From: Subject: Laparoscopic Repair of Inguinal Hernia Date: Thu, 16 Aug 2007 15:35:54 +0800 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0015_01C7E01B.222CF920" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.3138 This is a multi-part message in MIME format. ------=_NextPart_000_0015_01C7E01B.222CF920 Content-Type: text/html; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.edu.rcsed.ac.uk/lectures/lt10a.htm Laparoscopic Repair of Inguinal Hernia


= =20 =20 = =20 =20 = =20 =20 = =20 =20 = =20 =20 =20

LAPAROSCOPIC REPAIR = OF INGUINAL=20 HERNIA ( ADULT )
PRE-PERITONEAL APPROACH=20 (TEP)

P= ATIENT=20 SELECTION
THEATRE=20 LAYOUT AND EQUIPMENT
PRE-OP= ERATIVE=20 CHECKS
PATIEN= T=20 PREPARATION
INSUFFLATION=20 AND PORT INSERTION
DIREC= T=20 HERNIA
IND= IRECT=20 HERNIA
MESH= =20 INSERTION
CLOSURE
DETA= ILED=20 INDEX

PATIENT SELECTION Top=

SUITABLE = PATIENTS

Patient 12 years plus
  For a=20 child of 12 years or less, see Repair of = Inguinal
  Hernia (=20 Child ) File name INGHERCH.
Male Patient
Female=20 Patient

SUITABLE HERNIAS

ELECTIVE REPAIR
   For emergency = operation,=20 see Emergency SCALPELFAX.
INDIRECT HERNIA
DIRECT = HERNIA
SLIDING=20 HERNIA
EXPLORATION FOR SUSPECTED HERNIA
RECURRENT HERNIAS (NOT=20 PREPERITONEAL)
BILATERAL HERNIAS

RELATIVE = CONTRAINDICATIONS

PREVIOUS PREPERITONEAL HERNIA OPERATION
PREVIOUS=20 SUBUMBILICAL MIDLINE, PARAMEDIAN, OR PFANNENSTIEL INCISION
RENAL = TRANSPLANT=20 ON SAME SIDE
HIP ARTHROPLASTY ON SAME SIDE
PREVIOUS CENTRAL = DISLOCATION=20 OF HIP
PROTRUSIO ACETABULAE
GRIDIRON INCISION ON SAME = SIDE
STOMA ON=20 SAME SIDE

THEATRE LAYOUT AND EQUIPMENT Top

NON-SURGICAL EQUIPMENT = LIST

VIDEO SYSTEM (WOLF)

2190.20 VIDEO TROLLEY WITH ISOLATION = TRANSFORMER
5370.01=20 CCD VIDEO CAMERA complete with Control Unit
5261.27 27mm. = LENS
5370.52=20 20" SONY MONITOR

VIDEO RECORDER

5631.01 SONY U-MATIC RECORDER VO = 7630)

LIGHT SOURCE

5108.01 AUTO IRIS HIGH POWER LIGHT=20 SOURCE

CABLES

815.009 HIGH FREQUENCY CONNECTING CABLE FOR = ELECTRODES AND=20 PROBES
8106.009 HIGH FREQUENCY CONNECTING CABLES FOR=20 FORCEPS

INSUFFLATION SYSTEM

2154.75 HIGH FLOW INSUFFLATOR with recirculating = Smoke Filter=20 System including sterile filters.

SPARES

STERILE FILTERS for insufflator.
CO2 = CYLINDER
SPARE=20 LIGHT BULB
SPARE FUSES

STANDARD STERILE SURGICAL EQUIPMENT = (FRIARAGE=20 HOSPITAL)

1 X MINOR PACK
3 X SPONGEHOLDERS
2 X = GALLIPOTS
1 X=20 MEDIUM RECEIVER
2 X SMALL RECEIVER
1 X MEDIUM BOWL
2 X LARGE = WATER=20 BOWLS
1 X NO 3 KNIFE HANDLE
1 X 15 Swann MORTON BLADE
2 X = LITTLEWOODS=20 FORCEPS
4 X CURVED JOLLS FORCEPS
2 X ROBERTS FORCEPS
1 X = GROOVED=20 HERNIA DIRECTOR
1 X 5" STRAIGHT SCISSORS
1 X MCINDOES = SCISSORS
2 X=20 SMALL LANGENBECK RETRACTORS
2 X LARGE LANGEBNBECK RETRACTORS
1 X = HEAVY=20 NONTOOTHED FORCEPS
1 X 2ML SYRINGE FOR ULTRASTOP
1 X 2O ML = SYRINGE FOR=20 20ML 0.25% BUPIVACAINE
1 X GREEN 21 SWG NEEDLE FOR BUPIVACAINE
1 = X SMALL=20 NEEDLE HOLDER
1 X DIATHERMY SHEATH
1 X SUCTION TUBING
1 X = IRRIGATION=20 TUBING
1 X GIVING SET
1 X PLASTIC SHEATH FOR CAMERA LEAD AND = STERILE=20 ADHESIVE STRIP
1 X POOLE SUCKER
8 X TOWEL CLIPS
0 X COTTON = BUDS
2=20 X FINE DIATHERMY LEADS
1 X INSUFFLATION TUBING
1 X PACKET SUTURE = STRIPS
1 X VERESS NEEDLE

STANDARD STERILE SURGICAL EQUIPMENT = (DARLINGTON=20 MEMORIAL HOSPITAL)

1 X GENERAL SET
1 X LAPAROSCOPY SET
1 X = GENERAL SET=20 EXTRAS
2 X SUCKER TUBING
1 X COMPLETE DIATHERMY SET
1 X = CYSTOSCOPY=20 IRRIGATION SET WITH 500ml SALINE
1 X HEAVY NON-TOOTHED FORCEP
1 = X VERESS=20 NEEDLE
1 X NO15 Swann-MORTON BLADE
2 X SMALL LANGENBECK = RETRACTOR
1 X=20 VOLSELLUM FORCEP
1 X PLASTIC SHEATH FOR CAMERA LEAD AND STERILE = ADHESIVE=20 STRIP
10 X COTTON WOOL=20 BUDS
1 X LAURENCE NEEDLE HOLDER
1 X = BOWL
1 X=20 RECEIVER
1 X 2ml SYRINGE FOR ULTRASTOP
1 X 2ml SYRINGE FOR = SALINE
1 X=20 20ml SYRINGE FOR BUPIVACAINE
1 X 21 SWG GREEN TOP NEEDLE
4 X = EXTRA TOWEL=20 CLIPS

STANDARD STERILE SURGICAL EQUIPMENT = (ST JOHN OF=20 GOD HOSPITAL)

SPECIAL STERILE SURGICAL = EQUIPMENT

TELESCOPES

8934.441 PANOVIEW TELESCOPE 0 10MM. = DIAMETER
8061.455 LIGHT=20 TRANSMITTING CABLE 2.4M LONG

TROCARS AND SLEEVES

2 X 8934.01 10MM. TROCAR SLEEVE WITH PISTON = VALVE
8934.12=20 10MM. TROCAR WITH PYRAMID TIP
8934.981 REDUCING SLEEVE 10MM. - = 5MM.
2 X=20 8940.01 5MM. TROCAR SLEEVE WITH PISTON VALVE
8940.12 5MM. TROCAR = WITH=20 PYRAMID TIP

VERESS NEEDLE

2 X 8302.12 VERESS NEEDLE

FORCEPS, SCISSORS AND CLIP = APPLIERS

8385.10 GRASPING FORCEPS WITH LARGE TEETH 10MM. (THE = ROTWEILERS)
2 X 8383.08 GRASPING FORCEPS WITH ALLIGATOR TEETH WITH = LOCK=20 (THE ALLIGATORS)
8383.141 ATRAUMATIC GRASPING FORCEPS 5MM. FLAT = (THE=20 RACQUETS)
2 X 8383.45 HOOKED SCISSORS 5MM.

SUCTION/IRRIGATION = PROBES

8383.732 SUCTION AND IRRIGATION PROBE=20 5MM.

ELECTRODES 2 X 8383.421 HOOK = ELECTRODES=20 5MM.

MISCELLANEOUS

815.009 HIGH FREQUENCY CONNECTING CABLE FOR = ELECTRODES AND=20 PROBES
8106.009 HIGH FREQUENCY CONNECTING CABLE FOR = FORCEPS
89.08 10MM.=20 SEALING CAPS PER 10
89.02 5MM. SEALING CAPS PER 10
88.02 SEALING = CAPS=20 FOR FORCEPS PER 10
8383.78 INTRODUCER FOR ETHIBINDERS / = ENDOLOOPS
SUTURE=20 INTRODUCER

SURGICAL DISPOSABLES

171025 SURGIPORT DISPOSABLE TROCAR 10MM = 50.00
176615=20 ENDOCLIP DISPOSABLE APPLIER 110.00
?175006 SURGIPORT CONVERTER = 5.5MM.=20 5.00

SURGICAL DISPOSABLE = SPARES

178009 ENDOCLIP 10 ML ACCESSORY KIT 286.00
1 = ENDOCLIP ML=20 DISPOSABLE APPLIER WITH MEDIUM- LARGE TITANIUM CLIPS
1 SURGIPORT = 10MM.=20 TROCAR WITH 1 STAINLESS SLEEVE, 1 RADIOLUCENT SLEEVE
1 SURGIPORT = 5MM.=20 TROCAR WITH 1 STAINLESS SLEEVE, 1 RADIOLUCENT SLEEVE
1 SURGINEEDLE = 120MM.=20 INSTRUMENT
2 SURGIGRIP 5MM. DISPOSABLE SLEEVES
1 SURGIGRIP 10MM. = DISPOSABLE SLEEVE
3 SURGIPORT CONVERTERS 3.5MM.,=20 4.5MM.,5.5MM
ENDO-SHEARS DISPOSABLE SCISSORS
ENDOLOOP = SUTURES
2 X=20 EH495G CHROMIC CATGUT 1 69.00
10MM. DISPOSABLE SEAL
5MM. = DISPOSABLE=20 SEAL

THEATRE FURNITURE

1 X LARGE TROLLEY
1 X SMALL TROLLEY
1 X DRIP = STAND
1=20 X PRESSURE INFUSOR

MATERIALS

ARTERIAL SLOOP
FASCIA CLOSURE NO 1 VICRYL = (ETHICON=20 W9251)
SUTURESTRIPS
SKIN SPRAY NOBECUTAINE
SKIN DRESSING=20 MEPORE
BACTERIOLOGY SWAB

PHARMACEUTICALS

CEFUROXIME 750MG IV
IRRIGATION SALINE 500ML 0.9% = NO=20 HEPARIN
SKIN INJECTION BUPIVACAINE 2OML 0.5%
DICLOFENAC=20 SUPPOSITORY

ASSORTED EXTRAS AND ITEMS FOR FUTURE=20 PURCHASE

20" SONY MONITOR
UNICOL MONITOR STAND for 2nd=20 Monitor
8385.13 GRASPING AND EXTRACTING FORCEPS 10MM. (NO = LOCK)
8389.801=20 CLIP APPLICATOR FOR ETHICON TI 300 CLIPS
8383.022 SCISSORS=20 INSULATED
28378 C RIMMER OLSEN CHOLANGIOCATHETER GUIDED = GRASPER
3MM.=20 NEEDLE HOLDER FOR INTERNAL SUTURES
5MM. NEEDLE HOLDER FOR INTERNAL=20 SUTURES

PRE-OPERATIVE = CHECKS Top

PATIENT = CHECKS
CHECK YOU HAVE THE CORRECT PATIENT
CHECK YOU HAVE = THECORRECT=20 SIDE
CHECK THE PATIENT HAS EMPTIED THE BLADDER WITHIN THE = HOUR
CHECK=20 PATIENT HAS AGREED TO AN OPEN OPERATION IF NECESSARY
CHECK THERE IS = NO=20 OTHER PROCEDURE TO DO
CHECK THERE IS A DIATHERMY PAD
CHECK THERE = IS AN=20 ECG MONITOR
CHECK THE PATIENT IS SHAVED FROM UMBILICUS TO=20 PUBIS

PATIENT = PREPARATION Top

ANAESTHESIA
GENERAL

LOCAL anaesthesia is used during this technique as = well as=20 general anaesthesia.
An acceptable upper dose of Bupivacaine with = Adrenaline=20 is 3 mg per kilogram (200 mg for a 70 Kg person). (80 ml of 0.25% = Bupivacaine).=20 *** dose needs checking
A higher dose raises the risk of toxic = effects if the=20 drug reaches the circulation.
NB You MUST have facilities and staff = to=20 correct any complications of local anaesthesia eg. Hypotension, cardiac=20 arrhythmias, respiratory arrest, coma, convulsions, and anaphylactic=20 reactions.

POSITION SUPINE
with bare=20 skin from costal margin to mid thigh, free from all tubing, wires, = electrodes,=20 etc.
STANCE
Stand=20 on the opposite side to the hernia with one assistant on the hernia=20 side.
For a double hernia, start on the less severe side.
This = will get=20 your eye in for the more difficult side.
PREPARING THE SKIN
Use two swabs on = sticks with=20 Povidone Iodine, followed by one to dry off.
Clean the skin from = the=20 mid-epigastrium to the upper thigh, and from one iliac crest to the=20 other.
TOWELLING = UP
Place an upper towel down 5cm above the umbilicus.
Place a = lower=20 towel up to the symphysis pubis.
Place a lateral towel to the = anterior=20 superior iliac spine.
Place a medial towel to the opposite anterior = superior iliac spine.
FIX THE = TOWELS
Use 4 towel clips
CHECK DIATHERMY IS WORKING =

INSUFFLATION AND PORT INSERTION = Top

INCISING THE UMBILICAL = SKIN

Use a 15mm Swann-Morton scalpel.
Make a vertical = 2cm skin=20 incision 2cm lateral, and 2cminferior to the umbilicus.
Make the = incision=20 on the side of a single hernia, or on the side of the bigger of = bilateral=20 hernias.
Deepen the incision to find the anterior rectus=20 sheath.
Coagulate any bleeding vessels.
INSERT A PURSE STRING SUTURE
This = will hold the=20 umbilical port in position and prevent CO2 leaks.
Use a number 1 = silk=20 stitch (Ethicon 799)
Make a horizontal mattress stitch into the = skin and=20 subcutaneous tissues 2cm around the skin incision.
RETRACT THE SUBCUTANEOUS FAT
Use 2=20 small Langenbeck retractors held by your assistant.
Hold the = retractors=20 laterally to display the anterior rectus = sheath.

OPENING THE RECTUS = SHEATH

Use a 15mm. Swann-Morton scalpel.
Make a vertical = 2cm=20 incision into the anterior rectus sheath.
MOBILISE THE RECTUS MUSCLE
This will = enable you=20 to make an opening into the posterior rectus sheath for insertion of = the=20 laparoscope.
The opening will be medial to the rectus muscle and = the=20 inferior epigastric artery.
Use cholecystectomy forceps.
Free = the=20 medial side of the rectus muscle from the anterior and posterior = rectus=20 sheaths.
This will also sweep the inferior epigastric artery=20 laterally.
Display a 2 X 2cm square of posterior rectus=20 sheath.
Coagulate any bleeding vessels.
Tie off any bleeding = inferior=20 epigastric vessels with 2/0 Vicryl (Ethicon 9250).
OPEN THE POSTERIOR RECTUS = SHEATH
Use a 15mm. Swann-Morton scalpel.
Make a 2cm transverse = incision=20 into the posterior rectus sheath.
Hold the sheath incision open = with=20 dissecting forceps.

OPENING THE PREPERITONEAL=20 SPACE

CHECK THE UMBILICAL = PORT
Check it is a 12mm. SoftPort with conical tip = trocar.
Check the=20 trocar is locked into the port.
PUSH THE PORT = INTO THE=20 PREPERITONEAL SPACE
Push the port and trocar through the = opening in=20 the posterior rectus sheath.
Cut the opening with a scalpel if it = is too=20 narrow.
Push the instrument obliquely downwards to run just behind = the=20 posterior rectus sheath.
You should feel the instrument pass below = the=20 inferior limit of the posterior sheath about 5cm below the=20 incision.
START OPENING = THE=20 PREPERITONEAL SPACE
Push the port and = trocar=20 down to their full lengths.
Waggle the instrument from side to = side to=20 free the preperitoneal fat from the posterior rectus sheath, and = rectus=20 muscle.
You are in the correct plane if the tissues open easily. = If not,=20 reinsert the trocar pointing more superficially.
TIE=20 THE PURSE STRING STITCH
Tighten the stitch to get a gas = tight fit.=20
Tie off with 4 throws.
Cut the ends 4cm long with = scissors.
ATTACH THE CO2 TUBE TO THE PORT
SWITCH ON THE=20 CO2
Run the CO2 at 4 litres a minute (automatic) at 15mm. = mercury=20 pressure.
TAKE OUT THE = TROCAR
INSERT A 10MM DOWNSIZER
INSERT THE=20 TELESCOPE
Check it is a 110 degree view 0 degree = telescope.
Check=20 the Pre-Vu spacemaker is attached to the telescope.
CHECK THE TELESCOPE IS IN THE CORRECT = SPACE
Check loose areolar tissue is visible = distally.
Feel=20 the telescope hitting on the pubis.
Check you can see the arcuate = line=20
anteriorly at the lower edge of the posterior rectus = sheath.
Check you=20 can see rectus muscle anteriorly below the arcuate line.
If the = muscle or=20 the rectus sheath are not visible, run the telescope more = anteriorly.
If=20 you are still uncertain about your position, call a more experienced=20 surgeon.
Consider an open herniorrhaphy.

DEALING WITH A CLOUDY = VIEW=20

Withdraw the telescope and clean it with a saline = swab and=20 drip on Ultrastop.
Check the focus.
Check the irrigating saline = is=20 warm.
Check the is no condensation between the telescope and the=20 camera.
Check there is no condensation inside the camera.
Remove = any fat=20 or Cidex contamination of the lens with 15 seconds rubbing with a swab = plus=20 drip on Ultrastop.
Check the seal on the Pre-Vu is not = leaking.
Consider=20 using a new telescope.

CONTINUE OPENING UP THE = PREPERITONEAL=20 SPACE

Use side to side pushing movements of the Pre-Vu = space maker=20 and telescope.
Feel the hardness of the pubis with the = telescope.
See=20 the spidery adipose tissues part in front of you as the dissection=20 progresses.
Open the space medially and distally.
Identify the=20 epigastric vessels as landmarks.
They run obliquely upwards and = medially=20 from the centre of the field at this stage towards the lateral side of = the=20 telescope.
Look for the blueness of the vein and the pulsation of = the=20 artery.
OPEN THE SPACE = MEDIALLY
Push with the=20 Pre-Vu and telescope to open the space 5cm across the midline.
Open = the=20 space to the opposite side of the pubic bone.
This will enable you = to=20 insert the medial port.

INSERTING THE MEDIAL=20 PORT

IDENTIFY THE SITE FOR THE = MEDIAL=20 PORT
Use a 21SWG needle on a 20ml syringe containing = Bupivacaine=20 with Adrenaline.
Choose a skin site 5cm across the midline, 5cm = above the=20 symphysis pubis.
Infiltrate 2ml anaesthetic into the skin.
Push = the=20 needle through the skin, and subcutaneous tissues into the = retroperitoneal=20 space 5cm across the midline.
Open up the space more medially if = the=20 needle does not appear in the space.
Infiltrate anaesthetic as you = push=20 the needle through the tissues.
INCISE THE = MEDIAL PORT=20 SKIN
Use a 15mm. Swann-Morton scalpel.
Use the site of = the=20 needling for the incision.
Make a 20mm. incision into the = skin.
CHECK THE MEDIAL PORT
Check it is a 12mm.=20 OpenPort.
Check the CO2 tap is closed.
Check the trocar is = locked into=20 the port.
INSERT THE MEDIAL = PORT
Push the=20 port into the preperitoneal space.
REMOVE THE = TROCAR
FIT A 10MM. DOWNSIZER
INSERT DIATHERMY SCISSORS INTO THE = MEDIAL=20 PORT
CONTINUE ENLARGING THE PREPERITONEAL SPACE
Use=20 scissor/coagulation dissection.
Or use a blunt rod = (obturator).
Or use a=20 10mm. spacemaking spreader for easier dissection in a fat = patient.
Swap the=20 telescope and dissecting instrument for better access in a fat=20 patient.
Extend the space laterally and distally.
Dissect = towards the=20 anterior superior iliac spine.
Usually the inferior epigastric = vessels will=20 be visible.
Feel the rod through the
abdominal wall with a hand = on the=20 abdominal skin.
Open the space at least 5cm more laterally than the = epigastric vessels for the insertion of the lateral port.
Also, if = you=20 have made the initial incision into the opposite rectus sheath for a = bilateral=20 hernia repair, the whole operative field will be shifted 5cm or so = even more=20 medially.
Make allowance for this by deliberately opening the = space more=20 laterally.
You may safely spend 30 minutes or more gently = dissecting the=20 fatty tissues before the above structures emerge and are identified. =
Do=20 not rush.
Check you are dissecting far enough laterally.
Use = the=20 anterior superior iliac spine felt through the skin as a=20 landmark.

INSERTING THE LATERAL=20 PORT

IDENTIFY THE SITE FOR THE = LATERAL=20 PORT
Use a 21SWG needle on a 20ml syringe containing = Bupivacaine=20 with Adrenaline.
Choose a skin site 5cm medial to the anterior = superior=20 iliac spine.
Infiltrate 2ml anaesthetic into the skin.
Push the = needle=20 through the skin, and subcutaneous tissues into the retroperitoneal = space 5cm=20 from the anterior superior iliac spine.
Open up the space more = laterally=20 if the needle does not appear in the space.
Infiltrate anaesthetic = as you=20 push the needle through the tissues.
INCISE = THE LATERAL=20 PORT SKIN
Use a 15mm. Swann-Morton scalpel.
Use the site = of the=20 needling for the incision.
Make a 10mm. incision into the = skin.
CHECK THE LATERAL PORT
Check it is a 5mm.=20 SoftPort.
Check the CO2 tap is closed.
Check the trocar is = locked into=20 the port.
INSERT THE LATERAL = PORT
Push the=20 port into the preperitoneal space.
TAKE OUT = THE=20 TROCAR
ROTATE THE PATIENT
This will keep the tissues away = from=20 the hernia under gravity for a clearer view.
Rotate the patient 15 = degrees=20 towards the surgeon.
Tilt the patient 15 degrees head = down.
INSERT SCISSORS IN THE PORT OF YOUR DOMINANT = HAND
INSERT=20 GRASPERS IN THE PORT OF YOUR OTHER HAND

ENLARGING THE PREPERITONEAL=20 SPACE

Aim to demonstrate a direct sac, an indirect hernia, = and a=20 lipoma of the cord in that order.
There is a tendency to open the = space too=20 medially.
The bladder will be present inferiorly, medial to the = hernia.=20
Do not deliberately dissect it out, because of the danger of = bleeding from=20 vessels on its surface.
Identify the edge of the arcuate line=20 anteriorly.
Find the inguinal ligament (ilio-pubic tract) running = laterally=20 towards the origin of the epigastric vessels.
Identify Cooper's = ligament on=20 the pubic bone just below the inguinal = ligament.

DIRECT HERNIA Top

FINDING A DIRECT=20 SAC

The hernia may show up at this stage.
It looks = like a hump=20 of fat occupying the lower part of the field.
A direct sac will be = medial=20 to the epigastric vessels, bulging through the transversalis = fascia.
A=20 pantaloon hernia will be both medial and lateral to the vessels.
A = direct=20 sac will be attached to the anterior abdominal wall=20 between:
   the inguinal ligament (ilio-pubic=20 tract)
   the arch of the conjoint tendon = (transversus=20 abdominus arch),
   and the inferior epigastric=20 vessels.
The CO2 makes the sac stretch into the wound.
If in = doubt about=20 the anatomy, use the hardness of the pubic bone as a reference=20 point.
Beware an indirect sac extending round the back of the = epigastric=20 vessels and bulging through a dissection defect in the transversalis=20 fascia.

DISSECTING A DIRECT=20 SAC

Dissect the peritoneum of the hernia = carefully.
The=20 abdominal peritoneum may be tented up towards the hernia.
Pull the = sac out=20 of the direct defect.
Most sacs are less than 5cm long and will = dissect out=20 easily.
If the sac is longer than 5cm, make a deliberate dissection = around=20 the sac.
Avoid tears in the peritoneum.
Close peritoneal tears = with an=20 Endoloop.
Tears larger than 5cm may need to be sutured if an = Endoloop will=20 not control the defect
DISSECT MEDIALLY = BETWEEN THE=20 BLADDER AND THE HERNIA
This will dissect the tissues down = towards=20 Cooper's ligament (Reflected part of the inguinal ligament)
This is = where=20 femoral hernias and aberrant obturator arteries would be = present.
DISSECT SUPERIORLY BETWEEN THE CONJOINT TENDON AND THE = DIRECT=20 HERNIA
This will be under the transversus abdominis = arch.
DISSECT LATERALLY BETWEEN EPIGASTRIC VESSELS AND THE = DIRECT=20 HERNIA
The epigastric vessels are a hazard.
Control minor = bleeding with coagulation.
Control major bleeding with ligaclips = and=20 division of the epigastric vessels.
DISSECT = INFERIORLY=20 BETWEEN THE INGUINAL LIGAMENT AND THE DIRECT HERNIA
Open up = the=20 space along the inguinal ligament.
Continue the dissection 2.5cm = below the=20 inguinal canal ligament.
The inguinal ligament (ilio-pubic tract) = may look=20 like the genital branch of the genito-femoral nerve.
Also look at = the=20 bladder.

TREATING A DIRECT = SAC

If the sac is less than 5cm long, do not excise = it.
If the=20 sac is more than 5cm long, dissect the junction between the peritoneum = of the=20 abdominal cavity and that of the hernia.
If the 5+cm sac is a = sliding=20 hernia, do not excise it.
For a 5+cm non-sliding sac which does not = pull=20 out from the hernial defect:
Consider dividing the sac and leaving = the=20 distal part of the sac in situ.
For a sliding hernia which does not = pull=20 out of the defect:
   Call a more experienced=20 surgeon.
   Consider converting to an open=20 operation.
Dissect the sac laterally and anteriorly into the = hernial=20 defect.
Identify the genital branch of the genito-femoral nerve = running=20 along the lateral aspect aspect of the inguinal ligament.
TIE OFF THE SAC
Use an Endoloop
CUT OFF THE REDUNDANT SAC
Use = scissors.
Check there=20 is no peritoneal tear.

INDIRECT HERNIA Top

FINDING AN INDIRECT = SAC

An indirect sac will be lateral to the epigastric = vessels,=20 with transversalis fascia medially.

DISSECTING AN INDIRECT = SAC

Dissect the peritoneum of the hernia = carefully.
The=20 peritoneum may be tented up towards the hernia.
Dissect the = junction=20 between the peritoneum of the abdominal cavity and that of the hernia. =
Avoid tears in the peritoneum.
Close peritoneal tears with an = Endoloop.=20
Tears larger than 5cm may need to be sutured if an Endoloop will = not=20 control the defect
DISSECT MEDIALLY BETWEEN = THE=20 EPIGASTRIC VESSELS AND THE INDIRECT SAC
DISSECT LATERALLY BETWEEN = THE=20 INTERNAL RING AND THE INDIRECT SAC
Identify the cord = structures=20 laterally.
DISSECT SUPERIORLY BETWEEN THE = CONJOINT=20 TENDON AND THE INDIRECT SAC
DISSECT INFERIORLY BETWEEN THE CORD AND = THE=20 INDIRECT SAC
THE VAS, Continue down as far as the iliac = vessels, as=20 as this appears safe. The blue iliac vein is easy to see unless the = patient is=20 very obese
2.5cm below the inguinal canal.
Dissect the medial = aspect of=20 the sac. See the external iliac vein. Find the vas on the medial side = of the=20 vein somewhat more posteriorly.
Dissect the sac off the vas and = other cord=20 structures.
Check the space is free from the opposite side of the = symphysis=20 pubis ?
Identify the epigastric vessels
Identify the vasand = spermatic=20 vessels.

TREATING AN INDIRECT=20 SAC

DEALING WITH A=20 PNEUMOPERITONEUM
If you open the peritoneum there may be a = leak of=20 gas into the peritoneum causing it to bulge into the operating = field.
INSERT A VERESS NEEDLE
Insert it just above = the=20 umbilical port.
Reduce the pressure in the preperitoneal space from = 15mm.=20 to 10mm.
Check the CO2 is coming out through the Veress = needle.
Inject=20 saline or listen for a hiss.
Consider enlarging the peritoneal = defect to=20 let the CO2 out into the preperitoneal space.
Look for a lipoma of = the=20 cord.
Look for colon in a sliding hernia.
Free the epigastric = vessel=20 from the sac anteriorly.
Look for an indirect sac = laterally.
Identify=20 the ileo-pubic tract with the conjoint tendon laterally.
To detect = an=20 indirect sac, look for at the peritoneum near the cord.
FREEING THE SAC
For a tear, close this off = with an=20 Endoloop.
For a bigger defect use suturing.
Consider = extracorporeal=20 knots with a knot tightener.

FINDING A LIPOMA OF THE = CORD
TREATING A=20 LIPOMA OF THE CORD FOR A HERNIA ON THE OPPOSITE SIDE

MESH INSERTION Top

PREPARING THE MARLEX = MESH

Marlex mesh has a sufficiently wide weave to allow = structures=20 behind the mesh to be visible.
Check it is a complete 15 X 10cm=20 length.
Cut a V in the middle of the upper edge of the mesh for = later=20 orientation.
Consider wetting the mesh with saline.
Roll the = mesh=20 anticlockwise tightly around a
5m. forceps.
INSERT=20 THE MESH
Remove the suprapubic port downsizer.
Push the = mesh and=20 forceps down the suprapubic port.
The port valve will prevent CO2=20 leaks.
REPLACE THE = DOWNSIZER
Release the mesh=20 into the preperitoneal space.
UNROLL THE=20 MESH
Use 2 forceps in the suprapubic and the lateral = ports.
Let=20 the mesh unroll like a carpet.
Turn the mesh over if it is not = unrolling=20 the easy way.
Beware the edges of the mesh catching on the = tissue.
POSITION THE MESH
Take time to position the = mesh=20 correctly.
The mesh should extend from 5cm beyond the midline to = 5cm beyond=20 the internal inguinal ring.
It should extend from 2cm above the = internal=20 ring to 5cm below the inguinal ligament.
It should be as free as = possible=20 from kinks and folds.
Do not accept folds caused by accident.
It = should=20 tuck right down between the peritoneum and the retro pubic = tissues.
STAPLING THE MESH
Use a re-usable = stapler.
Keep=20 some pressure on the clip when passing the applicator through the port = to=20 prevent the clip falling out.
Press with the stapler onto the mesh = and=20 onto a hand held on the anterior abdominal wall.
Ensure the staples = grip=20 the anterior abdominal wall proper and not to the preperitoneal = fat.
STAPLE MESH ONTO THE PUBIC TUBERCLE
INSERT STAPLE = ONTO=20 CONJOINT TENDON
Lateral to the epigastric vessels
Staple=20 laterally above the ilio-inguinal and ilio-hypogastric = nerves.
Check the=20 peritoneum and sac are nicely placed cephalically.
Divide any = adhesions=20 between the peritoneum and preperitoneal fat.
FOR=20 INSERTING MESH ON THE OPPOSITE SIDE

CLOSURE Top=

CLOSE OFF THE SAC =

Use an Endoloop.

CLOSING STAGES

DEFLATE THE PREPERITONEAL=20 SPACE
Hold the mesh in place = especially=20 laterally while you deflate the preperitonal space
Use the grasping = forceps.
REMOVE THE PURSE STRING
REMOVE = ALL=20 INSTRUMENTS
CLOSE THE RECTUS SHEATH
Use number1 = PDS
CLOSE THE SKIN
Use 2/0 PDS subcuticular=20 stitch.
SWITCH OFF THE = INSUFFLATOR
This will=20 prevent the CO2 bottle emptying.
SWITCH OFF = THE LIGHT=20 SOURCE BULB
Let the Light Source fan run for a further 10=20 minutes.
CHECK THE SWAB, NEEDLE, AND = INSTRUMENT=20 COUNTS
CHECK THERE IS NO OTHER PROCEDURE TO = DO

FINAL = TOUCHES

WRITE LEGIBLE OPERATION = DETAILS
FILL IN=20 THE SURGICAL AUDIT FORM
DICTATE AN OPERATION LETTER TO THE GENERAL=20 PRACTITIONER PLUS A COPY TO THE REFERRING PHYSICIAN
312 SWITCH OFF = POWER=20 TO VIDEO TV MONITORS LIGHT SOURCE INSUFFLATOR = DIATHERMY
Unless=20 another laparoscopic procedure is being done on the operating=20 session.
313 CLOSE CO2 BOTTLE
314 END OF=20 OPERATION

DETAILED INDEX Top

PATIENT SELECTION

INTRODUCTION
PRINCIPLES
OVERVIEW

THEATRE LAYOUT AND EQUIPMENT

THEATRE LAYOUT
NON-SURGICAL EQUIPMENT
VIDEO=20 SYSTEM
VIDEO RECORDER
LIGHT SOURCE
CABLES
INSUFFLATION=20 SYSTEM
SPARES
OPEN HERNIORRHAPHY STERILE SURGICAL = INSTRUMENTS
(FRIARAGE=20 HOSPITAL)
LAPAROTOMY STERILE SURGICAL INSTRUMENTS
(FRIARAGE=20 HOSPITAL)
TELESCOPES
TROCARS AND SLEEVES
VERESS = NEEDLE
FORCEPS,=20 SCISSORS, AND CLIP APPLIERS
SUCTION/IRRIGATION=20 PROBES
ELECTRODES
MISCELLANEOUS
SURGICAL = DISPOSABLES
SURGICAL=20 DISPOSABLE SPARES
THEATRE FURNITURE
SURGICAL=20 MATERIALS
PHARMACEUTICALS
ASSORTED EXTRAS AND ITEMS FOR FUTURE=20

PRE-OPERATION CHECKS

VIDEO CAMERA CHECKS
VIDEO RECORDER CHECKS
TV = MONITORS=20 CHECKS
LIGHT SOURCE CHECKS
INSUFFLATOR CHECKS
SMOKE EVACUATOR=20 CHECKS
DIATHERMY CHECKS

PATIENT PREPARATION

POSITION
STANCE
ANAESTHESIA
OFF-PATIENT = EQUIPMENT=20 POSITIONING
SKIN PREPARATION
TOWELLING UP
ON-PATIENT EQUIPMENT=20 PREPARATION
ON-PATIENT EQUIPMENT CHECKING

INSUFFLATION AND PORT INSERTION

INCISING THE SKIN
OPENING THE RECTUS = SHEATH
INSERTING THE=20 UMBILICAL PORT
OPENING THE PREPERITONEAL SPACE
DEALING WITH A = CLOUDY=20 VIEW
DEALING WITH BLEEDING
DEALING WITH A = PNEUMOPERITONEUM
INSERTING=20 THE MEDIAL PORT
INSERTING THE LATERAL PORT
ENLARGING THE = PREPERITONEAL=20 SPACE

DIRECT HERNIA

FINDING A DIRECT SAC
TREATING A DIRECT = SAC

INDIRECT HERNIA

FINDING AN INDIRECT SAC
TREATING AN INDIRECT = SAC
FINDING A=20 LIPOMA OF THE CORD
TREATING A LIPOMA OF THE CORD
EXPLORING THE = OPPOSITE=20 GROIN

MESH INSERTION

INSERTING THE POLYPROPYLENE MESH
STAPLING THE = POLYPROPYLENE=20 MESH
INSERTING MESH ON THE OPPOSITE SIDE

CLOSURE

CLOSURE
FINAL TOUCHES
END OF = OPERATION

 

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