Procedures

Question 1

1-1 Open Lichtenstein Tension-free Herniorrhaphy

Answer 1

1. Oblique skin incision 2 fingerbreadths superior to the inguinal ligament
2. External oblique cut in the direction of its fibers
3. Cord structures dissected free from the sac. Identify all: ilioinguinal iliohypogastric, gen fem.
4. Sac and contents returned to abdomen
5. Polypropylene mesh secured to pubic tubercle medially, inguinal ligament inferiorly, and the rectus sheath and internal oblique muscle superiorly in a tension-free fashion. Pubic tubercle must be completely covered to prevent recurrnece.
6. External oblique is reapproximated and the skin closed

Question 2

1-2 Laparoscopic Totally Extraperitoneal Repair of Inguinal Hernia

Answer 2

1. Infraumbilical incision is made down to the anterior rectus sheath through which a balloon dissector is introduced into the retromuscular space.
2. The balloon dissector is slowly inflated to bluntly dissect the preperitoneal space
3. Two 5 mm trochars are placed in the lower midline
4. Careful and complete dissection is performed to adequately identify the relevant anatomy (the inferior epigastrics superiorly, Cooper’s ligament medially, and the iliopubic tract laterally)
5. The hernia sac is dissected from the cord structures and returned the peritoneal cavity.
6. Mesh is introduced and positioned to cover the entire myopectineal oriface
7. Fixation may be used but is not necessary

Question 3

1-3 Laparoscopic Transabdominal Preperitoneal Repair of Inguinal Hernia

Answer 3

1. The first port is placed at the umbilicus. 2 add’l ports are placed on either side lateral to the rectus sheath.
2. The peritoneum is incised from the ipsilateral medial umbilical fold to the level of the ASIS.
3. The preperitoneal space is bluntly dissected from the ASIS laterally to the medial umbilical fold medially, and below Cooper’s ligament inferiorly
4. The hernia sac is dissected from the cord structures and returned to the peritoneal cavity
5. Mesh is introduced and positioned to cover the entire myopectineal orifice. It should not be allowed to curl or shift.
6. The peritoneal defect is closed using tacks or sutures. Avoid injury to the epigastric vessels.

Question 4

2-1 Recurrent Inguinal Hernia (Transabdominal Preperitoneal Repair)

Answer 4

1. Incision of the peritoneum and development of the preperitoneal space
2. Reduction of direct, femoral, or obturator hernias medially
3. Dissection of an indirect hernia sac off the cord structures/round ligament and subsequent reduction of the sac and cord lipoma from within the deep inguinal ring. Triangle of doom deep to cord, triangle of pain (gen fem) lateral
4. Extensive peritoneal dissection with parietalization of the cord
5. Placement of nonabsorbable mesh to cover the entire myopectineal orifice
6. Closure of the peritoneum

Question 5

3-1 Open Inguinal Hernia Repair with Mesh

Answer 5

1. Verify laterality
2. Abx ppx
3. Groin incision
4. Expose and incise the external oblique in the direction of the fibers to the external ring
5. Identify and protect the ilioinguinal nerve
6. Mobilize flaps of external oblique
7. Attempt reduction of hernia contents to better establish anatomical landmarks
8. Encircle spermatic cord/round ligament at the external ring with a penrose drain
9. Identify the hernia sac on the anterolateral surface of the cord and dissect it free from the surrounding structures
10. In the case of an indirect hernia, open the sac, reduce the contents, and highly ligate with suture ligature
11. If direct hernia, free sac from surrounding attachments and reduce into the abdomen
12. Assess the floor of the canal and prepare the mesh
13. Begin medially at the pubic tubercle and secure the mesh in place to the shelving edge inferiorly and the conjoined tendon superiorly
14. Avoid narrowing the internal ring or incorporating nervous tissue into the repair
15. Ensure hemostasis
16. Close the external oblique aponeurosis and Sarpa’s fascia in layers
17. Approximate skin edges, apply dressing

Question 6

3-2 TAPP Inguinal Hernia Repair with Mesh

Answer 6

1. Verify laterality
2. Abx ppx
3. Infraumbilical incision for the 10-12 mm trochar followed by insufflation
4. Placement of two 5mm trochars at the level of the umbilicus, lateral to the rectus sheath
5. Creation of peritoneal flap starting lateral to inferior epigastric vessels
6. Dissection of contents of inguinal canal and identification of a hernia sac
7. Skeletonize cord
8. If direct: reduce the sac and the preperitoneal from ther internal ring by gentle traction
9. If indirect: mobilize the sac from the cord structures, and reduce into the peritoneum
10. Place precut lateralized mesh in proper orientation to completely cover direct, indirect, femoral spaces
11. Place tacking suture on the medial aspect of the mesh in cooper’s ligament suturing the mesh in place
12. Tack peritoneal flap back to the abdominal wall to fully cover newly introduced mesh
13. Desufflation and trochar removal under direct visualization

Question 7

5-1 Component Separation

Answer 7

1. Remove all prosthetic material, and address any bowel issues as necessary
2. Perform complete adhesiolysis of the entire anterior abdominal wall to the paracolic gutters to allow muscular components to slide to the midline during reconstruction
3. Elevate lipocutaneous flaps 2cm lateral to the linea semilunaris, edge of the rectus. DO NOT cause a through-and-through injury at the semilunaris. DO NOT undermine/destgroy medial perforators: skin necrosis
4. Incise the external oblique fascia and separate the external and internal oblique muscles in their avascular plane
5. Continue the dissection 3-4 cm above the costal margin and inferiorly to the inguinal ligament
6. Release the posterior rectus shealth by making an incision 1 cm lateral to the linea alba
7. Develop the retromuscular plane out to the linea semilunaris while preserving the neurovascular bundles to the rectus muscle
8. Place an appropriately sized biologic graft as an underlay, redistributing tension across the graft to help medialize the rectus complex
9. Drains placed over the mesh
10. Medline fascia reapproximated with interrrupted figure-of-8 sutures
11. Remove excess devascularized skin, and close over multiple drains

Question 8

6-1 Enterocutaneous Fistula

Answer 8

1. Elliptical incision to encompass the EC fistula and any inflamed tissue
2. Careful entry into the abdomen in an area with intact fascia, either superior or inferior to the fistula
3. Through abdominal exploration w/ complete adhesiolysis and circumferential dissection of the fistulized segment of SB.
4. Resection of the EC fistula and any involved abdominal wall, includin all foreign body material while preserving as much notmal tissue as possible
5. Drainage of any intra-abdominal abscess
6. Restoration of GI continuity (SS or EEA anastomosis)
7. Abd wall closure

Question 9

7-1 Infected Ventral Hernia Mesh

Answer 9

1. Laparotomy in the area of the infected mesh
2. Complete adhesiolysis and evaluation of bowel and surrounding structures
3. Repair any GI issues as appropriate
4. Excision of all prosthetic mesh, taking care to preserve abdominal wall muscles
5. Utilize landmarks such as transfascial sutures or tacks to identify the periphery of the mesh
6. Repair the resulting hernia defect w/ 1ary closure vs resorbable mesh

Question 10

8-1 Postoperative Dehiscence

Answer 10

1. Debride nonviable fascia
2. Reinforce w/ absorbable biologic mesh if necessary to achieve tension-free closure. Tension = fascial necrosis
3. Consider temporary abdominal closure for pts at risk for abd compartment syndrome

Question 11

9-1 Laparoscopic Paraesophageal Hernia Repair

Answer 11

1. Gentle reduction of herniated intra-abdominal contents as able
2. Dissection of the hernia sac along the inner border of the crura
3. Identification of the anterior and posterior vagus nerves
4. Circumferential control of the distal esophagus and vagus nerves within a penrose drain
5. Careful mediastinal dissection for complete hernia reduction including 3-cm of intra-abdominal esophagus. Don’t damage pleura.
6. Division of the short gastrics if performing fundoplication
7. Closure of the curral defect with nonabsorbable pledgeted sutures
8. Fundoplication or gastropexy

Question 12

10-1 Gastroesophageal Reflux Disease

Answer 12

1. Incision of the gastrohepatic ligament through the avascular space to expose the right crus. Watch out for replaced right hepatic!
2. Blunt dissection to develop a plane between the esophagus and the crus until the crural decussation is visualized. Don’t injure a/p vagus
3. Complete mobilization of the fundus. Don’t avulse short gastrics off spleen
4. Extensive mediastinal dissection to deliver at least 2.5-3 cm of distal esophagus into the abdomen
5. Snug closure of the crural defect with nonabsorbable sutures.
6. Creation of a 2 cm long posterior fundoplication (Nissen or Toupet) over a dilator, using nonabsorbable suture

Question 13

11-1 Siewart Classification

Answer 13

Siewert 1: Tumor 1-5 cm above EGJ
Siewart 2: Tumor 1cm above to 2 cm below EGJ
Siewart 3: Tumor 2-5 cm below EGJ.
Siewart 1-2 treated like esophageal Ca, Siewart 3 like gastric Ca

Question 14

11-2 Total Gastrectomy

Answer 14

1. Midline laparotomy
2. Mobilize GEJ and esophagus, taking margin of diaphragmatic crura. Watch out for replaced L hepatic in gastrohepatic ligament
3. Separate the omentum and lesser sac lining en bloc from the transverse colon
4. Divide the short gastric vessels, and skeletonize the celiac, splenic, and common hepatic arteries, taking LNs (D2 lymphadenectomy)
5. Ligate left and right gastric and gastroepiploic arteries at their bases
6. Divide the esophagus, stomach, jejunum
7. Reconstruction with EJ and JJ