Background <p>The extended view totally extraperitoneal (e-TEP) technique has gained increasing attention for treating ventral hernias. Establishing the preperitoneal space is a crucial yet challenging initial step in the e-TEP procedure. This study compares the optical gasless trocar technique with the traditional open method for preperitoneal space establishment, highlighting technical details and analyzing their respective characteristics.</p> Methods <p>A retrospective analysis was conducted on 201 patients who underwent e-TEP repair across four centers from October 2021 to October 2023. Patients were divided into two groups: 106 cases using the optical gasless trocar technique and 95 cases using the open method. We compared patient characteristics, preperitoneal space establishment time, and other perioperative data between the two groups. Follow-up was performed via phone calls or outpatient visits. Data analysis was conducted using SPSS 29.0, with Student's <i>t</i>-tests for continuous data and chi-square tests for categorical data.</p> Results <p>There were no significant differences in age, gender, BMI, or other baseline characteristics between the two groups (<i>P</i> &gt; <i>0.05</i>). The optical gasless trocar group (OGT) had a significantly shorter preperitoneal space establishment time (1.87 ± 0.68&#xa0;min) compared to the open method group (OM) (3.52 ± 0.93&#xa0;min) (<i>P</i> &lt; <i>0.001</i>). In eight cases, the trocar initially entered the abdominal cavity but was successfully repositioned to the correct plane without complications. On the first postoperative day, the visual analog scale (VAS) score for pain was lower in the OGT group (2.55 ± 0.66) than in the OM group (2.86 ± 0.88) (<i>P</i> = <i>0.004</i>).</p> Conclusion <p>The optical gasless trocar technique for preperitoneal space establishment is time-saving, convenient, and effective, as it avoids repeated tissue retraction and cutting. It is a valuable addition to the e-TEP procedure.</p>