General Surgery

World Laparoscopy Hospital

FMAS & DMAS, January 2018

 

A hernia is protrusion of viscus or parts of viscus through the wall along with its sac. The first known description of a hernia dates back to at least 1550 BC in the Ebers Papyrus from Egypt. Most commonly they involve the abdomen, specifically the groin. Groin hernias are most common of the inguinal type (70%) - indirect, direct, pantaloon. Symptoms are present in about 66% of people with inguinal hernia, like pain or discomfort, especially with coughing, exercise, or going to the toilet. Often it gets worse throughout the day and improves when lying down. An expansible cough impulse is a positive symptom. Groin hernias occur more often on the right than the left side. The main concern is strangulation, due to blocked blood supply particularly in indirect type. TAPP and TEP are the most common techniques used now a days for groin hernias. TAPP became a gold standard for bilateral inguinal and femoral hernia. But recently IPOM technique used for the repair of ventral hernias are also used to repair inguinal hernia with no tissue dissection and little morbidity as compared to TAPP, particularly for unilateral groin hernia.

 

Risk factors:
 

1. Smoking

2. Chronic obstructive pulmonary disease

3. Obesity

4. Pregnancy

5. Peritoneal dialysis

6. Collagen vascular disease

7. Pevious open appendectomy

8. Partly genetic and also may be due to heavy lifting.

 

Repair may be done by open surgery or by laparoscopic surgery. Laparoscopic surgery generally has less pain and early recovery following the procedure. 

 

 

• Tension free repair reinforcing the entire myo-pectineal orifice.

• Least disruption of anatomy, minimum ports and least complications.

• Early return to work with speedy recovery.

 

 

• Patients with reducible, non-complicated inguinal hernia.

• Without any severe COPD, cardiac diseases and with adequate lung and cardiac reserve.

 

 

1. Procedural steps

2. Executional 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

 

 

 

a. General Anesthesia with endo tracheal tube is required with proper multi parameter monitoring, specially ETCO2, regular intraoperative temperature measurement.

b. Single shot of pre-operative antibiotics should be given just before surgery according to guidelines.

c. Foley catheter must be placed and stockings have to be applied particularly in high risk patients.

 

 

The patient is placed in the Trendelenburg position in 15-200 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 depending on target site.

 

 

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 20cm from his/her visual axis

d. Surgeon - hernia site - monitor all should be in same coaxial line.

 

 

• 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.

 

 

• Connect the CO2 either to the Veress needle (for closed technique) or the hasson cannula (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 gets distended (there should be a parallel rise between intra abdominal pressure and total volume of gas).

• For the closed technique, after the intra-abdominal pressure reaches the preset pressure of 12-15mmHg, take the veress needle out of the abdomen.

 

 

• 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 300 telescope is then advanced down through the umbilical port into the abdominal cavity.

• All four quadrants of the abdomen are examined for any possible accidental injury and other pathological findings, if present.

• Then locate the target of action. It may be either left or right inguinal hernia

• 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 under direct vision. Ports should be 5 to 7.5 cm on either side of telescope to keep azimuth angle of 150 to 450.

 

 

• 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 – 

a. Median umbilical ligament 

b. Medial umbilical ligaments on either side

c. Two lateral umbilical ligaments                            

d. Triangle of doom

e. Triangle of pain 

f. Trapezoid of disaster

 

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

 

 

• 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.

• 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 are taken terminated with aberdeen knot.

• Note – Inexperience can lead to major morbidity and mortality in this method due close relation with external iliac artery and vein. In that case IPOM should be tried with fibrin glue rather than suturing.

 

 

• 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.

 

 

• 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!!

 

 

• No complications have been reported in WLH. But this technique is unsafe in inexperienced hands and can lead to intra operative complications of injury to various vessels and nerves.

• Prolonged ileus, which is usually managed conservatively. 

• Surgical-site and port site infections are very rare.

• Seroma formation - may resolve on its own in few days.

• Discomfort of mesh decreases as the fibrosis sets in.

 

 

 

1. Task Analysis of Laparoscopic procedures, from World Laparoscopy Hospital Website

2. https://www.laparoscopyhospital.com/ -  youtube video by Dr. R.K. Mishra

3. Guidelines for laparoscopic inguinal hernia repair, SAGES, from:

 https://www.sages.org/publications/guidelines/guidelines-for-laparoscopic-inguinal-hernia-repair/

4. https://en.wikipedia.org/wiki/Hernia

5. Richard L. Whelan, James W. Freshman & Dennis L. Fowler (2006), The SAGES Manual: Perioperative Care In Minimally Invasive Surgery.