Procedure Card - Hernia

Question 1

IPOM - Patient Positioning

Answer 1

Supine with bed level
Tuck and pad arms on the side ports will be placed

Question 2

IPOM port placement

Answer 2

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

Question 3

What is Palmer’s point?

Answer 3

3cm below the costal margin and in the midclavicular line. Safe and reproducible

Question 4

IPOM - deployment and docking

Answer 4

1. Flatten and lower the bed as much as possible.
2. drive the cart in at a 45-degree angle to the patient bed.
3. dock endoscope arm and then the remaining two arms
4. manually adjust arms as needed.

• When targeting, point the target anatomy at the center of workspace, not at the hernia

Question 5

IPOM - Procedure steps - #1

Answer 5

Lysis of adhesions

Question 6

Lysis of adhesions

Answer 6

• using a combination of sharp scissors dissection and electrocautery.

be cautious to avoid bowel.

If necessary, resect the falciform ligament and medial umbilical ligaments.

Question 7

IPOM - procedure step - 2

Answer 7

Reduction of the hernia contents

Question 8

Reduction of the hernia contents

Answer 8

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

Question 9

IPOM - Step 3

Answer 9

Primary closure of the hernia defect

Question 10

Primary closure of the hernia defect

Answer 10

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)

Question 11

Suture techniques for a hernia

Answer 11

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

Question 12

IPOM - Step 4

Answer 12

Suturing of the mesh

Question 13

Suturing of the mesh steps

Answer 13

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

Question 14

IPOM - step 5

Answer 14

Closure

Question 15

Closure steps

Answer 15

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.

Question 16

What does eTEP stand for?

Answer 16

extended Totally extraperitoneal

Question 17

eTEP- port placement

Answer 17

• consider placing ports on the side of the abd. that will result in the greatest distance from the defect.

1. Identify and mark the outline of the hernia defect, linea alba, and the linea semilunaris on the side of the abd.
2. 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

Question 18

eTEP - initial access

Answer 18

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

Question 19

eTEP - port placement, once retrorectus space has been developed

Answer 19

place 3 ports in-line inferior starting at the LUQ. Using arms 2,3&4.

Question 20

eTEP - step 1

Answer 20

Development of the retrorectus space

Question 21

Development of the retrorectus space steps

Answer 21

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.

Question 22

eTEP - step 2

Answer 22

Reduction of the hernia sac

Question 23

Reduction of the hernia sac steps

Answer 23

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

Question 24

eTEP - step 3

Answer 24

Development of the contralteral retrorectus space

Question 25

Development of the contralateral retrorectus space steps

Answer 25

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

Question 26

eTEP - step 4

Answer 26

Closure of the hernia defect

Question 27

Closure of the hernia defect

Answer 27

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

Question 28

eTEP- step 5

Answer 28

mesh placement

Question 29

Mesh placement steps

Answer 29

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.

Question 30

What does TAR stand for?

Answer 30

Transversus Abdominis Release

Question 31

TAR - patient position

Answer 31

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.

Question 32

TAR- port placement

Answer 32

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

Question 33

TAR - step 1

Answer 33

Lysis of adhesions and reduction of the hernia contents

Question 34

Lysis of adhesions and reduction of the hernia contents steps

Answer 34

Adhesiolysis using blunt diss. and electro. Avoid termal injury to the bowels. Reduce hernia contents including omental fat and bowel.

Question 35

TAR - step 2

Answer 35

Rectus sheath division and retrorectus diss.

Question 36

Rectus sheath division and retrorectus dissections steps

Answer 36

-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.

Question 37

TAR - step 3

Answer 37

Transversus abdominus release

Question 38

Transversus abdominus release steps

Answer 38

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.

Question 39

What is a technique that can be used to carefully incise the posterior lamella

Answer 39

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

Question 40

TAR - step 4

Answer 40

Mesh placement and contralateral fixation

Question 41

Mesh placement and contralateral fixation steps

Answer 41

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.

Question 42

TAR - step 5

Answer 42

Contralateral port placement

Question 43

Contralateral port placement steps

Answer 43

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

Question 44

TAR - Step 6

Answer 44

Rectus sheath division, retrorectus dissection, and transversus abdominis release

Question 45

Rectus sheath division, retrorectus dissection, and transverus abdominis release part 2 steps

Answer 45

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

Question 46

TAR - step 7

Answer 46

Closure of the posterior rectus sheath and hernia defect

Question 47

Closure of the posterior rectus sheath and hernia defect steps

Answer 47

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

Question 48

TAR - additional things to consider when closing

Answer 48

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.