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

PATIENT SELECTION
THEATRE LAYOUT AND EQUIPMENT
PRE-OPERATIVE CHECKS
PATIENT PREPARATION
INSUFFLATION AND PORT INSERTION
DIRECT HERNIA
INDIRECT HERNIA
MESH INSERTION
CLOSURE
DETAILED INDEX

PATIENT SELECTION Top

SUITABLE PATIENTS

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

SUITABLE HERNIAS

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

RELATIVE CONTRAINDICATIONS

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

THEATRE LAYOUT AND EQUIPMENT Top

NON-SURGICAL EQUIPMENT LIST

VIDEO SYSTEM (WOLF)

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

VIDEO RECORDER

5631.01 SONY U-MATIC RECORDER VO 7630)

LIGHT SOURCE

5108.01 AUTO IRIS HIGH POWER LIGHT SOURCE

CABLES

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

INSUFFLATION SYSTEM

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

SPARES

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

STANDARD STERILE SURGICAL EQUIPMENT (FRIARAGE HOSPITAL)

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

STANDARD STERILE SURGICAL EQUIPMENT (DARLINGTON MEMORIAL HOSPITAL)

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

STANDARD STERILE SURGICAL EQUIPMENT (ST JOHN OF GOD HOSPITAL)

SPECIAL STERILE SURGICAL EQUIPMENT

TELESCOPES

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

TROCARS AND SLEEVES

2 X 8934.01 10MM. TROCAR SLEEVE WITH PISTON VALVE
8934.12 10MM. TROCAR WITH PYRAMID TIP
8934.981 REDUCING SLEEVE 10MM. - 5MM.
2 X 8940.01 5MM. TROCAR SLEEVE WITH PISTON VALVE
8940.12 5MM. TROCAR WITH 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 (THE ALLIGATORS)
8383.141 ATRAUMATIC GRASPING FORCEPS 5MM. FLAT (THE RACQUETS)
2 X 8383.45 HOOKED SCISSORS 5MM.

SUCTION/IRRIGATION PROBES

8383.732 SUCTION AND IRRIGATION PROBE 5MM.

ELECTRODES 2 X 8383.421 HOOK ELECTRODES 5MM.

MISCELLANEOUS

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

SURGICAL DISPOSABLES

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

SURGICAL DISPOSABLE SPARES

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

THEATRE FURNITURE

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

MATERIALS

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

PHARMACEUTICALS

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

ASSORTED EXTRAS AND ITEMS FOR FUTURE PURCHASE

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

PRE-OPERATIVE CHECKS Top

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

PATIENT PREPARATION Top

ANAESTHESIA
GENERAL

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

POSITION SUPINE
with bare skin from costal margin to mid thigh, free from all tubing, wires, electrodes, etc.
STANCE
Stand on the opposite side to the hernia with one assistant on the hernia side.
For a double hernia, start on the less severe side.
This will get your eye in for the more difficult side.
PREPARING THE SKIN
Use two swabs on sticks with Povidone Iodine, followed by one to dry off.
Clean the skin from the mid-epigastrium to the upper thigh, and from one iliac crest to the other.
TOWELLING UP
Place an upper towel down 5cm above the umbilicus.
Place a lower towel up to the symphysis pubis.
Place a lateral towel to the anterior 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 incision 2cm lateral, and 2cminferior to the umbilicus.
Make the incision on the side of a single hernia, or on the side of the bigger of bilateral hernias.
Deepen the incision to find the anterior rectus sheath.
Coagulate any bleeding vessels.
INSERT A PURSE STRING SUTURE
This will hold the umbilical port in position and prevent CO2 leaks.
Use a number 1 silk stitch (Ethicon 799)
Make a horizontal mattress stitch into the skin and subcutaneous tissues 2cm around the skin incision.
RETRACT THE SUBCUTANEOUS FAT
Use 2 small Langenbeck retractors held by your assistant.
Hold the retractors laterally to display the anterior rectus sheath.

OPENING THE RECTUS SHEATH

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

OPENING THE PREPERITONEAL SPACE

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

DEALING WITH A CLOUDY VIEW

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

CONTINUE OPENING UP THE PREPERITONEAL SPACE

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

INSERTING THE MEDIAL PORT

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

INSERTING THE LATERAL PORT

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

ENLARGING THE PREPERITONEAL SPACE

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

DIRECT HERNIA Top

FINDING A DIRECT SAC

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

DISSECTING A DIRECT SAC

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

TREATING A DIRECT SAC

If the sac is less than 5cm long, do not excise it.
If the sac is more than 5cm long, dissect the junction between the peritoneum of the abdominal cavity and that of the hernia.
If the 5+cm sac is a sliding hernia, do not excise it.
For a 5+cm non-sliding sac which does not pull out from the hernial defect:
Consider dividing the sac and leaving the distal part of the sac in situ.
For a sliding hernia which does not pull out of the defect:
Call a more experienced surgeon.
Consider converting to an open operation.
Dissect the sac laterally and anteriorly into the hernial defect.
Identify the genital branch of the genito-femoral nerve running 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 is no peritoneal tear.

INDIRECT HERNIA Top

FINDING AN INDIRECT SAC

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

DISSECTING AN INDIRECT SAC

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

TREATING AN INDIRECT SAC

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

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

CLOSURE Top

CLOSE OFF THE SAC

Use an Endoloop.

CLOSING STAGES

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

FINAL TOUCHES

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

DETAILED INDEX Top

PATIENT SELECTION

INTRODUCTION
PRINCIPLES
OVERVIEW

THEATRE LAYOUT AND EQUIPMENT

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

PRE-OPERATION CHECKS

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

PATIENT PREPARATION

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

INSUFFLATION AND PORT INSERTION

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

DIRECT HERNIA

FINDING A DIRECT SAC
TREATING A DIRECT SAC

INDIRECT HERNIA

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

MESH INSERTION

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

CLOSURE

CLOSURE
FINAL TOUCHES
END OF OPERATION