Thursday, November 10, 2011

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Laparoscopic repair of bilateral inguinal hernias - OP Report

PREOPERATIVE DIAGNOSIS: Bilateral inguinal hernias.

POSTOPERATIVE DIAGNOSIS: Bilateral inguinal hernias.

OPERATION PERFORMED: Laparoscopic repair of bilateral inguinal hernias.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: None.

ANESTHESIA: General.

SPECIMEN SENT: None.

OPERATIVE FINDINGS: There was a large hernia on the right side, indirect in nature, with a fairly substantial lipoma of the cord and properitoneal fat within the internal ring as well as a fairly scarred in hernia sac. On the right side, there was a patulous ring with properitoneal fat sitting unreduced within the internal ring and minimal sac exiting through the internal ring.

OPERATION: The patient was brought to the operating room, placed supine on the operating room table. General anesthesia was induced. A Foley catheter was inserted aseptically. The abdomen was prepped and draped sterilely below the umbilicus. Just below the umbilicus, a small midline incision was carried down through skin and subcutaneous tissues until the fascia was reached. To stop the midline to the right, an incision was made 12 mm long. Entry was gained into the properitoneal space by elevating the rectus muscle and bilateral balloon trocar was placed without difficulty into properitoneal space. It was insufflated under direct visualization and then was drawn under direct visualization. Following this, a Hasson 12-mm trocar was inserted and secured using 0 Vicryl stay sutures into the properitoneal space, which was insufflated to a maximum pressure of 15 mmHg using a flow rate of 3 L to 4 L per minute of CO2 gas. Patient was placed in Trendelenburg position after two 5 mm ports were placed 25% and 50% of a distance between the pubis and the umbilicus. On both sides, properitoneal dissection of peritoneum was performed. On the right side, this was much more tedious than on the left side, but eventually we were able to pull peritoneum into the upper portion of the retroperitoneal space revealing very significant non-reduced component of fat on the right side. This was reduced manually by the grasper over grasper retraction and occurred without difficulty. A tedious dissection was required to separate the hernia sac on the right side from the vas deferens and from the cord vessels. The configuration here was somewhat unusual, in the sense that the vas deferens laid almost directly anterior to the cord vessels instead of immediately, as normally occurs. However, eventually, we were able to separate and tease apart the hernia sac from the cord vessels and the vas deferens and bring it into the properitoneal space, teasing it away from the underlying vas deferens and cord structures, so that it came to lie in the upper properitoneal space. Similar maneuver was performed on the left side, but was much less tedious and difficult due to the fact that there was no actual hernia sac exiting through the internal ring. There was a smaller area of properitoneal fat that had exited through the internal ring to create the patulous defect in the sac. In both cases, when the properitoneal fat and peritoneum had been reduced into the properitoneal space and separated from the underlying cord structures and vas deferens, we brought 3DMax mesh larges sizes into each side securing the right sided and the left sided mesh with 2 or 3 ProTack to the pubis and to the Cooper’s ligament and then splaying the mesh out under any potential direct defect and over the cord structures, so as to completely cover the internal ring on each side. When this had been accomplished and meshes were placed appropriately, the space was deflated thereby allowing peritoneum and fatty tissues to lie against the meshes immobilizing them against the pubic floor. All trocars were then removed under the direct visualization. The fascia at the infraumbilical incision was closed with interrupted 0 Vicryl suture. All skin incisions were closed with 4-0 Monocryl subcuticular suture and Steri-Strips. The patient tolerated the procedure well. The Foley catheter was removed and he was then awaked and extubated on the operating room table and returned to recovery in stable condition. It should be noted preoperatively that the patient did also have a history of asymmetric cardiomyopathy and had a pacemaker placed which was managed perioperatively by the Cardiology and Pacemaker Service. This was managed uneventfully.

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