A prospective randomised control trial to compare the perioperative outcomes and ergonomic challenges between triangular versus midline port placement in total extra-peritoneal repair of uncomplicated unilateral inguinal hernia

A Correction to this article was published on 11 June 2020

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Routine TEP technique requires three skin incisions for placement of three trocars in the midline. Otherwise, this can be done by three-port triangular technique or two-hand technique. This study reports a randomised trial of perioperative outcomes and ergonomics characteristics of this procedure using two different techniques of port insertion.


N = 28 patients were randomised into two groups for triangular three-port (TTEP) versus midline three-port TEP (MTEP) hernioplasty after informed written consent in Department of Surgery, King George’s Medical University UP between September 2016 and September 2017 after institutional ethical approval. Patient-related outcomes in terms of quality of life (QOL) and ergonomic evaluation of the technique were compared in double-blinded fashion.


Postoperative pain score at 24 h post surgery (5.1 ± 0.6; 95% CI 4.9–5.3 vs. 4.8 ± 0.4; 95% CI 4.6–4.9) differed, while hospital stay, time to return to routine work, tolerance to oral feeds and intraoperative complications occurrence (OR 2.1; 95% CI 0.2–24.3) were comparable in both groups. Time to return to office work (5.5 ± 0.5; 95% CI 5.4–5.7 vs. 4.0 ± 0.8; 95% CI 3.7–4.3) and immediate postoperative sensation of mesh and pain score were significantly higher in MTEP compared to TTEP. Ergonomic parameters including visualization of landmark score, spreading of mesh score and total surgeon satisfaction score (TTEP 8.4 ± 0.7; 95% CI 8.1–8.6 vs. MTEP 7.0 ± 0.8; 95% CI 6.7–7.3), mental effort quotient (SMEQ score: TTEP 50.6 ± 12.7; 95% CI 45.9–55.3 vs. MTEP 70.8 ± 12.6: 95% CI 66.1–75.4) and physical effort quotient (LEDQ scores in wrist, hand, arm and shoulders) were also superior in triangular technique of port placement.


Triangular three-port TEP hernioplasty is ergonomically feasible and enables a surgeon to perform surgery safely using basic principles of laparoscopy.

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Correspondence to Awanish Kumar.

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Dr SS and Dr AA have shared co-first authorship of this paper since both have worked equally in conceptualising the study, methodology, data analysis and interpretation. Dr AA has additionally been one of the surgeons in the operative team and has primarily prepared this manuscript. None of the author has any financial conflicts of interest to disclose.

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Appendix A: Ergonomics evaluation

Surgeon’s satisfaction score = A + B


Appendix B: Intraoperative findings


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Singh, S., Anand, A., Kumar, A. et al. A prospective randomised control trial to compare the perioperative outcomes and ergonomic challenges between triangular versus midline port placement in total extra-peritoneal repair of uncomplicated unilateral inguinal hernia. Surg Endosc 35, 1395–1404 (2021). https://doi.org/10.1007/s00464-020-07525-4

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  • TEP hernioplasty
  • Triangular
  • Midline
  • Ergonomic
  • Port placement