- today
https://www.laparoscopyhospital.com/SERV01.HTM
In the evolving landscape of minimally invasive surgery, the combination of a Total Laparoscopic Hysterectomy (TLH) with concurrent hernia repairs represents a significant advancement. This article delves into the specifics of performing a TLH alongside right inguinal and left incisional hernia repairs using a three-port technique, highlighting its benefits, challenges, and key considerations.
Understanding the Procedures:
Total Laparoscopic Hysterectomy (TLH): A TLH is a surgical procedure for removing the uterus using laparoscopic techniques. This method involves small incisions and the use of a laparoscope (a thin tube with a camera) to guide the surgery, offering advantages such as reduced scarring and quicker recovery.
Hernia Repairs:
Right Inguinal Hernia Repair: This procedure addresses hernias in the right groin area, where abdominal contents protrude through a weak spot in the abdominal muscles.
Left Incisional Hernia Repair:
This surgery corrects hernias that occur at the site of a previous surgical incision on the left side, involving the strengthening of the abdominal wall.
Three-Port Technique:
The three-port technique involves three small incisions or 'ports.' Through these ports, surgical instruments and a camera are inserted. This approach minimizes tissue damage and reduces the recovery time.
Advantages:
Reduced Recovery Time: The minimally invasive nature of the procedure allows for faster recovery and shorter hospital stays.
Decreased Pain and Scarring: Smaller incisions lead to less post-operative pain and minimal scarring.
Efficiency: Combining these procedures reduces the need for multiple surgeries, minimizing overall patient risk and healthcare costs.
Challenges and Considerations:
Surgical Skill and Experience: The success of this combined approach heavily relies on the surgeon's expertise in laparoscopic techniques.
Patient Selection: Not all patients are suitable candidates for this procedure. Factors like the patient’s overall health, the size and complexity of the hernias, and the uterine condition must be considered.
Risk of Complications: As with any surgery, there are risks of complications such as infection, bleeding, or injury to surrounding organs.
Postoperative Care:
Monitoring: Close monitoring post-surgery is essential to ensure proper healing and to identify any complications early.
Pain Management:
Effective pain management strategies are vital for patient comfort and faster recovery.
Follow-up:
Regular follow-up appointments are necessary to monitor the healing process and address any concerns.
In the evolving landscape of minimally invasive surgery, the combination of a Total Laparoscopic Hysterectomy (TLH) with concurrent hernia repairs represents a significant advancement. This article delves into the specifics of performing a TLH alongside right inguinal and left incisional hernia repairs using a three-port technique, highlighting its benefits, challenges, and key considerations.
Understanding the Procedures:
Total Laparoscopic Hysterectomy (TLH): A TLH is a surgical procedure for removing the uterus using laparoscopic techniques. This method involves small incisions and the use of a laparoscope (a thin tube with a camera) to guide the surgery, offering advantages such as reduced scarring and quicker recovery.
Hernia Repairs:
Right Inguinal Hernia Repair: This procedure addresses hernias in the right groin area, where abdominal contents protrude through a weak spot in the abdominal muscles.
Left Incisional Hernia Repair:
This surgery corrects hernias that occur at the site of a previous surgical incision on the left side, involving the strengthening of the abdominal wall.
Three-Port Technique:
The three-port technique involves three small incisions or 'ports.' Through these ports, surgical instruments and a camera are inserted. This approach minimizes tissue damage and reduces the recovery time.
Advantages:
Reduced Recovery Time: The minimally invasive nature of the procedure allows for faster recovery and shorter hospital stays.
Decreased Pain and Scarring: Smaller incisions lead to less post-operative pain and minimal scarring.
Efficiency: Combining these procedures reduces the need for multiple surgeries, minimizing overall patient risk and healthcare costs.
Challenges and Considerations:
Surgical Skill and Experience: The success of this combined approach heavily relies on the surgeon's expertise in laparoscopic techniques.
Patient Selection: Not all patients are suitable candidates for this procedure. Factors like the patient’s overall health, the size and complexity of the hernias, and the uterine condition must be considered.
Risk of Complications: As with any surgery, there are risks of complications such as infection, bleeding, or injury to surrounding organs.
Postoperative Care:
Monitoring: Close monitoring post-surgery is essential to ensure proper healing and to identify any complications early.
Pain Management:
Effective pain management strategies are vital for patient comfort and faster recovery.
Follow-up:
Regular follow-up appointments are necessary to monitor the healing process and address any concerns.
Category
📚
LearningTranscript
00:00Hello friends, this is a case of total laparoscopic hystectomy and this patient has inguinal hernia as well as incisional hernia.
00:10So we will do all the three surgery and here supra-umblycal port we are using approximately 10 cm above the umbilicus
00:18so that we can perform all the three surgery by only three port.
00:24So this is where a signal is getting introduced.
00:30And you have two click and the varicinal is in.
00:38After that we will do irrigation suction and hanging drop test.
00:45So this is irrigation test.
00:50Then suction test.
00:51And this ball, this is disposable varicinal.
00:58So this ball will float up.
01:00And after that, this is hanging drop.
01:05If you lift, this ball will sink down.
01:08And that will replace the hanging drop.
01:10Otherwise you can do plunger test.
01:12So you can take the piston out and then you will see all the fluid of this plunger will be pulled inside the abdomen.
01:20Because we have two to four millimeter minus millimeter of mercury pressure.
01:28Interpretent negative pressure is there.
01:30Now we are inserting the insufflator tubing.
01:35And the CO2 insufflation started at a rate of one liter per minute.
01:40Here preset pressure we are using 15 and waiting for actual pressure to be reached to 15.
01:52Approximately 3.5 liter gas is introduced.
01:56And slowly you can see homogenous distension is started in the abdomen.
02:14So almost now reaching to the preset pressure.
02:20And actual pressure is gradually increasing.
02:24And it is about to reach to the preset pressure.
02:29So this patient has right-sided inguinal hernia.
02:33Left-sided incisional hernia.
02:37And fibroid uterus with the abnormal uterine bleeding.
02:42So first we will do histectomy.
02:45Then tap repair for right side.
02:48And eye palm for left side.
02:51So first we will do TLH.
02:54So now this incision is enlarged to 11 mm.
03:03And then it is stretched up to the rectus.
03:06And now this alayabu namam trokar is introduced.
03:12We are always applying little betadine over the cannula.
03:16And that will prevent any infection.
03:20Although all our...
03:21This is hissing sound.
03:22Hissing sound.
03:24Although all our port we always autoclave.
03:26And this is base ball diamond concept.
03:30And 7.5 cm lateral to the umbilicus.
03:33This is the second port.
03:35And then third port is again 7.5 cm lateral and below.
03:47This is third port.
03:49Now patient is in trendel and birth position.
03:51And we can see here this is sigma and colon.
03:55This is sacral parliamentary.
03:56Here is the appendix.
04:03And just below the appendix you can see the peristalsis of ureter.
04:07And this is ureter of the right side.
04:09This is ip ligament.
04:14Right ip ligament left.
04:17So everything is okay.
04:19This uterus is bulky.
04:21And there is a fibroid on the right lateral wall.
04:24This is the inguinal hernia.
04:26This is indirect inguinal hernia.
04:30This is on the right side.
04:33And here this is one esysmal hernia.
04:36On the left side.
04:37And this is the deep ring.
04:40Here is the triangle of doom.
04:42This is round ligament.
04:43This is iliac vessel.
04:45So was muscle medial umbilical ligament.
04:48And this is the hernia.
04:51So initial diagnostic is performed.
04:54This was the incision somewhere with the you know previous surgery.
04:58And that has developed after that.
05:01So this is the deep ring.
05:04And here is the medial umbilical ligament.
05:09This is median.
05:11And this is medial of other side.
05:14And this is the round ligament of the right side.
05:17And here is one hernia on the right.
05:20So this is the diagnostic we will do.
05:24And after that.
05:26Where the inferior epigastic vessel is going laterally.
05:30And then we will start histectomy.
05:32So dissection is just started with the ligation.
05:34We will do the round ligament.
05:36Philippian 2 ovarian ligament of the right side will be taken first.
05:41And generally we always start 4 cm lateral to the uterus to the round ligament.
05:45And with the ligation we are taking round ligament.
05:52After that this is falapian tube.
05:57This is approximately 3 cm lateral.
06:01And we always remove the tube later.
06:04We don't remove the tube in the beginning.
06:06And we will remove later.
06:08And now this is ovarian ligament.
06:09Here we are not using ICG or Infrared Euretric Catheter.
06:17Otherwise we generally use Indosinine Green.
06:23Or Euket Infrared Euretric Catheter in many cases.
06:27But this is a simple surgery.
06:29So here we are not using.
06:31And we will perform all the 3 surgeries.
06:34With only 3 ports.
06:35So this right side of adnexal structure is dissected.
06:40After that this is left side.
06:47This is left side of round ligament is taken.
06:54Followed by falapian tube.
06:55And followed by ovarian ligament.
07:15And then we will do 2.5 cm over the broad ligament.
07:20So all these structures are taken.
07:32Now uterus will be fully retroverted.
07:35And we will lateralize the anterior leaf of the broad ligament.
07:39And then we will start dissecting the anterior leaf of the broad ligament.
07:42And slowly uterus will be rotated from 5 to 7 o'clock.
07:49Left hand should always make a lateral window.
07:53This patient has previous caesarean section as you can see.
07:57So it is always better to remain as nearer as possible to the uterus.
08:01As well as with the left hand you should always reflect the peritoneum by making a lateral window.
08:06So this is left hand is stretching always.
08:12And that is important to prevent the bladder injury.
08:20So left hand is very important in the laparoscopy.
08:25More important than right hand which will give you the plane of dissection for the right hand.
08:31And now this anterior leaf of the broad ligament of the right side is also done.
08:58And below is sigmoid colon.
09:01So you have to...
09:06The sigmoid has to be taken care that vibrating jaw of harmonic should not touch.
09:12And now this anterior leaf of the broad ligament is separated and ureter is lateralized.
09:19After that next step is again bladder separation.
09:23So uterus will be kept at 6 o'clock position.
09:25Again with the left hand you should try to make a lateral window in the bladder pillar.
09:33And then it should be a combination of sharp as well as blunt dissection to separate the bladder.
09:39Because of previous cesarean section you can see bladder is adhered and we have to be...
09:47This is the vagina here you can see this pearly white color with the crisscross pattern and these are the bladder fibers of the adhesion.
09:56So with this lateral window it has to be separated from right to left.
10:03And after that bluntly over the colputomizer separation of the bladder will continue.
10:11So these all adhesion has to be separated and at least 3 cm of the vagina should be separated out of the bladder.
10:19Bladder pillar you may cut and slowly slowly this dissection should be carried on either side.
10:25And these muscles of the bladder pillar is better to cut so that when you will take uterine artery your jaw of the ligature will be optimized.
10:36And it will give you better traction over the uterine lumen to seal it.
10:42So lateralization is done and bladder is separated.
10:46This is the bladder which is going up and uterus should be fully cranial traction with the colputomizer as well as retroversion when this entire bladder is separated.
10:58After that uterus will be antiverted at 1 o'clock position and will start opening the posterior plutonium.
11:23Here also left hand has a lot of roll so that it should try to always lift the peritonium in ferro medially and then it should be cut.
11:36So that your tip of the harmonic should not lock any vane.
11:41Otherwise vane will puncture and it will create problems.
11:44So slowly you should keep on separating the peritonium.
11:46This is just little bit attachment which is separated and then you will keep on going above the arc of uterus sacral ligament.
11:59Here we can see this is the uterine hump of the left side and vane and visible.
12:07So be careful that it should not be injured.
12:10We can see vane as well as artery is visible on the left side.
12:15And left hand should keep this peritonium away from the vessels.
12:18And while you are going from left to right, your assistant will keep on moving the uterus from 1 o'clock to 11 o'clock.
12:30Now this is again on the right side and the left hand is making a lateral window and giving inferno medial traction so that here it is a little bit fibrosis so that your harmonic should not touch the vessel.
12:49We can see here we are just above the vessel.
12:52This is the vessel and it should not be injured.
12:56And this is the posterior peritonium which is getting separated.
13:10And separating the posterior peritonium and pushing it down will drop the ureter also down.
13:18I will show you the ureter here.
13:20This is the IP ligament and if you lift it and you can see this is the ureter here.
13:25Just watch the peristalsis of the ureter.
13:28This is ureter.
13:30So it is quieted down and it is done.
13:33Now we will take the uterine artery of the left side which is divided and dissected and coagulated by the ligature.
13:43Now it is separated.
13:45So left side of uterine is done.
13:46If you should also take care of the reverse bleeding and vein particularly is more important to keep in mind.
13:56And tip of the ligature should be against the culpritomizer so that full lumen of the uterine should be taken.
14:06And now this is the right side of the uterine artery which is coagulated and dissected out.
14:15And you should try to remain as medial as possible because this is only three ports.
14:20So you need a cooperation by the assistant who is doing uterine manipulator to give you contralateral traction.
14:28And now this is the culpritomy.
14:30Culpritomy is started.
14:31Always we start above the arc of uterocircle ligament.
14:35And generally we use harmonic so that only the cervical part of uterocircle ligament will be cut.
14:44Vaginal arc will be maintained.
14:47And assistant will keep on rotating the uterus at the time of culpritomy.
14:53So the camera person should keep the light cable down at 6 o'clock position so that easily you can see from below up.
15:05And this is culpritomy started.
15:09So once you have cut it, this is the right side and then we will do again the left side.
15:18So here also your assistant cooperation is required.
15:23We are using here mangeskar uterine manipulator and appropriate size of the culpritomizer.
15:35You should try to be slow here because if your tip of the harmonic will touch the silicon part of the culpritomizer then it may break.
15:45And it should never touch the middle part otherwise it will definitely break.
15:50So this is now going and this is culpritomy of the left side is continued.
15:57We can see this white color of the culpritomizer is visible.
16:01And always we remain within the ring of the culpritomizer so that there will be no any vaginal shortening.
16:10So now this is the final culpritomy and we can see this is teflon part of moving part of the harmonic even if you touch the bubble nothing will happen.
16:34Because only active is the straight jaw.
16:39So this culpritomy is over.
16:42After that we will see posteriorly if some fibers are attached posteriorly that also should be separated.
16:52So it's done.
16:54After that uterus will be removed.
16:56And this uterus is taken out.
17:07After removing the uterus out.
17:11It was little bulky.
17:13So you have to be little careful.
17:16It is out.
17:17Now we will do the.
17:20Here we can see these are the hernias which we will separate.
17:23And we will repair later.
17:25But before that we will remove both the tube.
17:30So this is the.
17:33Antromedial traction.
17:34And this is eye ligament.
17:36We will not remove the ovary.
17:38And both the fallopian tube will be removed.
17:41So this is the right fallopian tube.
17:55Which is removed.
17:56And this is a stone holding forcep coming.
17:59And it will hold the tube.
18:02Now this is again right tube.
18:05Left is done.
18:06And right again.
18:07Antromedial traction.
18:09After removal of the uterus.
18:11Taking the tube out is very easy.
18:13Because you have.
18:15Enough space.
18:17And it is very easy.
18:20Just few seconds.
18:22You can remove both the tube.
18:25So this is done.
18:26And now we will remove the tube.
18:29And now suturing will start.
18:32And here this is the.
18:34Utero sacral of the right side.
18:36And this is anterior vagina.
18:38Of the right side.
18:41And this is the continuous suturing.
18:43With the number one white krill.
18:45Sometime if you want.
18:46You can use bob suture.
18:49V-lock or a stratafix.
18:50But that may be.
18:54Unnecessarily expensive.
18:57So we are using here.
18:58Simple number one white krill.
19:00And this continuous suturing will continue.
19:03And only three bite is required.
19:05One on the right side.
19:07One on the middle.
19:08And one on the left side.
19:10Vaginal epithelium should must be included in this bite.
19:14So that any garration tissue should not form.
19:17And take care that cranial tracts should be maintained.
19:21At the time of taking the anterior vagina.
19:25So that accidentally bladder should not be pricked.
19:29And after taking these two continuous.
19:32Now the third one is on the left end.
19:35And then you will take left utero sacral.
19:38And left anterior vaginal aises will be taken.
19:47Bladder will be pushed away.
19:54And this is left side is done.
19:57Once we reach to the left side.
19:59Then we lock it always.
20:02And here it is interlocking.
20:03Just by going with the loop.
20:05And you can put the needle out.
20:06And then you will pull the tail as well as needle end.
20:11And try to slide the first layer.
20:14So that both the edges will be approximated.
20:17And now it is tight enough.
20:20If you have a fore port.
20:22Then assistant can hold the tail.
20:24And now we will start returning back.
20:27During returning back.
20:29We will take both the layers together.
20:32And then we pass.
20:35And every time we lock.
20:37So go through the loop.
20:39And then you can lock it.
20:42So this is the second layer.
20:45Of the suturing.
20:46Which will be done to close the vault.
20:50Here we will make it very tight and secure.
20:53Because we don't want any ascending infection to happen.
20:56Because we have to perform hernia surgery also.
21:02So this is tectomy.
21:04And two hernias.
21:06Will be performed in this patient.
21:09So that's why it's locking is important.
21:11After that we will remove the needle.
21:14Because needle end is small.
21:17So needle has to be removed.
21:19And with tail end is big.
21:21So with the tail end we will tie the knot.
21:24So 5 mm port is enough to take the needle out.
21:29And now you will make a C reverse C.
21:32And with the same starter tail you can terminate the knot.
21:37So these are the first two wraps.
21:39Followed by single opposite wrap.
21:42And this is just a simple sergerous knot.
21:45Again this is reverse C.
21:53And again just single wrap.
21:59And again this is C.
22:03And this is the final knot.
22:05So it's over.
22:11After that we will cut the suture.
22:13And take the suture out.
22:16Now we will start at hernia of the right side.
22:19And this is the approximately 6, 4 to 6 cm lateral.
22:24At 2 o'clock position.
22:27From the outer margin of defect.
22:29We will start dissecting the peritoneal.
22:31Here we will do.
22:33On the right side.
22:34Trans abdominal preperitoneal hernia surgery.
22:37And we can see above is the inferior epigastric vessel.
22:42And slowly this is pulsation of inferior was also visible.
22:47Because here we have the epi lateral port.
22:50So it is little struggling.
22:51With the same three port we are performing.
22:54Same port which we have used for hystectomy is also used for hernia.
23:00And this is slowly slowly.
23:03Inferromedial traction is important on the peritoneum.
23:07So that any transversalis fascia should not cut.
23:11And you can make a transabdominal preperitoneal pocket.
23:17And we have to dissect.
23:19Here we can see this is inferior epigastric vessel above.
23:23This is inferior epigastric vessel pulsation.
23:26And medially we have to reach up to the medial umbilical ligament.
23:31Medial to medial umbilical ligament is not allowed to go.
23:35To prevent the bladder injury.
23:38Now this is lateral dissection.
23:41We will do lateral dissection.
23:45Lateral to the sac.
23:49And it is making lateral pocket.
23:52So this pocket is formed.
23:54So this lateral pocket.
23:59And we may say it is a part of the triangle of pain.
24:03And this preperitoneal pocket is formed.
24:08After that you can make a medial pocket.
24:11And again it will be separated.
24:15And this is the shaft of the left hand instrument.
24:20It is giving inferromedial traction.
24:24And medially you should dissect.
24:26And we should medialize the bladder.
24:28And we should go up to the couper ligament.
24:33So we can see it is reaching up to the couper ligament.
24:41So here is the lighthouse.
24:45So all blunt dissection.
24:49Generally in hernia surgery we never use any sharp instrument.
24:54Entire surgery we perform with the two atraumatic grasper.
24:58And this is the lighthouse.
25:02This is the couper ligament which is found.
25:05So this is the medial dissection is over.
25:09So first we do lateral dissection.
25:11Then we do medial dissection.
25:13And then we do sac dissection.
25:19And bladder injury can happen if you will use any energy for this.
25:23Now this is the sac.
25:25And we will take the sac out.
25:29So as we can see it clearly.
25:32It is lateral to the inferior pegastic vessel.
25:35So that is why it is an indirect hernia.
25:38And take care.
25:39That it should be.
25:41Complete sac should be separated from transversal fascia.
25:45And it should be pulled out.
25:47Means sac should be separated from.
25:50Pseudo sac.
25:52And for that blunt dissection is required.
25:55And slowly slowly you can pull it out.
25:58Just below is the, you know, iliac vessel.
26:03So you should be careful.
26:04And this is the fat at the level of the neck.
26:07And then slowly slowly sac is getting separated.
26:12You have to do ambidextivity.
26:15One hand will pull the sac.
26:16Another will separate the transversal fascia away.
26:20And that is important.
26:23And slowly slowly inferomedial traction will be given.
26:27And sac should be separated.
26:30So we can see here this sac is out.
26:33And after that you should enlarge your pocket to put the mesh.
26:40An entire sac is taken out.
26:43Because this is a female patient.
26:45So there is no spermatic vessel.
26:46The hair is the round ligament.
26:49And sometimes Samsung's arteries are visible.
26:52But this is the round ligament which is separated.
26:57And after that below we can see there we have the iliac vein.
27:04So here is the iliac vein.
27:06This is iliac vein.
27:07And this is iliac artery.
27:09So this is triangle of dome.
27:11External iliac artery and vein is visible.
27:13And this is cupid ligament.
27:15And below is the bladder.
27:17This is a space of radius.
27:19So now this all dissection of the right side of hernia is over.
27:23After that we will put the mesh.
27:27And we will do the peritonization.
27:29We have enough peritonium to do that.
27:32And here we are using the mesh to cover.
27:36So this mesh will be covering the entire myopectenial orifice.
27:42And this mesh is fixed here.
27:46And we will use the tacker.
27:49There are different options.
27:51Here we will use absorbable tacker.
27:53And we only apply normally two tackers.
27:57One complete inferomedially over the cooper ligament here.
28:02This tacker is fixing the mesh with the cooper ligament.
28:06And another extreme superolateral or anterolateral.
28:11This is the on the other corner.
28:16And that's all.
28:17Only two tackers we apply over the mesh.
28:20And after that we will do peritonium.
28:23Peritonial closure has different options.
28:25Suchering and knotting also you can do.
28:27But here we will do double brass technique.
28:30At this point of time the pressure should be decreased to 8 mm of mercury.
28:35So that peritonium should not tear.
28:38And it's a small defect.
28:40So maximum 3-4 tacker will be sufficient to cover the peritonium.
28:46We should never fire any tacker lateral to the medial umbilical ligament.
28:51And left hand should must oppose it.
28:53So it's over.
28:56Inferior apigastic should must be taken care of.
28:59Now we will go for the left side.
29:02And here we will do eye palm directly.
29:04You can use titanium mesh or other composite mesh also.
29:08And directly we will put the mesh.
29:10And we will fix it with the tacker.
29:12So this will be simple eye palm.
29:17And that will take care.
29:18Because it is hardly 1 cm defector.
29:22So this surgery is over.
29:23Thank you very much for watching this video.
29:26This was just a simple case of total laparoscopic hystectomy.
29:32And right sided transabdominal preperitoneal hernia surgery.
29:36And left sided intraperitoneal only mesh repair of the incisional hernia.
29:44So thank you very much.
29:45Have a nice day.
Recommended
12:32
5:36