- 5 days ago
https://www.laparoscopyhospital.com/SERV01.HTM
This Video demonstrates Recurrent Incisional Hernia with Severe Small Bowel Adhesion with Subacute Obstruction. The prevalence of incisional hernia after laparotomy is reported to be between 11% and 20%,3,4, and incisional hernia recurrence after surgical repair is as high as 45%. Incisional hernias cause pain and other more serious problems, such as bowel obstruction, incarceration, and strangulation. After Laparoscopic Surgery these recurrences are very less.
For more information please contact:
World Laparoscopy Hospital
Cyber City, Gurugram, NCR DELHI
INDIA 122002
Phone & WhatsApp: +919811416838, + 91 9999677788
This Video demonstrates Recurrent Incisional Hernia with Severe Small Bowel Adhesion with Subacute Obstruction. The prevalence of incisional hernia after laparotomy is reported to be between 11% and 20%,3,4, and incisional hernia recurrence after surgical repair is as high as 45%. Incisional hernias cause pain and other more serious problems, such as bowel obstruction, incarceration, and strangulation. After Laparoscopic Surgery these recurrences are very less.
For more information please contact:
World Laparoscopy Hospital
Cyber City, Gurugram, NCR DELHI
INDIA 122002
Phone & WhatsApp: +919811416838, + 91 9999677788
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LearningTranscript
00:00hello friends this is a case of laparoscopic recurrent incisional hernia this patient has
00:08previous two time surgery and there was a feature of sub acute obstruction and she was having
00:14recurrent incisional hernia so let us start the procedure I will demonstrate you that this is a
00:21complicated case but how to perform so now we will enter inside and here we are using the Palmer's
00:31point for the entry so this is coastal margin this is left side coastal margin you can feel the coastal
00:42margin a splenomegaly is a absolute contraindication so palpation should be correct and here is the
01:04left coastal margin this is now mid clavicular line here this is mid clavicular and this is the Palmer's
01:18point and here two centimeter above we put this is misra's point after that you should hold the
01:34abdominal wall this is the hernia and there is a rectus divertication also so this is the entire
01:44boundary of the hernia you should give one a small stab wound and then stretch the abdominal
02:03wall down so this point should come below the coastal margin and then with the various needle you have to go
02:18perpendicular right towards the stomach then irrigation test suction test and hanging drop test will be
02:33carried out and we can see preset pressure is 15 actual pressure is 89 and after one liter of the gas flow rate is increased so once the actual pressure come to the preset pressure then various needle should be removed and incision has to be enlarged
03:01and incision has to be enlarged now this trocar 10 millimeter optical trocar is introduced
03:09then you can introduce the telescope and then you can have the examination of the entire area this is the hernia so you will have the baseball diamond concept and you will put the other ports into
03:29other ports into a snuff box telescope is 24 centimeter and the instrument is 18 centimeter from the target and this is your one port and this will be your other port because in this present we have to do repair of the abnormal wall also by switching so it is better to do three ports
03:57and this is the one port that is the right hand and this is left hand port so now all the ports are in the position and after that you will enter inside and then you will start the procedure
04:17here we can see here we can see there is a huge incarceration
04:25and lot of adhesion is there in this patient
04:29a lot of additional issues have to be performed in this patient that is mandatory sometime in those situation
04:51now we will start the adhesive lysis and the left hand grasper is stretching the abdominal wall and you should start the periphery of the bubble with the peytonial dissection
05:13because it is important in those cases that you should not touch with the harmonic the directly the bubble loop
05:21and a stretch left hand abdominal atraumatic grasper is giving a stretch inferiorly and the boundaries of the peytonium
05:31of the peytonium of the defect which is completely incarcerated in the abdominal wall should be dissected with the vibrating jaw of harmonic
05:43these cases has to be very sensitively performed because there is a fair chance of obstruct this perforation
05:55115Š°Ń half obstruct this perforation
06:25Very meticulous dissection is required.
06:48This is one of the problem of open surgery that you have more recurrence and incarceration
06:54and adhesion.
06:55If the previous surgery would have been laparoscopy, then probably these problems would not arise.
07:07Slowly the combination of a blunt dissection and the sharp dissection, you have to separate
07:16all the bowel loops, keeping yourself nearer to the abdominal wall.
07:23Now the periphery you can see in between the media alum legally comment.
07:30Entire bubble is adhered.
07:36Now the periphery you can see in between the media alum legally comment.
07:47Entire bubble is adhered.
07:54Now the periphery you can see in the meantime.
08:01Not that at all, you can see in the middle of the room you can see in the middle of the
08:08Home offenders.
08:09Now the ability of the eye is also and is WWW.
08:16I'll see you next time.
08:46so slowly the dissection is carried out left hand is stretching the bowel loop down and
09:06right hand is separating the sac peritoneum this is the sac of the hernia which is getting
09:15separated carefully
09:38this is prepatoneal fat and this is a good plane for separation and the defect is also clearly visible
09:54there are multiple defect in this case and all the defect has to be separated size of the mess also
10:03will be all the defect will be considered as one defect
10:33these are the lateral addition with again incarceration of the bubble loop
10:51so
10:55so
11:58So, this is a little aggressive dissection.
12:09So, you have to keep the patience.
12:12Although in laparoscopy, you have limited tactile feedback.
12:17So, you have to be more rely upon the visual interpretation.
12:23And slowly the sac will be separated.
12:30And plutonium of the sac together with the bubble loop will come out.
12:34So, let's see.
12:35Let's see.
12:36Let's see.
12:37Let's see.
12:39Let's see.
12:40Let's see.
13:12Behind also we can see that there is a lot of bubble loop so you have to be first see
13:26the boundaries and clear boundaries should be identified and then further dissection
13:33will be carried out.
15:19So.
15:20This is slowly.
15:21so this is slowly continued and in this situation
15:49you cannot lose the presence it should be very careful
16:19this is another defect and here the sack of the defect
16:37which will be trimmed out
16:49so
16:57so
17:03This is the previous proline suture.
17:32We could not find any mess here, in previous treasury the mess was not probably used.
18:01We could not find any mess here, but we could not find any mess here.
18:08We could not find any mess here, but we could not find any mess here.
18:15We could not find any mess here, but we could not find any mess here.
18:22We could not find any mess here, but we could not find any mess here.
18:29We could not find any mess here, but we could not find any mess here.
18:50We could not find any mess here, but we could not find any mess here.
18:57We could not find any mess here, but we could not find any mess here.
19:04We could not find any mess here, but we could not find any mess here.
19:11We could not find any mess here, but we could not find any mess here.
19:18We could not find any mess here, but we could not find any mess here.
19:53So, this is approximately 75% of the region has been removed and we can see Rectus
20:21has a divertication here so it is important that you should do the suturing and to closure
20:30of the Rectus edges because just putting the mesh will not make sufficient in these cases.
21:23So this is now the lower ease.
21:53Left hand is stretching the bubble down and with the right vibrating jaw over the ring
22:11of the rectus, you can cut these fibrotic tissue so that it will release the bubble without
22:21harming it.
22:28So this surgery is even by the open surgery is not going to be easy.
22:52So this surgery is not going to be easy.
22:59So this surgery is not going to be easy.
23:04So this surgery is not going to be easy.
23:08So this surgery is not going to be easy.
23:15So this surgery is not going to be easy.
23:20So this surgery is not going to be easy.
23:55So this part is over, now again in this area these all power loop has to be separated.
24:25Below is the bladder area so you have to be more careful in between both the medial
24:53umbilical ligament.
24:55So as we can see now.
24:57So as we can see now.
24:59We will inspect the bubble careful.
25:01So as we can see now.
25:03We will inspect the bubble careful for any of the perforation.
25:35Now this is the closure with the extra corporeal misraz knot.
25:40You can close the defect.
25:42These are the rectus margin.
25:49And we have to take a bite with the proline number one proline.
25:56And close the defect.
25:57If you will not close the defect.
26:00Then these patients recurrence is very common.
26:03Even after putting the mesh.
26:05So first we will close the defect.
26:09And after that you will put the mesh.
26:12So here it will be this is first hitch.
26:19First wind.
26:21First lock.
26:23Then you can take second wind.
26:30And second lock.
26:35After that third wind.
26:38And this is third lock.
26:40So it has to be carefully separated.
26:43And this is the extra corporeal knot.
26:46Pressure should be reduced to 8 mm of mercury.
26:49And the both the edges of the rectus is tightly approximated.
26:55And then one more lock you will give.
26:59For this knot.
27:01Now again another bite.
27:03And we have taken 6-7 knots.
27:07Just to approximate the edges of the.
27:10So this is useful because.
27:14Intracorporeal won't do here.
27:17Intracorporeal will not have any advantage.
27:33And again another one will slash it's jeopardy.
27:46Quite the seamstress to add a base.
27:48Intracorporeal kindly Wilka.
27:49Now again it's held out.
27:54This is the first Sh FIRST HITCH.
27:55This is the first Wind.
27:58This is the first Lock.
28:00lock here is the second wind this is second lock this is the third wind and
28:12here you have the third lock and this is again the past pointing and you can lock
28:25it extracorporeal knot has a great power to pull the edges near to each other only the
28:34pressure should be decreased at this time
28:57so this margin should be carefully taken the bite reverse bite is required and that has to be taken in a manner that it should approximate and there should not be any defect right now we are taking little distance in between if you are seeing this a small defect that also later we will close
29:21these are the multiple extracorporeal knot
29:26which is closing the defect
29:51couple of western knot also we have given in between to close the defect now this is in between intermediate defects
30:10so now the tension is released and these defects will be easy to take out and this is also tightened
30:18so all the defect is now closed these are two medial umbilical ligament and this is bladder in between the medial umbilical ligament which you can see
30:33now this is where the defect is closed now we will put the mesh this is polyurethane mesh
30:44with the cortex suture tied on the all the four corner
30:50and then the mesh will be taken out one by one for the trans facial fixation these sutures will be pulled out
30:58this will create trans facial fixation
31:14and all the corners
31:17is stabilized now we are using here the titanium tacker
31:22and with the attacker we will do outer crowning and after that inner crowning
31:37so this is outer crowning with the mesh
31:47the conjugate arm令
32:13inferior epigastic vessel should be taken care of
32:17when you are doing outer grounding these are little oozing from the side of the
32:24hernia sack but once the pressure of the mesh will apply it will stop
32:47now these are inner crowning at the age of the defect
33:10you should not fire where you have suture
33:13left hand will guide you because left hand will support from outside and that will guide you
33:24because you can see the indentation you can feel the tip of the tracker that will be useful
33:43so
33:54so
34:08so more tracker hair was used because of the tension should be released and better fixation
34:29should be done now you have to do strapping put the sponge and just with the elastic adhesive
34:36you should give abdominal support strapping to prevent seroma formation and that is useful
34:44so thank you very much for watching this video have a nice day
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