Dr. L.K. GANESH
GENERAL SURGERY
MANIPAL
KARNATAKA


A) Patient Position:
1. The patient is placed in the Trendelenburg position to make bowel fall away from the operative site

B) Instruments and Surgeon’s Position:
1. The height of the table should be 0.49 times the surgeon's height.
2. The monitor should be at a distance of 5 times its diagonal length from Surgeon.
3. The surgeon should stand on the right side.
4. The Surgeon, the hernia site, and the monitor should be along the same axis.

Port positioning:

1) The Optical Port should be placed at infra umbilical crease.
2) The other two-port is placed according to the baseball diamond concept,i.e., one on the right side and other on the left side.

Access to peritoneal cavity:

1. Make an incision 2 mm with 11 no blade at the inferior crease of umbilicus.
2. Lift the abdominal wall and insert the Veress needle directing towards anus through the incision at a 450 angle to the spine and perpendicular to the lifted abdominal wall.
3. Make confirmation of intraperitoneal entry by double click sound, Hanging drop test, and Plunger test.

After confirmation:

1. Connect the CO2 either to the Veress needle & begin inflating the intra-peritoneal space initially at one ltr/min and later at three ltr/min till the intra-abdominal pressure reaches the preset pressure of 12-15mmHg,
2. Take the veress needle out of the abdomen
3. Enlarge the infra umbilical incision up to 11mm.
4. Put the cannula inside the trocar
5. Slowly screw the cannula with the trocar into the peritoneal cavity in the perpendicular direction to the abdominal wall.
6. The camera is white-balanced and then focused.
7. The telescope is then advanced through the umbilical port into the abdominal cavity under direct vision.
8. Perform diagnostic laparoscopy/peritenoscopy and locate the site of pathology
9. Make two 5mm operating ports on either side of the optical umbilical port under direct vision on the concept of baseball diamond concept.

Procedural Steps:

1. Define the laparoscopic anatomy, Start the peritoneal dissection at 2 O’clock position at a distance of 6 cm from the outer margin of the hernia defect.
2. Hold the peritoneum by Maryland and lift it and cut the peritoneum with a scissor at a point mentioned above
3. Allow the CO2 to enter inside which will create the plane of dissection
4. Then lift the leaf of peritoneum & start dissecting the peritoneum using scissor till you reach the medial umbilical ligament.
5. While dissecting the peritoneum, push the fat and fibrous strands towards the anterior abdominal wall.
6. Make medial Pocket: Push the bladder down and push the fibrous tissue towards anterior abdominal wall till u see the coopers ligament(lighthouse).
7. Make lateral pocket:
• Push the fibrous tissues towards the abdominal wall and push the posterior leaf downwards   
• Complete dissection over the triangle of doom and pain
8. Start dissection of sac
• Hold the sac with Maryland
• Do blunt dissection by pulling the sac towards you and pushing the vas deferens, spermatic vessels away till the sac separate from spermatic cord.

Mesh Placement: 

1. Take Prolene mesh – 10*15 cm and make a roll of mesh outside the abdomen.
2. Hold the mesh with a needle holder and put it inside the reducer
3. Introduce the mesh assembly through the 10 mm optical port.
4. Put the telescope in and unroll the mesh under vision.

Fixation of Mesh:

With Tackers:

1. Fix the medial corner of the mesh to the cooper’s ligament using either tackers.
2. Apply one tacker on mesh over rectus abdominis in the anterior abdominal wall
3. Apply one tacker on mesh over transverse fascia in the anterior abdominal wall
With Suture
1. Hold the need holder with the right hand and rotate it anticlockwise and take bite over cooper ligament and mesh and fix with intracorporeal surgeon knot
2. Take a bite on rectus abdominis muscle and mesh and fix with intracorporeal surgeon knot.
3. Take a bite on transverse fascia and mesh and fix with intracorporeal surgeon knot.

Peritoneal closure:

With Tackers:

    1. Do double breasting of the lower leaf over the upper leaf of peritoneum and apply tackers.
With Suture 
    1. Start Suturing from medial to lateral with continuous intracorporeal suture with vicryl 2.

Portside closure:
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1. The port entry sites are examined for bleeding.
2. Close the optical port using a veress needle under vision with 5 mm telescope from 5 mm cannula.
3. Pneumoperitoneum is deflated.
4. The Cannula is removed with a telescope within so as to make nothing comes along with it and.
5. Tighten the knot after removal of the canula.
6. The other two-port site is closed.
7. The skin around the port site is cleaned with an antiseptic solution.
8. Dry sterile dressings are applied to the port sites.

Elaboration of Steps:

Position the patient in the supine position.

Administer general anesthesia.

Insert a urinary catheter to empty the bladder.

Preoperative antibiotics are administered.

Make a 10-12mm incision at the level of the umbilicus.

Use a Veress needle to insufflate CO2 into the abdomen.

Insert a 10mm trocar through the incision.

Insert a laparoscope through the trocar and visualize the abdominal cavity.

Identify the hernia sac and reduce the hernia contents.

Identify the left inguinal region.

Make an additional 5mm incision lateral to the left rectus muscle.

Insert a 5mm trocar through the incision.

Use a laparoscopic grasper to retract the peritoneum.

Use a monopolar or bipolar electrosurgical device to incise the peritoneum along the left inguinal region.

Create a dissection plane between the peritoneum and the transversalis fascia.

Develop the preperitoneal space using a balloon dissector or other blunt instrument.

Insert a 10mm trocar through the left lower quadrant.

Use a laparoscopic grasper to retract the peritoneum.

Use a monopolar or bipolar electrosurgical device to dissect the peritoneum and develop the preperitoneal space.

Insert a self-retaining retractor to maintain the preperitoneal space.

Dissect the hernia sac and reduce any hernia contents.

Reduce the hernia sac by pulling it into the preperitoneal space.

Close the hernia defect with sutures or mesh.

Use a laparoscopic stapler to secure the mesh in place.

Ensure adequate mesh coverage and fixation.

Close the peritoneum with sutures.

Inspect the surgical site for any bleeding or hematomas.

Remove the self-retaining retractor.

Deflate the abdomen and remove the trocars.

Close the incisions with sutures or staples.

Apply sterile dressing to the incisions.

The patient is awakened from anesthesia.

Extubate the endotracheal tube.

Move the patient to the post-anesthesia care unit.

Administer analgesics for pain management.

Monitor vital signs and urine output.

Check the dressing for bleeding or drainage.

Observe the patient for any signs of infection or complications.

Advise the patient to avoid strenuous activity for 2-4 weeks.

Advise the patient to avoid lifting heavy objects for 2-4 weeks.

Schedule a follow-up appointment.

Evaluate the patient's postoperative course.

Monitor for any complications, such as bleeding or infection.

Evaluate the patient's recovery of bowel and bladder function.

Adjust medication as needed.

Evaluate the healing of the incisions.

Provide the patient with a detailed report of the procedure and postoperative care.

Advise the patient on any potential complications or side effects of the procedure.

Provide the patient with instructions on follow-up appointments and monitoring.

Advise the patient on when to resume normal activities, such as driving, work, and exercise.

The patient follows up with the surgeon at regular intervals.

The surgeon evaluates the patient's healing and progress at each follow