An alternative access technique under direct vision for preperitoneoscopic pelvic surgery: Easier for the beginners

Background: We present an alternative access technique to facilitate preperitoneoscopic (extraperitoneal laparoscopic) approach for radical prostatectomy, herniorrhaphy, and other pelvic procedures. Methods: A 0° telescope was mounted into a Visiport Optical Trocar (Visiport), and via a periumbilical incision it was advanced under direct vision at first vertically through different layers of the anterior abdominal wall. Immediately before the posterior rectus sheath, it was redirected caudally and horizontally toward the symphysis pubis. The Visiport was withdrawn and replaced by a dissection balloon that was inflated for developing the working space, then it was substituted with a 12-mm trocar to begin the pneumo-extraperitoneum. The surgical procedures are detailed in the attached video. Results: This technique was used in 168 of 179 patients undergoing preperitoneoscopic surgery (97 radical prostatectomies, 80 totally extraperitoneal herniorrhaphies, and 2 urinary bladder diverticulectomies). Operative parameters were compared with 11 preceding patients approached with the open Hasson technique. All of the procedures to create the preperitoneoscopic space were successfully with no complications. For radical prostatectomy, there was a significantly faster access to the preperitoneal space (38 ± 12 vs 540 ± 69 seconds) and a faster setup of the whole operative space (15 ± 5 vs 29 ± 9 minutes, both P < .05) with the new technique. Less pericannular CO₂ leakage was experienced during the preperitoneoscopy with our technique. Conclusion: This alternative technique offers a simple, safe, quick, and effective access for creating a preperitonescopic working space.