usa ) .
sils - tapp was performed with a similar technique to the standard tapp repair through a single umbilical port .
the sils - port ( covidien corp , mansfield , ma , usa ) was introduced through a single 2.0 - 3.0 cm transverse transumbilical skin and facial incision [ figure 1 ] .
after creation of pneumoperitoneum at pressure of 12 mmhg , two 5-mm working ports and a 10-mm camera port was inserted [ figure 2a ] .
a mesh was placed , and the peritoneum was closed with standard laparoscopic instruments or tackers . after releasing the pneumoperitoneum ,
the umbilical fascia was routinely closed with polypropylene loop suture ( surgipro ii , tyco , usa ) and the skin was sutured with 4 - 0 absorbable intradermic sutures ( monocryl , ethicon , usa ) .
a 3-cm skin and facial incision was performed ( a ) to insert the sils port ( b ) two working ports and a camera port were inserted to the abdomen ( a ) , the peritoneum incised from the upper edge of the inguinal floor ( b ) the peritoneum was separated from epigastric vessels and the vas deferens
the evaluation of patient data was performed by using statistical package for the social sciences ( spss ) version 18.0 program ( ssps , inc . ,
continuous variables were presented as mean  standard deviation and categorical variables as the number ( % ) .
categorical variables were compared using the chi - square test and fisher 's exact test . a p level of < 0.05 was accepted as statistically significant .
in total , 148 patients underwent laparoscopic inguinal hernia repair . of the 148 patients ,
the mean follow - up period was 15.4  3.8 months for patients who underwent tapp and 14.8  3.6 months for patients who underwent sils - tapp .
there was a statistically significant difference between the two groups regarding age : the mean age of the patients was 57.1  12.4 years in the tapp group and 50.7  10.1 years in the sils - tapp group .
the groups were also similar in terms of gender , nyhus classification , asa classification , and follow - up time .
all sils - tapp procedures were completed successfully without conversion to tapp or open repair , and no additional port was required in both groups .
there were no differences in operative time , length of hospital stay and vas scores of patients 24 h after the operation .
the mean operative time was 36.8  8.7 min in the tapp group and 38.7  9.2 min in the sils - tapp group .
no intraoperative major complications were observed such as vessel , intestine , or bladder injury .
the first control examination was performed 2 weeks after the operation to record the short - term complications for all patients .
every 2 months , telephone surveys were conducted to investigate the patients ' complaints related to surgery .
one patient in each group had a complaint of pain for longer than 3 months .
several small seroma and hematomas were reported in both groups , and all of them were resolved with conservative treatment .
long - term complications such as mesh infection and recurrence were not detected in both the groups .
three patients ( 5.0% ) in the sils - tapp group experienced port site hernia ( psh ) .
two of the patients were obese ( bmi : 33.7 kg / m and 34.1 kg / m ) , diabetic , and male .
the other psh had occured in 52-year - old female patient with chronic obstructive pulmonary disease .
all of the pshs were confirmed by ultrasound , and elective mesh hernioplasty was performed .
preoperative patients ' characteristics comparison of the operative time , length of hospital stay and vas scores comparison of the intraoperative , short - term and long - term postoperative complications
sils is developed in an attempt to minimize the abdominal wall trauma by reducing the number of ports .
the most important advantage of sils has been reported as the improvement in cosmetic results .
one of the important results of this study is that the sils - tapp is associated with high psh rate when compared with tapp .
however , in the short - term and long - term complication rates , and pain scores showed no difference with surgical technique . in this study
, we have evaluated conventional three - port tapp and single - incision tapp repair with respect to perioperative events and postoperative outcomes .
but there was a limitation of this study , namely , the choice of surgical technique to be used was based on patients ' demands .
however , the bigger umbilical incision to accommodate the sils port should not be underestimated .
several studies have very low incidence of psh but the current follow - up period of patients who underwent sils is limited .
reported a psh rate of 2.9% in a study of 211 patients that included appendectomy , cholecystectomy , nissen fundoplication , sleeve gastrectomy , gastric banding , colectomy and gastrojejunostomy .
authors were recommended to extend the duration of the follow - up period to 2 - 3 years to determine the  true  risk of incisional hernias .
the prospective study of christoffersen et al . demontrated the incisional hernia rate to be similar with a long - term follow - up period of median 4 years .
it is known that the incisional hernia rate is significantly higher in patients with comorbidities such as diabetes mellitus , obesity and chronic obstructive pulmonary disease . in our sils - tapp group ,
therefore , the bigger umbilical incision is not a single factor for incisional hernia ; the patient selection seems to be a cornerstone of decreasing the risk of psh . in a majority of the studies ,
sils groups have a longer operative time because of the proximity of the instruments with limited triangulation and limited motion of the laparoscope .
the problem of clashing of instruments was partially offset by using articulating dissector , grasper and shear .
the learning curve with conventional instruments is not very long , and after the first 10 - 20 cases the training process was almost completed .
the surgeons who are at the learning curve period for sils should select uncomplicated patients with lower bmi . in fact , obesity is not a contraindication for sils technique .
patients with bmi of 40 kg / m or higher underwent sils procedures in our clinic without any major complication .
therefore , the operative time of the groups were found to be similar in our study .
the analysis of patient demographics demonstrated that patients undergoing sils - tapp were significantly younger than patients undergoing tapp . among younger people
in the experienced laparoscopic surgery centers , sils - tapp inguinal hernia repair is a feasible and safe technique with remarkable cosmesis , and comparable postoperative pain scores although the single umbilical incision may also lead to an incisional hernia risk to patients . with careful patient selection , sils - tapp
prospective randomized studies with long - term follow - up are necessary to evaluate the true psh rates , and potential benefits associated with these approaches .
 background : laparoscopic surgery has been a frequently performed method for inguinal hernia repair . 
 studies have demonstrated that the laparoscopic transabdominal preperitoneal ( tapp ) approach is an appropriate choice for inguinal hernia repair . 
 single - incision laparoscopic surgery ( sils ) was developed to improve the cosmetic effects of conventional laparoscopy . 
 the aim of this study was to evaluate the safety and feasibility of sils - tapp compared with tapp technique.materials and methods : a total of 148 patients who underwent tapp or sils - tapp in our surgery clinic between december 2012 and january 2015 were enrolled . 
 data including patient demographics , hernia characteristics , operative time , intraoperative and postoperative complications , length of hospital stay and recurrence rate were retrospectively collected.results:in total , 60 sils - tapp and 88 tapp procedures were performed in the study period . 
 the two groups were similar in terms of gender , type of hernia , and american society of anesthesiologists ( asa ) classification score . 
 the patients in the sils - tapp group were younger when compared the tapp group . 
 port site hernia ( psh ) rate was significantly high in the sils - tapp group , and all pshs were recorded in patients with severe comorbidities . 
 the mean operative time has no significant difference in two groups . 
 all sils procedures were completed successfully without conversion to conventional laparoscopy or open repair . 
 no intraoperative complication was recorded . 
 there was no recurrence during the mean follow - up period of 15.2  3.8 months.conclusion:sils tapp for inguinal hernia repair seems to be a feasible , safe method , and is comparable with tapp technique 
 . however , randomized trials are required to evaluate long - term clinical outcomes . 
INTRODUCTION
MATERIALS AND METHODS
Operative techniques
Statistical analysis
RESULTS
DISCUSSION
CONCLUSION
Financial Support and Sponsorship
Conflicts of Interest