Operative Flashcards
Oblique subcostal incision (Kocher’s on right, spleen access on left)
- can be etended across midline as a roof top incision if required eg for liver and pancreas surgery
- incision about 2 finger breadths below subcostal margin and towards xiphi
- deepen incision to expose the external oblique and the anterior rectus sheath
- divide these layers and the rectus muscle and incise the internal oblique muscles with diathermy
- helpful to insert a long artery forceps such as a Robert’s or Kelly’s under the muscle belly to facilitate this
- divide the posterior rectus sheath and transversus abdominis aponeurosis to expose the pre-peritoneal fat and open the peritoneum in line with the incision picking it up with artery forceps initially
- take care to spare the 9th costal nerve, which is visible at this stage
- a midline superior extension through the linea alba to form a ‘Mercedes Benz’ incision provides further access if required
Trauma splenectomy
- widely prepped, crucifix, wear a headlight, stand on pt’s right
- midline laparotomy
- eviscerate the small bowel, scoop out clots, pack to all quadrants
- use an omnitract, ask anaesthetist to provide trendelenburg and left-side up
- with my left hand scoop around spleen to medialise (may be mobile in trauma or stuck)
- if stuck, divide splenorenal and splenocolic ligaments by gently retracting upwards and medially; spleen is then gently pulled downwards and the splenophrenic ligaments are divided with mayo scissors so the spleen can be brought to midline
- may have short and unyielding splenorenal ligament - retract medially and beyond tip of fingers can make a nick in stetched ligament posteriorly with your scissors; enlarge the nick with scissors or your fingers up and around the spleen
- once spleen is mobilised and in my hand, can control bleeding by pinching the vascular pedicle, including both the gastrosplenic ligament containing the short gastrics in front and splenic hilum behind
- place packs behind spleen to bring it forward and assess damage
- decide whether to remove or repair depending on
- pt’s trauma burden, age of patient, severity of injury, surgeon experience
- removal
- identify and clamp vessels at hilum of spleen with Roberts clamps and divide between the clamps, taking care to avoid injury to tail of pancreas - ligate all vessels that are clipped using 0 vicryl ties
- divide the short gastrics between ties or clips (automatic clip applier), being careful not to get too close to the greater curve which can cause ischaemia
- (in brisk bleeding and if have other things to do also, a large artery clamp can be placed across both the main pedicle and short gastrics to control, and spleen later removed)
- check: haemostasis, damage to stomach (repair), pancreas tail (repair/divide/leave drain)
- occasionally may find ruptured spleen stuck to abdo wall and diaphragm and rapidly developing a plane behind it not realistic; in this case can
- quickly control splenic artery by entering lesser sac through gastrocolic omentum, and isolate artery along the upper border of pancreas
- or go straight at hilum - gently pull stomach towards you to put the gastrosplenic ligament on tension and divide it between clamps
- immediately behind it you will find the splenic hilar vessels - clamp them then start dissection to mobilise the devascularised spleen
Methods of splenic preservation
- Capsular tears
- Pressure
- Place haemostatic agent
- Lacerations
- Mesh wrap with polyglycolate (to tamponade)
- Liquid haemostatics ie fibrin glue
- Repair with synthetic absorbable sutures on long blunt needle using pledgets, or a strip of Teflon on each side, or omentum as a bolster
- Partial splenectomy
- Use a TA stapler to come across the spleen
- or
- Ligate segmental vessels
- Incise capsule in line w ischaemic zone
- Finger fracture technique
- Preserve 30% to maintain function
Lap splenectomy
- pre-op vaccines
- patient in modified right lateral decubitus at 45 degrees, appropriately secured with a beanbag and all pressure points padded, with the table flexed to open up the space between the costal margin and iliac crest
- modified at 45 degrees cf 90 bc can then roll the table to get 90, so if you have to convert to open its easier than if they are in true lateral decubitis
- well secured so I can ask the anaesthetist to move the table to use gravity to assist my dissection
- optical entry or open Hasson technique in MCL, total 4 ports in the subcostal position with camera port in the midline
- 2x 5mm in midline, 2x12mm in MCL and mid axillary line
- occasionally an additional port is required for retraction towards the midline, near the xiphoid process
- extensive search for ectopic splenunculi (14%) - splenic hilum, gastrocolic ligament, omentum, base of mesentery, along left gonadal vein - need to do this at beginning of case bc if start to mobilise tissues will get some bleeding espec if platelet disorder then harder to find
- mobilise splenic flexure as required and divide any attachments or adhesions between the colon and spleen or omentum and the spleen (omental attachments to lower pole of spleen often contain one or two vessels which supply lowermost segment of the spleen, so care required when dividing these)
- two common approaches to lap splenectomy are
- initial dissection of hilar vessels followed by splenic mobilisation
- or division of the posterior leaf of the splenorenal ligament first which allows teh spleen to fall medially under its own weight, facilitating further posterior dissection, which progresses til spleen is fully mobilised, revealing a ‘mesentery’ which contains the panc tail and the splenic vessels
- i prefer to leave the posterior and superior attachments initially so that the spleen remains retracted while i’m dissecting out the hilar vessels
- i start with the inferior pole and work my way up towards the hilum, taking small vessels and the peritoneum over the hilum
- when that becomes difficult I enter the lesser sac by dividing the gastrocolic ligament and take the gastrosplenic ligament and short gastrics with a ligasure or haemoloks; I continue up to the level of the left crus (til there are no short gastrics left), and the stomach can be retracted to the right
- now I’‘m left with the hilum of the spleen and the tail of the pancreas medially; I dissect out the vessels at the hilum and take the artery and vein using a vascular load on an endoscopic linear stapler
- I’m careful to avoid injuring the tail of the pancreas so I hug the spleen and might end up taking branches of the splenic vessels closer to the hilum
- I then further divide the inferior and lateral attachments, and lastly the splenophrenic ligament
- I place the spleen in a bag and check haemostasis and again for splenunculi
- If it’s for benign disease, morcellate it to allow extraction without extending my port sites
Specific post-op care
- monitor for haemorrhage, atelectasis, infection
- know that pts will usu have an increase in leukocytes post-op; physiologic
- infectious complications include subphrenic abscess and OPSI
- give vaccinations 2wks post-op if didn’t get pre-op
- if compliance a concern then give prior to d/c
- if immunocompromised, wait 3m
- careful education about OPSI, back-pocket script
- thrombocytosis can occur immediately post-op but peaks up to 3wks
- antiplatelets only indicated for complications or when platelet counts hit 1 million
- portal or mesenteric vein thrombosis = serious, reported in up to 14%, some studies reporting higher rate in lap spleens
Elective open splenectomy
- supine, sandbag under LUQ
- either upper midline laparotomy or left subcostal incision
- full exploratory laparotomy
- carefully search for splenunculi (14%) - anywhere along splenic vessels, gastrosplenic ligament, splenorenal ligament, retroperitoneally, in mesentery, omentum and occasionally in gonads or path of descent
- ligate splenic artery at beginning of operation if spleen is v large or prior to infusing platelets
- enter lesser sac by dividing 10cm of gastrocolic omentum
- incise peritoneum at superior border of pancreas
- right angle to pass ligature behind artery (careful as often quite thin)
- ligate in continuity
- can then find splenic vein further laterally in splenic hilum or revert to posterior approach which is to divide the posteiror leaf of the splenorenal ligament which allows spleen to be gently mobilised medially
- w v large spleens can be difficult approaching splenic artery by anterior approach & the operation can be difficult; consider embolising splenic artery under rad control pre-op - can lead to much smaller and more pliable spleen
- divide omental adhesions to lower pole of spleen and the splenocolic ligament
- draw spleen medially w left hand and incise peritoneum that attaches spleen to the lateral sidewall extending incision up along lateral border of spleen towards diaphragm
Perforated gastric ulcer
- preparation: NG, IDC, broad spectrum abx, PPI
- GA, supine, headlight
- access
- upper midline from pt’s right
- on entering, suction free fluid and ligate falciform
- exploratory laparotomy; expect to find the perforated ulcer in the first part of the duodenum, the prepyloric region of the stomach or along the lesser curve of the stomach
- check mesentery, peritoneum and liver for any evidence of metastatic disease
- if gastric, biopsy ulcer with sharp scissors and Debakey forceps
- 4% overall risk of malignancy; 30% for ulcers >3cm
- options for gastric ulcer:
- freshen edges and primary closure
- omental patch repair
- distal gastrectomy
- patch repair
- use a nearby tongue of omentum - may need to mobilise right omentum from transverse colon to achieve this
- place 3 interrupted 3-0 PDS sutures either side of the ulcer and lay the omentum tongue between them
- tie gently so as not to cause ischaemia of the omental patch
- if omentum unavailable use falciform ligament or ?serosal patch
- distal gastrectomy
- aim is to remove antrum of stomach and perform an appropriate reconstructoin
- marked oedema or scarring in the region of the pylorus, pancreas and hepatoduodenal ligament is a relative contraindication to gastrectomy
- landmark for my proximal resection is a line between the incisura of the lesser curve and the terminal branches of the right gastroepiploic on the greater curve; distal resection margin will be proximal D1 (~2cm past pylorus)
- careful not to injure pancreas
- begin dissection inferiorly, incising gastrocolic omentum near terminal branches of right gastroepiploic to enter lesser sac
- mobilise greater curvature and ligate the branches of the right gastroepiploic until I reach the distal pylorus and main trunk of right gastroepiploic artery which I ligate wiht 0-vicryl
- my assistant now elevates the stomach carefully, retracting it proximally while I divide any congenital adhesions between the stomach and pancreas
- next I mobilise the lesser curve; I incise the lesser omentum near the incisura and dissect distally, ligating the descending branch of the left gastric artery and the right gastric artery; GDA should be preserved
- on reaching pylorus my assistant elevates distal stomach and I mobilise any final attachments between pylorus/prox D1 and pancreas if safe to do so; branches of GDA may need to be divided)
- having confirmed the position of the NGT I divide the stomach proximally (incisura to greater curve) with a linear cutting stapler; I underrun this with 3-0 PDS for haemostasis
- next I divide D1 ~2cm distal to the pylorus (linear cutting stapler) - remove specimen and bury stump staple line with 3-0 PDS if duo isn’t thickened/oedematous
- if duo retracted and fibrous may need to place a malecot through the duo stump or protect it with a side duodenostomy T tube at the junction of D2 and D3
- Kocher manoeuvre not required for Bilroth II or REY
- abdominal lavage
- side-to-side gastrojejunostomy in antecolic fashion
- bring up loop of jejunum that will reach stomach w/o tension but short (~20-30cm distal to DJ)
- continuous back-wall suture (~3cm proximal to staple line) with double-armed 3-0 PDS left long; place packs around site of join
- 5cm gastrotomy and jejunotomy
- use double armed 3-0 PDS at midpoint of join and sew a continuous suture around to front wall, coming around the corners with Connell sutures and positioning the NG in afferent jejunum beyond anastomosis before completing it in the middle
- continue the back-wall as a front-wall suture
- leak test
- final lavage, 2 drains (24 Fr silicon drain next to duodenal stump and blakes drain near gastrojejunostomy); close abdomen
- post-op: HDU, NBM 48hrs w NGT free drainage, IV abx, PPI BD, DVT prophylaxis, H pylori eradicatoin, gastroscopy in 6wks
Repair of perforated duodenal ulcer
- patch repair if small
- >2cm shouldn’t be managed with patch repair - risk of leak, nonhealing, stricture; and hazardous to dissect out and close the duodenum; options
- if unstable, damage control with tube duodenostomy: kocherise duodenum, debride ulcer wall, place malecot catheter directly into ulcer defect and close duodenum around Malecot (?pursestring suture) then place a pedicle of omentum around the pursestring at the base, and a closed suction drain nearby
- NG and consider feeding jejunostomy
- malecot left for 6wks, feed through tube jejunostomy as soon as ileus resolves and start oral feeds on day 5-6; prior to removing Malecot do a 2-3 day clamp trial
- or consider above with pyloric exclusion + gastrojejunostomy rather than feeding jej
- consider lateral T tube
- or Nissen closure of duodenum - if anterior duodenal wall is soft and pliable, duodenum can be left attached to the ulcer posteirorly and anterolateral duo wall mobilised (Kocher manoeuvre) so that it can be sewn down to distal fibrotic edge of ulcer crater (Nissen’s manoeuvre); a second layer of Lembert sutures are inserted between the anterior wall of the duodenum and the proximal edge of the ulcer
- or jejunal patch
- or Roux-Y drainage of perforation
- or resection of perforation bearing duo and gastric antrum with partial gastrectomy & Billroth II reconstruction - but resection of these large ulcers risks CBD injury
- if unstable, damage control with tube duodenostomy: kocherise duodenum, debride ulcer wall, place malecot catheter directly into ulcer defect and close duodenum around Malecot (?pursestring suture) then place a pedicle of omentum around the pursestring at the base, and a closed suction drain nearby
- post-op: >90% have H pylori infection - eradicate & 8wks PPI
Trauma laparotomy
- GA, abx, SCDs, IDC, supine, prep and drape from nipples to knees
- Skilled assistance, headlight, 2 large suckers, multiple rolled large packs, vascular instruments, haemostatic agents, omnitract available
- Good communication with team
- Goals:
- Arrest haemorrhage
- Control peritoneal contamination
- Definitive repair of injury only if stable; early termination of surgical intervention before the development of irreversible physiological changes (lethal triad)
- Rapid midline entry from xiphi to pubic symphysis
- Eviscerate SB, evacuate clots by hand, pack all 4 quadrants
- assistant elevates the abdominal wall of each quadrant in turn
- begin with RUQ by placing by left hand over dome of liver, pulling it gently towards myself and placing packs over my hand above and then below the liver
- pack right paracolic gutter
- pull spleen towards me with left hand then pack over my hand above the spleen and left lobe of liver; create sandwich by packing medial to spleen
- pack left paracolic gutter then pelvis
- check swab covering the eviscerated bowel; if blood accumulating deal with mesenteric bleeder
- while packing am feeling for any obvious injury
- Once packs in, communicate with anaesthetics and allow them to catch up with resuscitation & place omnitract
- Assess each quadrant carefully by removing packs and methodically assessing all organs and vascular structures to find the source of bleeding, beginning with the quadrant least likely to be source of haemorrhage (removing packs frees up space)
- I systematically assess the entire abdominal contents, paying particular attention to the liver, spleen, small and large bowel in blunt abdominal trauma
- supramesocolic compartment: liver, GB, right kidney, stomach to GOJ, duodenum (kocherise if need full exposure), spleen, left kidney, diaphragm, lesser sac incl posteiror wall of stomach and body/tail of pancreas
- bleeding from spleen in unstable pt: splenectomy
- bleeding from liver: pack
- inframesocolic compartment: small bowel, colon, bladder, reproductive organs
- hollow organ injuries: staple off (but bleeding takes priority over contamination)
- retroperitoneum: I perform medial and lateral visceral rotation to access the major vessels and retroperitoneal structures as indicated
- supramesocolic compartment: liver, GB, right kidney, stomach to GOJ, duodenum (kocherise if need full exposure), spleen, left kidney, diaphragm, lesser sac incl posteiror wall of stomach and body/tail of pancreas
- Major arterial haemorrhage originating from below thoracic aorta: supracoeliac clamp
- Retract stomach caudally, retract left lobe of liver upwards and open pars flaccida of gastrohepatic ligament to access the lesser sac
- Retract oesophagus to left and separate the muscle fibres of the aortic hiatus of the diaphragm
- Apply aortic clamp above the origin of coeliac trunk
- Remove clamp as soon as definitive control achieved
- Washout
- Temporary closure
Left-sided medial visceral rotation (Mattox manoeuvre)
- to get to midline supramesocolic sector - contains suprarenal aorta and its branches (if try to get to this from front have to transect stomach and pancreas then struggle through dense connective tissue and nerve plexuses)
- mobilise lower descending colon from retroperitoneum, heading toward splenic flexure, and continue upward along same line which extends lateral to spleen - enables you to rotate the spleen, pancreas and left kidney in a medial direction toward the midline
- plane is directly on the muscles of the posterior abdominal wall - can feel it with fingertips
- continue medial rotation all the way up to the diaphragmatic hiatus - can then cut left diaphragmatic crus laterally and bluntly dissect around aorta with finger to gain access to distal thoracic aorta as high as T6 which is a quick and easy way to get proximal aortic control w/o opening chest
- gives access to abdominal aorta & most of its branches incl celiac, superior mesenteric, left renal and left iliacs
- if target is aorta itself or its anterior branches, rotate the left kidney w the other left-sided organs - if leave it in place & develop plane anterior to it, left renal vein and artery will be in the way so access to anterolateral aspect of aorta will be restricted, and left ureter will be vulnerable to injury
- in front of suprarenal aorta is thick periaortic tissue; easier to get into the periaortic plane at infrarenal level then proceed upwards
- but if target is left kidney or renal vessels, leave kidney in place
- afterwards check for:
- splenic injury - common w this manoeuvre
- avulsion of left descending lumbar vein while mobilising left kidney - comes off left renal vein and crosses over left lateral aspect of aorta immediately below the left renal artery; if you plan to work on the aorta around the level of the renal vessels, good idea to identify, ligate and divide this lumbar vein to avoid avulsion during retraction of the mobilised kidney
Elective tracheostomy
- preparation
- usually ventilated in ICU; discuss choice of tracheostomy wiht ICU and anaesthetics; usually use tracheostomy tubes size 5-7, one size above and one size below the ETT size
- in theatre under GA, sandbag under shoulders with extended neck (not too much), tie placed under pt’s neck ready to secure trache tube with once it’s in
- this procedure requires careful coordination with anaethetics and nursing team - careful time out and discuss plan; pt will need to be pre-ventilated prior to entering trachea
- check all necessary equipment available and checked, including testing cuffs of tube and ensuring ventilator extension tubing is available
- palpate and mark if possible thyroid notch, cricoid cartilage and suprasternal notch
- infiltrate 1% lignocaine w adrenaline
- procedure
- skin crease incision 2cm above sternal notch, subplatysmal flaps
- check for high-riding brachiocephalic in suprasternal notch
- divide midline raphe and retract straps laterally
- divide isthmus - ligate thyroid ima artery, clamp isthmus between artery forceps, divide and oversew edges with 2/0 vicryl (makes reinsertion safer and easier in setting of accidental dislodgement)
- divide or diathermy pretrachal venous plexus below cricoid
- identify space between 2nd and 3rd tracheal rings by palpation with artery clip
- check in with anaesthetist who will have been pre-ventilating the patient and ask if they are ready for me to enter the trachea; before doing so I ask that they deflate their cuff or advance the tube distally
- horizontal incision between the 2nd and 3rd ring with a scalpel and can be extended laterally in each direction using scissors
- I place an 0-maxon suture around the 3rd ring and leave it long and subseuqently use this to retract the trachea anteriorly as I place my tube (can also be used to help reintroduce tube later if accidentally dislodged)
- I communicate with the anaesthetist who will pull out their ET tube slowly til just above the newly created tracheotomy (should leave in subglottic position til ventilation confirmed with tracheostomy)
- tracheostomy tube then placed through opening into trachea
- inflate
- confirm placement with CO2 monitor or ventilator
- oral ETT removed
- secure trache tube to skin with 2-0 silk then close skin
- secure neck tie to tube (allowing at least 1 finger to slide underneath to minimise constriction)
- flexible extension tube used to connect tube to ventilator circuit to minimise unnecessary movement of tube in immediate post-op period
Tracheostomy indications
- Prolonged ventilation
- Better bronchial toilet
- Gradual weaning
- Sub-acute airway obstruction (supraglottic infection or inflammation)
- Pts requiring protection of their airway (vocal cord paralysis, stroke)
- Pts requiring permanent airway access – oropharyngeal tumours/resection
- As an emergency procedure for airway obstruction, although cricothyroidotomy is usually preferred if endotracheal tube (ETT) placement is unsuccessful
- Increasingly, percutaneous trache is performed, espec in ICU in pts requiring prolonged ventilation or intubation; relative contraindications to this include: obesity, short neck, cervical spien injury, enlarged thyroid
- Don’t make incision at cricoid cartilage or 1st tracheal ring as high risk of subglottic obstruction post removal
Tracheostomy complications
- Tracheoesophageal fistula
- Bleeding – can occur from thyroid or jugular veins or from a trachea-innominate fistula
- A dislodged tube
- Creation of a false passage – can occur if tube not placed into trachea correctly or if there is inadvertent removal and blind replacement
- Infection – uncommon
- Obstruction – can occur due to drying of mucus secretions; therefore good tracheostomy toilet and humidified air is important; obstruction can also occur following dislodgement of the tube
- Subglottic tracheal stenosis – due to pressure effects of the cuff and may require corrective surgery if trache is to be removed
- Vocal cord dysfunction – uncommon
- Tracheo-innominate fistula – uncommon (~1%) – may be preceded by a sentinel bleed, due to erosion of any part of the tube into the brachiocephalic trunk – rapidly fatal
- tube tilts forward eroding into innominate arterial trunk
- manage with finger in stoma and inflated endotracheal balloon
Emergency tracheostomy
- Vertical incision from lower border of thyroid cartilage to one finger breadth above suprasternal notch, extending incision between strap muscles
- Palpate first tracheal ring with left index finger
- Divide or retract thyroid isthmus to expose anterior tracheal wall
- Vertical incision through 2nd-4th rings
- Tracheal dilator
- Tube
Emergency cricothyroidotomy
- Indications: CICO
- Stand on pt’s left side
- Equipment: size 6 ETT
- Iodine, laryngeal handshake, steady with left hand
- Horizontal stab incision into cricothyroid membrane; rotate 90 degrees so blade points inferiorly – switch hands
- Insert bougie into trachea 10cm
- Thread ETT onto bougie while rotating
- Inflate, ventilate, confirm, secure
- (?or needle cricothyroidotomy done with 14G)
Femoral hernia - low approach (Lockwood)
- GA, supine, arms out
- Stand ipsilateral side
- Incision and dissection
- 4-5cm skin crease incision below medial half of inguinal ligament
- dissect onto the sac going through: skin, subcut tissue and fat, cribriform fascia, transversalis fascia, pre-peritoneal fat, peritoneum
- look out for small veins running into the GSV; ligate and divide them as necessary
- expose fat covered hernia sac and dissect it free so it can be traced proximally beneath the inguinal ligament, taking care not to injure femoral vein laterally
- Manage sac
- Open sac between artery forceps
- Bladder may be forming medial wall
- Sweep away fat within sac to expose neck (deep)
- Identify femoral vein and preserve
- Empty sac, transfix and ligate neck with 2/0 absorbable suture excising sac 1cm distal to ligature
- Open sac between artery forceps
- Repair
- The inguinal and pectineal ligaments meet medially through the arched lacunar ligament; the aim of the repair is to unite the ligaments for about 1cm laterally, w/o producing constriction of the femoral vein
- I use three interrupted sutures to close the defect:
- Kelly’s on the vein retracting laterally
- 2-0 Prolene on an SH2 needle
- inguinal ligament first then pectineal – insert a stitch deeply into the inguinal ligament and use this to draw the ligament upwards, while the needle is insinuated behind it, to take a good bite of the pectineal ligament
- place all three sutures first then tie
- check that vein has room to engorge, leave 4-6mm
- if excessive tension on inguinal ligament, a mesh plug could be inserted; polypropylene cut 10-12cm by 2cm, rolled into a cigarette shape (2cm long) and placed into defect
- three sutures of 2-0 prolene through inguinal ligament, mesh and pectineal line
- less likely to result in compression of femoral vein and ?less prone to recurrence
- Close in layers
Torn femoral vein during low femoral hernia approach
- If femoral vein is torn, control bleeding with pressure from gauze packs and request blood, arterial sutures, tapes, bulldog clamps and heparin solution, and summon assistance
- expose vein; don’t hesitate to approach it from above and below the inguinal ligament
- apply bulldog clamps and tapes above and below damaged segment
- insert fine 5/0 sutures set 1mm apart, 1mm from the torn edges, to evert them and close the hole
- flush with heparin at intervals
- release, then remove the clamps and tapes
Acute femoral hernia - modified McEvedy
- use for strangulated hernias as provides excellent access for assessment of bowel and if necessary for resection
- IDC preop to reduce risk of damage to the bladder
- Transverse skin incision on ipsilateral side 3 finger breadths above tubercle
- Incise lower rectus sheath vertically 1-2cm medial and parallel to lateral border
- Lift lateral edge of sheath and incise thin transversalis fascia from 2.5cm above pubic tubercle to mobilise lower lateral edge of rectus medially
- Ligate and divide inferior epigastric vessels which cross this line low down
- In this preperitoneal space I move inferiorly towards the pubic tubercle to expose the entire myopectineal orifice; this may require a deeper inferior retractor eg a Deaver
- If the sac is heading above the iliopubic tract, it’s an inguinal hernia; the inferior epigastric vessels provide a clue to the position of the deep ring and superficial ring
- If the sac is heading below the iliopubic tract, it’s a femoral hernia
- In the acute setting I would like to inspect the contents of the neria, so I open the peritoneumand follow the small bowel loop down to the femoral canal; I would gain control of it before reducing it to avoid potential peritoneal spillage and contamination either with soft bowel clamps or nylon tapes
- Reduce the sac, manipulating it from above and below
- If small bowel is compromised, resect
- Close peritoneum with 2/0 vicryl
- ?transfix, ligate and divide the neck of the sac
- For a femoral hernia, repair the canal from above – options
- Suture repair if strangulated
- Suture iliopubic tract anteriorly to Cooper’s ligament posteriorly (ie close in AP plane of femoral ring), with a permanent monofilament suture – usually 3 interrupted 2-0 nylon or prolene; care to avoid injuring or narrowing femoral vein bc it is the lateral border of the repair
- Or transversalis fascia can be fixed to Cooper’s ligament medially and iliopubic tract laterally
- Mesh – usually not in acute strangulation setting
- Suture repair if strangulated
- For an inguinal hernia, I would place a polypropylene mesh in the pre-peritoneal plane to cover the myopectineal orifice
- Close in layers; anterior rectus with 0 PDS, then Scarpa’s, then skin
Can’t reduce sac during McEvedy approach
- Having gently dilated the neck of the hernia with a finger alongside the sac, I would push gently over the hernia externally (from the groin) whilst applying gentle traction from within the (pre-) peritoneal surface
- Next, formally dissect the sac to free the surrounding tissue with blunt and sharp dissection in both the pre-peritoneal and subcutaneous planes, whilst leaving the neck of the sac adherent to the crural canal; occasionally it is necessary to open the sac layer by layer in the subcut plane if it is particularly thickened and oedematous
- If these measures are unsuccessful I would formally divide the lacunar ligament medially, having first made sure that there is not an aberrant obturator artery present
- Manually reduce externally with preperitoneal tension
- In rare circumstances in which the contents still can’t be reduced, inguinal ligament can be transected
- Hernia sac can be reduced through the femoral defect to transition it into an inguinal defect
High approach to femoral hernia (Lothieson)
- advantage = can be used for repairing coexisting inguinal and femoral hernias
- for femoral hernia alone it has the disadvantage that it damages the inguinal canal and could lead to a subsequent inguinal hernia
- expose inguinal canal and dislocate cord, as for inguinal hernia ops
- incise transversalis fascia
- identify neck of sac and external iliac vein
- isolate neck of sac and gently withdraw the fundus; if there is difficulty, have the lower skin flap retracted downwards, incise the cribriform fascia and isolate, open and empty the sac from below
- ensure the sac is empty & bladder is not adherent, then transfix, ligate and divide neck of sac
- with index finger, feel margins of femoral canal; in front is inguinal ligament, medially lacunar ligament, posteriorly pectineal ligament and laterally femoral vein
- narrow the triangular gap by inserting non-absorbable sutures of 2/0 prolene between the pectineal ligament and inguinal ligament
- if upper approach was selected bc there is also an inguinal hernia, deal w an indirect sac now
- either close the incision in the posterior wall transversalis fascia w a non-absorbable suture or carry out a mesh Lichtenstein repair
- close the inguinal canal, subcut tissue and skin as for an inguinal hernia
Local anaesthetic for inguinal hernia repair*
- Inject 20mL along the line of the proposed incision using a fine needle to raise a continuous bleb within the epidermis
- Replace the needle with a larger one to inject deeply and along the same line superficial to the anterior wall of the canal
- Blunt the needle to improve the ‘feel’ of passage through the aponeurosis and inject 5mL of fluid 2cm above and medial to the ASIS deep to the external oblique to block the iliohypogastric and ilioinguinal nerves
- Reserve about half the volume of anaesthetic to inject under the external oblique aponeurosis, around the neck of the sac and into other sensitive areas during the operation
Open inguinal hernia repair - tension free mesh repair (Lichtenstein)
- Skin crease incision based on the internal ring
- Dissection through subcut fat and Scarpa’s, controlling superficial epigastric vein with 2-0 vicryl ties
- External oblique aponeurosis exposed and incised sharply; incision extended along fibres of external oblique aponeurosis to external inguinal ring, to expose inguinal canal
- Identify and isolate iliohypogastric and ilioinguinal nerves
- IH typically found lying on int oblique abdominal muscle after edges of external oblique aponeurosis elevated
- II nerve runs along spermatic cord through superficial inguinal ring & terminates at skin of upper and medial parts of thigh
- I divide them if there is a risk of entrapment (studies suggest similar incidence of chronic pain whether nerves are intentionally transected or preserved; regardless of approach, identification critical to prevent inadvertent entrapment)
- Place artery on the 2 leaves of the external oblique and reposition the self-retainer
- Spermatic cord mobilized at pubic tubercle with blunt dissection and encircled with Penrose drain
- Retract cord laterally and inferiorly to complete dissection to deep ring and identify a direct hernia
- Separate cremaster muscle from spermatic cord with blunt dissection and identify indirect hernia sac if present
- Usu ant and superior to spermatic cord in indirect hernia
- Separate sac from spermatic cord down to level of internal inguinal ring
- If any concern that a femoral hernia may be present, incise the transversalis fascia to expose the upper aspect of the femoral canal; if a femoral sac is present, deal with it via a high approach (Lothiesen procedure)
- Pick up the sac with 2 artery forceps and open it with scissors between them; return any contents to the peritoneal cavity (look out for slider) then transfix neck with Vicryl and excise the sac 1cm distal to the ligature and reduce it (alternatively fully mobilise and simply invert the sac; need not be ligated for this)
- If lipoma of cord with retroperitoneal fat herniating through internal inguinal ring, ligate and excise it
- If margins of int ring have been stretched by the indirect hernia, narrow the gap in the posterior wall using a non-absorbable suture to approximate the attenuated margins of the transversalis fascia medial to the cord
- If large indirect sac, isolate proximal portion up to the internal ring, divide the sac within the inguinal canal, transfix and ligate the neck and leave the distal portion open
- If sliding hernia
- If sac intact, don’t open it; if sac has been opened, mark the fringe of peritoneum on the viscus with artery forceps and close the sac
- If distinct funicular direct sac, resulting for a localized defect in posterior wall, isolate it, empty it then transfix, ligate and divide it at the neck; define the margins of the posterior wall defect; if the hole is small and can be closed w/o tension, suture it with non-absorbable material on a fine, curved, round-bodied needle
- If diffuse direct sac and associated with a general weakness of posterior wall, don’t open it; push it inwards and maintain the invagination (plicate) with a running suture of 2/0 vicryl, carried across the stretched transversalis fascia to flatten the bulge wo tension; sutures mustn’t bite deeply or bowel or bladder may be damaged
- Using a nonabsorbable synthetic mesh cut to shape, a slit is cut in distal lateral edge to accommodate the spermatic cord
- Lower medial corner of mesh is slightly rounded; the upper medial corner more so; mesh is then incised from its lateral margin, placing the cut 1/3 of the distance from the lower edge, extending for approx. half the length of the mesh, depending on the size of the pt
- Mesh is first secured to PT with 2-0 prolene with 2cm overlap medially then inferolaterally, suture is run along shelving edge of inguinal ligament to a point 2cm lateral to the internal ring (remembering to be careful of femoral vessels which run directly below inguinal ligament in femoral sheath)
- Overlap the tails of the mesh by bringing the lower edge of the upper portion in front of the lower tail and securing it to the inguinal ligament with two interrupted sutures (or by including it in the lateral part of the continuous suture); the resulting opening in the mesh should be a snug, but not a tight, fit around the cord
- 4 ish interrupted sutures in superior part of mesh (to transversus abdominis muscle/conjoint tendon)
- Close external oblique with 2-0 vicryl (during which external ring is recreated), taking uneven bites
- Close scarpa’s fascia
- Continuous monocryl to skin
Spigelian hernia
- Repaired because of risk of incarceration associated with a relatively narrow neck (most 1-2cm diameter)
- Mark site preop
- Transverse incision made over defect and carried through ext oblique aponeurosis
- Can extend the incision medially to open the anterior rectus sheath (?why)
- Hernia sac dissected free; invert sac or open and excise, and develop pre-peritoneal space – can check along lateral edge of rectus for other defects
- Place a mesh extra-peritoneally
- Close layers of abdo wall (transversus abdominis, int oblique muscle then external oblique aponeurosis with 0 prolene
- Lap can also be used but care to completely reduce all contents prior to repair
Nerve damage during open inguinal hernia repair
- II & IH nerves relatively superficial & usu seen w/o difficulty, though if cord layers incised (or removed) II nerve is at risk & must be dissected free in order to protect it
- II also at risk when superficial ring being repaired at end of procedure – can get caught in suture closing ext oblique
- Supplies sensation to scrotal or labial skin & skin pubic region
- IH may only be seen if upper ext oblique flap mobilized for ≥2cm; if a darn or mesh is used, nerve at risk of being picked up by superiorly placed sutures, or if relaxing incision made in rectus sheath nerve may be divided
- Supplies motor to conjoint tendon & sensation to suprapubic region
- Genital branch of genitofemoral nerve at risk unless identified running w cremasteric vessels – at risk when cleaning region of deep ring
- Division can lead to some loss of labial/scrotal skin sensation & in male low-lying testicle
Lap TAPP repair
- GA
- Supine, both arms tucked, positioned head-down
- Transumbilical Hasson entry
- 2x 5mm ports placed, one at lateral border of each rectus muscle (avoid inferior epigastrics)
- Inspect both inguinal areas for hernias
- Identify following landmarks: medial umbilical ligament, testicular vessels, inferior epigastric vessels, external iliac vessels
- Ensure that any contents of the hernia sacs are reduced
- transverse incision made in the peritoneum, starting at the medial umbilical ligament 1-2 cm above the hernia orifice and continuing out laterally just short of the ASIS – this line parallels arcuate line (dissect down vertically at the lateral aspect to create an L shape) – be cautious of inf epigastrics
- peritoneum grasped at edge and peeled down from transversalis fascia to expose the entire myopectineal orifice and create a ‘pocket’
- when creating flap, care to avoid injury to epigastric vessels and to sweep all layers toward the anterior abdominal wall, except the thin peritoneal layer
- dissect the pocket medially to expose pubic symphysis and Cooper’s ligament, a white glistening structure along superior pubic ramus
- dissect laterally, continuing exposure to 3-5cm lateral to opening of internal inguinal ring and inferiorly until the edge of the psoas muscle is visible
- dissection of indirect hernia sac, if present, performed by placing inward traction on peritoneum & carefully separate sac from cord structures
- as sac is reduced, look for gonadal vessels posterolaterally and vas deferens medially
- if direct hernia present, sac must be separated from transversalis fascia within Hesselbach’s triangle
- once peritoneal sac completely reduced and pocket enlarged to expose entire myopectineal orifice, pocket is ready for placement of mesh
- check for any peritoneal defects that will result in mesh being exposed to abdominal cavity; will need to be repaired (eg if sac transected) or mesh with barrier coating used
- mesh then introduced through umbilical port, placed into preperitoneal pocket in the preperitoneal position and unrolled to cover entire myopectineal orifice
- peritoneum then reclosed with suture or tacks, thus excluding mesh from intraabdominal contents to prevent bowel adhesions and minimize risk of bowel being ‘trapped’ in preperitoneal space

