Dr Mahendra kumar Awotar
General Surgeon, World Laparoscopy Hospital
FMAS & DMAS, AUGUST 2017

Procedural steps:
 
1. General anesthesia 
2. Part preparation and patient positioning
3. Setting up -Surgeon and OT, according to ergonomics
4. Access to peritoneal cavity
5. Creating pneumoperitoneum
6. port positioning
7. Surgical steps
8. Mesh placement and fixation
9. Port closure 
10. Post operative care

Executional steps:

1. General anesthesia –

General Anesthesia with endo tracheal tube is required with proper multi parameter monitoring, specially ETCO2 .
Single shot of pre-operative antibiotics should be given.
Foley catheter must be placed and stockings have to be applied.

2. Part preparation and patient positioning:

The patient is placed in the Trendelenburg position so as to make bowel fall away from the operative site i.e. pelvic region. Optional left or right tilt can be given as required.

3. Setting up - Surgeon and OT, according to ergonomics:

All devices and instruments needed must be checked for proper functioning & insulation. OT should be set as per principles of ergonomics in laparoscopic surgery like-

a. suitable table height of 0.49 x surgeon’s height (around 60 to 70 cm from ground) 
b. placement of monitor at a distance of 5 times its diagonal length 
c. height of monitor should be  200  from his/her visual axis
d. Surgeon –hernia site- monitor all should be in same axis.

4. Access to peritoneal cavity (closed technique):

• Make a stab incision on the skin, using a scalpel blade No. 11 at inferior crease of umbilicus.
• Lift the abdominal wall and insert the Veress needle through the incision at a 450 angle to the body of patient and perpendicular to the lifted abdominal wall (directing to anal canal).
• After you hear the “two click” sounds, confirmation of intra-peritoneal entry is done by irrigation, aspiration and hanging drop tests.
• Make a smiling incision on the inferior crease of umbilicus of 11mm.
• Using Scandinavian technique (i.e. separating fibers of obliterated vitellointestinal duct), to gain safe entry to the intra-peritoneal space, insert the cannula using the pyramidal trocar with screwing movements into the peritoneal cavity till you get the air sound or loss of resistance.
• Access can even be achieved by open technique i.e. Hassan’s method by incising all abdominal wall layers except peritoneum and entry with blunt trocar which is fixed on either shoulders with sutures.

5. Creating pneumoperitoneum:

• Connect the CO2 either to the Veress needle (for closed technique) or the port (for open technique)
• Begin inflating the intra-peritoneal space with 1 lit/min for closed technique keeping an eye on Quadra manometer.
• Observe rise of the intra-abdominal pressure and total volume of gas as the abdomen and hernia gets distended.
• For the closed technique, after the intra-abdominal pressure reaches the preset pressure of 12-15mmHg, take the veress needle out of the abdomen.

6. Port positioning:

• Enlarge the infra umbilical skin crease incision up to 11mm.
• Slowly screw the cannula with the trocar into the peritoneal cavity in perpendicular direction. (Insufflation and abdominal wall lift will avoid the possible visceral injury.)
• camera settings - The camera is white-balanced and focused at a distance of 10 cm (focal length of 10 mm scope).
• Aperture and window should be wide with fibroscopic filter off and shutter speed in auto mode. The telescope is then advanced down through the umbilical port into the abdominal cavity under direct vision.
• All four quadrants of the abdomen are examined for any possible accidental pathological findings, if present.
• Then locate the site of action. It is the inguinal region either right or left or both depending upon the defect site/sites.
• Make an incision for 5mm lateral ports for operating instruments as per the “Baseball-Diamond” principle of port placement put forth by Dr. R. K. Mishra. Ports should be 5 to 7.5 cm on either side of telescope to keep azimuth angle of 150 to 450 .

7. Surgical steps:

• Contents of the hernia sac are reduced. Make wise use of energy sources for adhesiolysis as required.
• Identify all the anatomical landmarks in the inguinal region:

1. Median umbilical ligament 
2. Medial umbilical ligaments on either side
3. Two lateral umbilical ligaments                            
4. Triangle of doom
5. Triangle of pain 
6. Trapezoid of disaster 

• Proceed for mesh placement directly without any peritoneal or sac dissection which is advantage with IPOM technique.

8. Mesh placement and fixation:

• Adequate size of mesh selected with formula – size of defect + 12 cm, so that mesh projects 6 cm beyond the defect margin on each side.
• Mesh type usually selected is vypro / vypro II, ultra light weight mesh where polypropylene fibers are covered with polyglactin to avoid adhesions.
• This mesh covers all the hernia sites in groin.
• Now make a roll of mesh like cigar outside the abdomen.
• Hold the mesh with a needle holder with a 10 to 5mm reducer previously loaded over the shaft and pull the mesh within the reducer.
• Then introduce the mesh assembly through the 10 mm optical port.
• Now put the telescope in and unroll the mesh under vision.
• Now mesh is well placed in position to cover all the defects and area 6 cm beyond its margin.
• Multiple absorbable tackers are fired starting much lateral to triangle of pain, on inguinal ligament and then continued along arch of transverses abdominis muscle till cooper’s ligament (outer crowning).
• All the tackers must be fired above inguinal ligament to avoid entry in any danger area and even it should not be fired medial to medial umbilical ligament to avoid bladder.
• Inner crowning is done by firing couple of tackers near defect on and above inguinal ligament.
• Fixation of inferior margin of mesh started from inferomedial corner with absorbable suture using Dundee jamming knot and continuous sutures, as put forth by Dr. R.K.Mishra .
• Care should be taken to involve only peritoneum at 1 cm distance and avoid major vessels and nerves. Continuous interlocking suturing along the inferior edge of mesh from medial to lateral aspect with Aberdeen termination done.
• Note – inexperience can lead to major injuries and IPOM should be tried with fibrin glue rather than suturing.

9. Port closure:

• Before moving out the telescope the port entry sites are examined for bleeding.
• Suture passed within & out under vision using veress needle or suture passer to close all 10 mm ports under vision.
• Both 5 mm cannula taken out under vision without any fascial stitch.
• Pneumoperitoneum is relieved.
• Optic Cannula is removed with telescope within so as to make sure that neither the bowel nor the omentum had entered the port wound.
• Knot is tightened after removal of cannula.
• Skin is closed using skin staplers.
• Skin around the sutured wound is cleaned with antiseptic solution.

10. Post operative care:

• Elastic adhesive bandage with sponge at deep ring site for 2 days to avoid seroma collection.
• Immediately mobilize the patient on the same day.
• Remove the Foley’s catheter when the patient is able to void urine on his own.
• Administer appropriate antibiotic, analgesic, PPI, anti-emetics & I.V. fluids as required. Orals started on same day itself!!