This video demonstrates the Laparoscopic Management of Suprapubic Incisional Hernia by Dr. R K Mishra at World Laparoscopy Hospital. The suprapubic hernia is the term to describe ventral hernias located less than 4 cm above the pubic arch in the midline. Hernias with an upper margin above the arcuate line encounter technical difficulties, and the differences in repair methods forced us to define them as large suprapubic hernias. Laparoscopic repair of large suprapubic hernias can be considered as the first option in treatment. The low recurrence rates reported in the literature and the lack of recurrence, as observed in our video.
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00:00hello friends this is a case of suprapubic incisional hernia and this
00:08patient has a small 2 centimeter hernia just above the upper border of pubic
00:15symphysis because this patient has gone two times cesarean section and after
00:22that she has developed this incisional hernia now we will enter through the
00:27palmer's point and problem of these cases is that you cannot do I palm because
00:34you cannot cover the pubic symphysis and the bladder with the intrapaternal only
00:42mess otherwise bladder fistula will happen so here we should try to distance
00:49the bladder and the bladder should weigh down so a foliage catheter is introduced
00:54and now we are distending the bladder with the 300 cc 300 to 500 cc of methylene blue
01:04diluted normal saline so once you distend the bladder you can easily find out the
01:11delineated dome of the distended bladder and once you will make a prepatonal
01:17pocket the bladder will weigh down now this four centimeters above the delineated dome
01:25of the distended bladder prepatonal space is started making it and that you can do
01:33by sharp incision may be seizures or harmonic and it should be the four
01:38centimeter above the dome of the distended bladder in between both the medial
01:44umbilical ligament you should not go lateral to the medial umbilical ligament to
01:50prevent the injury of in phi apigastic vessel here in the middle you can see the
01:55median umbilical ligament that is obliterated urecus and either side you have
02:01the two medial umbilical ligament and just lateral to the medial umbilical ligament
02:06there in phi apigastic vessel so after giving this incision now rest of the
02:14prepatonal space will be formed by the blunt dissection you should not use a sharp
02:20dissection so this is done now now you can take the harmonic out and with the two
02:28atraumatic grasper you can make this prepatonal pocket
02:34so this is all blunt dissection and due to gravity bladder will drop down and then you
02:52can reach up to the pubic symphysis bone
02:59here we can see it is reaching to the pubic symphysis bone and either side of the
03:10cooper ligament also will be visualized that is also called as lighthouse and this is interior wall of the
03:18bladder which will be bluntly pushed down and here the pneumo plutonium will help you
03:25because gas will enter into this suprapubic prepatonal pocket and you can easily separate the plutonium
03:32from the anterior abdominal wall and this will be in the space of regius and these are the small hernias on the anterior abdominal wall
03:40these are the small hernias on the anterior abdominal wall now this is over and after that you can put the mesh
03:47here we will use the pro visc 3d this is the inferior pegastic vessel either side which you can see so here we are planning to use pro visc 3d polyurethane mesh so this is a dual mesh which is made for intra
04:02pitonial application it has two sides one layer is polyester another layer is polyurethane polyurethane is blue color b for bubble b for blue and this blue color will be towards the entire
04:22and you should push it up to the pubic symphysis bone and after that you will fix the intra-abdominal part with the tacker
04:41and the suprapubic part you can fix with the cooper ligaments so that it will cover the every defect up to the suprapubic area
04:51and now this plutonium of the bladder will be fixed with the mesh together with the anterior abdominal wall but remember only plutonium
05:02accidentally you should not fire the tacker over the bladder so this is the plutonium of the bladder
05:16which you will support over the anterior abdominal wall and fire this is at the level of the median umbilical ligament and then again you will fix it but but remember always you should fire medial to the medial umbilical ligament here our mesh is little bigger than the required size but it's okay
05:41but it's okay and it will be fixed completely so it will be not affecting the distension of the bladder and this mesh will strengthen the all the suprapubic hernia
05:56so this is
06:24this is absorbable tacker so it doesn't have problem it will get absorbed after some time
06:31now here one more will be fired but take care that it should be medial to inferior pegastic vessel
06:38now here one more will be fired but take care that it should be medial to inferior pegastic vessel
06:46now here one more will be fired but take care that it should be medial to inferior pegastic vessel
07:09now here one more will be fired but take care that it should be medial to inferior pegastic vessel
07:14so this is now over and now slowly the bladder will be deflated now you can open the clamp
07:25of the foliskothic catheter and bowel will be deflated and you may see the color of the
07:32you know saline coming out should not be red and if you want you can perform a cystoscopy
07:38to just check the integrity of the bladder so this way most of the supropivic incision hernia can be
07:45performed and how much you will make the pocket that depends upon the size of the hernia here there
07:51was a very small hernia so that's why a big pocket was not formed so thank you very much for watching
08:00this video this patient doesn't want any baby now because if again caesarean is required
08:07then the mesh has to cut so we have done tubectomy also so this is ligature and just two centimeter
08:15lateral to the cornual end both the tube was cut with the ligature for sterilization purpose
08:23so again because percent family was already completed you can see there is a small fibroid also
08:29on anterior wall of the uterus because percent is already 40 plus so it is not necessary because
08:37after few years we will go into the menopause and this fibroid will shrink so thank you for watching
