Procedure Card - Hernia Flashcards
IPOM - Patient Positioning
Supine with bed level
Tuck and pad arms on the side ports will be placed
IPOM port placement
1.Identify and mark the access site in the left-upper quadrant- use an optical trocar using a laparoscope - Palmers point
2. Then insuflate to 15mmhg
3.Place port 3 inferiorer
4. Place port 2 inferiorer
What is Palmer’s point?
3cm below the costal margin and in the midclavicular line. Safe and reproducible
IPOM - deployment and docking
- Flatten and lower the bed as much as possible.
- drive the cart in at a 45-degree angle to the patient bed.
- dock endoscope arm and then the remaining two arms
- manually adjust arms as needed.
- When targeting, point the target anatomy at the center of workspace, not at the hernia
IPOM - Procedure steps - #1
Lysis of adhesions
Lysis of adhesions
- using a combination of sharp scissors dissection and electrocautery.
be cautious to avoid bowel.
If necessary, resect the falciform ligament and medial umbilical ligaments.
IPOM - procedure step - 2
Reduction of the hernia contents
Reduction of the hernia contents
contents include: pre-peritoneal fat and bowel. - Be very cautious with applying traction to bowel
Clear the abd. wall so the edges of defect are visible. - this ensures the stitches are placed through the fascia
If necessary, continue to dissect any structures off the abd. wall to allow a min. of 5cm of mesh overlap in all directions
IPOM - Step 3
Primary closure of the hernia defect
Primary closure of the hernia defect
Decrease insufflation pressure to 10mmhg to reduce tension on the abd. wall.
While exchanging MCS for L. Needle driver, insert barbed, self-locking suture - close defect using a running suture
Orient closer to the axis that will require the least amount of force( ex. vertical defect, suture vertically)
Suture techniques for a hernia
Start one stitch outside of the hernia defect, and take small bites of fascia.
Consider, holding the needle in 1 hand while pulling the suture with the other to eliminate having to find the needle
continue past the edge of the defect by at least 1 stitch
lock the barbed suture in place by running the suture back over the defect two stitches
*at the discretion of the surgeon
IPOM - Step 4
Suturing of the mesh
Suturing of the mesh steps
Increase insufflation. Place the excess barbed suture through the center of the mesh, pulling the mesh up to the defect.
Suture the mesh to the abd. wall
Use a running horizontal mattress stitch around the bored of the mesh.
Place two to three stitches before pulling the suture.
Place a running stitch across the center of the mesh to eliminate dead space
lock suture into place by running back two stitches
*assistant may need to burp the ports to allow an adequate range of motion.
*mesh type, size, and placement at the surgeon’s discretion
IPOM - step 5
Closure
Closure steps
Remove any specimens that were resected
remove all instruments
undock and roll away the patient cart
desufflate the abdomen and remove all ports.
close the fascial defect for any incisions larger than 8mm.
What does eTEP stand for?
extended Totally extraperitoneal
eTEP- port placement
- consider placing ports on the side of the abd. that will result in the greatest distance from the defect.
- Identify and mark the outline of the hernia defect, linea alba, and the linea semilunaris on the side of the abd.
- Identify and mark the first access site, 2cm medial to the linea semilunaris and 2cm inferior to the costal margin
- a vertical line should be drawn at least 7-8 cm later to the defect
eTEP - initial access
Enter the retroperitoneal space optically using a 5mm optical trocar w/immediate insufflation
Place an 8mm incision, proceed slowly once the rectus muscle is reached to prevent penetrating the peritoneum
When the tip of the obturator enters the retrorectus space, immediately turn on insufflation to 15mmhg
direct the optical access port to be tangential to the retrorectus space and continue to enter the retrorectus space.
using a sweeping motion, bluntly dissect the areolar place to develop the retrorectus space. Keeping the fat directly anterior to avoid retrorectus vasculature and nerves
eTEP - port placement, once retrorectus space has been developed
place 3 ports in-line inferior starting at the LUQ. Using arms 2,3&4.
eTEP - step 1
Development of the retrorectus space
Development of the retrorectus space steps
Blunt dissect medially to the linea alba
cross over to the per-peritoneal space by sharply incising the posterior rectus sheath: take care not to incise the peritoneum and enter the abd. cavity
develop the pre-peritoneal space posterior to the linea alba using blunt dissection and electrocautery. Keep fat posterior
Keep the transversalis fascia, median umbilical ligaments and median umbilical ligaments posterior - at the umbilicus, the umbilical ligaments usually need to be divided.
eTEP - step 2
Reduction of the hernia sac
Reduction of the hernia sac steps
Reduce the sac back into the abd. cavity using electrocautery and blunt/sharp dissection.
The sac may include intestines, be cautious to avoid using thermal energy to the intestines. - consider opening the sac to observe contents w/in the sac
eTEP - step 3
Development of the contralteral retrorectus space
Development of the contralateral retrorectus space steps
Ensure that the pre-peritoneal space extends past the medial edge of the contralateral rectus abd.
Enter the contralateral retrorectus space by incising the posterior rectus sheath
incise inferiorly and superiorly the full length of the extaperitoneal space
develop contralateral space, keeping the fat directly anterior
extend space laterally enough to ensure space for the mesh
eTEP - step 4
Closure of the hernia defect
Closure of the hernia defect
reapproximate the linea alba using a running stitch w/barbed, self-locking suture. Incorporating the hernia sac into the stitch may prevent seroma formation
consider using a 30-degree up endoscope, and lower insufflation to 10mmhg
eTEP- step 5
mesh placement
Mesh placement steps
Using a ruler, measure the size to overlap the defect by 5cm in all directions
place mesh to overlap defect. Slowly start to desufflate to workspace and monitor the mesh to ensure that it does not shift or fold over.
What does TAR stand for?
Transversus Abdominis Release
TAR - patient position
Airplane both arms. OR, Tuck and drop both arms slightly below the level of the torso. Flex the table to open the space between the costal margin and the iliac crest.
TAR- port placement
Mark the first access site on the left anterior axillary line and 2 cm inferior to the costal margin
enter using a 5mm optical entry trocar
Place remaining ports6cm inferior and inline
TAR - step 1
Lysis of adhesions and reduction of the hernia contents
Lysis of adhesions and reduction of the hernia contents steps
Adhesiolysis using blunt diss. and electro. Avoid termal injury to the bowels.
Reduce hernia contents including omental fat and bowel.
TAR - step 2
Rectus sheath division and retrorectus diss.
Rectus sheath division and retrorectus dissections steps
-Identify the location of the medial edge of the contralateral rectus muscle : if not immediately apparent, apply mono energy to the peritoneum to find the rectus muscle
- Incise peritoneum and posterior rectus sheath vertically. Preserve the anterior rectus sheath for facial closure
- dissect the retrorectus plane inferiorly and superiorly until adequate mesh overlay is achieved.
TAR - step 3
Transversus abdominus release
Transversus abdominus release steps
Start the release in the upper abd. (top - down approach) where the muscular transversus abdominsis is visible
Incise posterior lamella of the internal oblique and the muscular transversus abdominis to enter pre-transversalis fascia plane - be careful not to incise into the peritoneum
Develop the plane between the transversus abdominis muscle and transversalis fascia
Continue to transect the transversus abd. muscle in the caudal direction. Avoid injury to the neurovascular bundles.
What is a technique that can be used to carefully incise the posterior lamella
Spread the muscle fibers and insert the grasper posterior to the muscle. While the grasper is spread, transect the muscle between the jaws.
OR
Bluntly dissect from the transversalis fascia as the transection of the muscle proceeds, ensuring there is no structures behind the muscle
TAR - step 4
Mesh placement and contralateral fixation
Mesh placement and contralateral fixation steps
Use a ruler to measure the width and length of the mobilized peritoneum/posterior sheath & double the measured width of the mesh to ensure there is enough.
during exchange for needle driver, have the assistant pass through the trimmed medium weight, macroporous mesh.
place three to four interrupted sutures through the edge of the mesh to the lateral most exposed portion of the transversus abdominis. - This will keep the mesh from sliding.
Roll the mesh toward the sutures to store the mesh out of the way while the ipsilateral extraperitoneal space is created.
TAR - step 5
Contralateral port placement
Contralateral port placement steps
Place ports in the contralateral side of the abdomen, mirroring the locations on the ipsilateral side ( Patient L & R)
Undock and rotate the boom to the patients other side and redock. Leave the other ports in to maintain insufflatio
TAR - Step 6
Rectus sheath division, retrorectus dissection, and transversus abdominis release
Rectus sheath division, retrorectus dissection, and transverus abdominis release part 2 steps
Repeat steps 2 (rectus sheath division & retrorectus dissection) on patients left side
When you reach the ports, have the assistant remove the ports through the dissection flap so that the dissection can continue laterally
repeat step 3 (transversus abdominis release ) on the patients left.
after the release, both sides should be able to be reapproximated using minimal tension
TAR - step 7
Closure of the posterior rectus sheath and hernia defect
Closure of the posterior rectus sheath and hernia defect steps
close sheath and peritoneum using a running stitch or barbed, self-locking suture. - take care not to incorporate any abdominal contents in the closure.
Use absorbable suture to close any other defects.
Unroll the mesh to cover the entire extraperitoneal cavity
Place 3-4 sutures through the edge of the mesh to the lateral-most-exposed portion.
Decrease insufflation pressure to 8-10mmHg.
Close the hernia defect by reapproximating the linea alba using a running stitch of barbed, self-locking suture. - encorporating the sac may prevent seroma formation
TAR - additional things to consider when closing
consider placing a drain into the extraperitoneal space through one of the patients left side ports.
slowly desufflate and watch the mesh to ensure it does not shift.
Inspect facial defects and consider closing any fascial defects about 10mm.
