Single 10mm Port Umbilical Hernia Surgery

Aaradhya Sharma

https://www.laparoscopyhospital.com/SERV01.HTM  This Video demonstrates a Single 10mm Port Umbilical Hernia Surgery performed by Dr. R K Mishra at World Laparoscopy Hospital. Umbilical hernia repair laparoscopic surgery is a minimally invasive procedure that fixes umbilical hernias. An umbilical hernia involves a bulge or pouch that forms in the abdomen. This type of bulge occurs when a section of the intestine or other abdominal cavity tissue pushes through a weak spot in the abdominal wall near the belly button. It can develop in young children and adults.  In rare cases, adults with umbilical hernias can develop a serious condition called strangulation. Strangulation occurs when the blood flow to the herniated tissue is suddenly cut off. This can occur in umbilical hernias that are non-reducible, or can’t be pushed back into the abdominal cavity.  Symptoms of strangulation include nausea, vomiting, and severe pain. The area around the umbilical hernia might look blue as if you have a bruise. The herniated contents could also become nonfunctional and die if they’re strangulated.  The risks of umbilical hernia repair surgery are generally low. However, complications might occur if you have other serious medical conditions. Speak with your doctor if you’re concerned about having an increased risk of complications.  Other risks that are rare may include:  allergic reaction to anesthesia blood clots infection injury to the small intestine or other intra-abdominal structures How do I prepare for umbilical hernia repair surgery? Umbilical hernia repair surgery is usually performed under general anesthesia. This means that you’ll be fully asleep and won’t experience any pain.  Some abdominal hernias can be repaired using a spinal block instead of general anesthesia. A spinal block is an anesthetic drug placed around your spinal cord. It allows you to feel numb in the area of the abdomen being repaired. You’ll be less asleep for this procedure, but you’ll be given pain relieving and sedation medications to keep you comfortable during the surgery.  You’ll likely need to stop taking nonsteroidal anti-inflammatory medications such as aspirin and ibuprofen several days before the surgery. This will reduce your risk of significant bleeding during the procedure.  Fasting for at least six hours before surgery is generally a standard requirement. However, your doctor may give you different instructions before the surgery.

Transcript

00:00hi generally umbilical hernia is performed by three port and umbilical hernia is one of the

00:07most common procedure performed by the general surgeon so welcome to world laparoscopy hospital

00:14and today we will see one new technique and new surgery hello friends this is a case of single

00:20port umbilical hernia surgery where you have used the laparocator this laparocator we have little

00:26bit modified with making a valve and using a washer inside and we have removed the fallop ring

00:33applicator so this is our own design of the laparocator and we are using 45 centimeter

00:42instrument to perform the surgery here so that the tip of the instrument can enough taken out of the

00:48laparocator and as you know in laparocator we have a separate eyepiece for attaching the camera

00:55and with the same hole which is inside we can put the tacker also to fix the mess so this is a our

01:03innovation this is first time in the world we are using single port with the help of laparocator it

01:08is not a single incision in single incision there is a 20 mm incision but here it is a single port where

01:15you will use only 10 mm port and we are using a striker 1688 camera which has a very high resolution

01:22and with the l10 i this light source and we will use pro visc 3d mesh which is polyurethane mesh

01:33it is a small hernia but we will use 15 by 12 size of the mesh to perform the surgery so let us see how

01:40to do we will use misra's point to do the access trans facial fixation of the mess is good idea on the

01:47partners so that mesh will be symmetrically placed and so that with the single 10 mm port we will

01:52perform the surgery this is called misra's point that is 2 centimeter above the costal margin

01:59so normally is palmer's point is 2 centimeter below but here we will put 2 centimeter above the this

02:05is costal margin and we will make a small point 2 centimeter above

02:11and that is called misra's point so how we do that we take a and stretch it down so that it will come

02:19below the costal margin and point the various needle right towards the stomach

02:23and we will go in after that this is the irrigation suction and hanging drop test to confirm that we

02:30are inside the abdomen

02:31then now the tubing of the insufflator will be attached

02:39and we will create pneumoperitoneum the pneumoperitoneum will be created as usual initially

02:45flow rate will be one liter per minute and once the one liter gas has gone inside then we can increase

02:51to three liter per minute so careful slow insufflation will be done and we can see

02:57liver dullness is obliterated and tympanic sound started all over

03:02once the pneumoperitoneum is complete after that we will introduce the trocar

03:08so waiting for preset pressure is used here 15 millimeter mercury

03:13and minimum 1.5 maximum 6 liter of gas will be required depending upon many factors

03:20now variation is removed and trocar is 10 mm port and this is the only port we will use for this surgery

03:25we will not use any other port and that is also in the misra's point so no chance of hernia

03:32because after removal of the port it will go over the rib and even after creating pneumoperitoneum it

03:39go over the rib because it is a stress so it will not hit the rib now we are in and we will introduce the

03:47laparocator laparocator laparocator is 10 mm instrument in which there is a channel

03:54for the instrument and this we have modified it to perform single port surgery

04:00in conventional single incision laparoscopic surgery they are

04:04120 mm port and in that you are using other three port but here

04:08here the same channel has the instrument and same channel has the telescope

04:14so the instrument is 45 centimeter instrument we will use which is used for bariatric surgery

04:20and we can see here the umbilical hernia is visible

04:24and we have little bit modified this laparocator so that instrument can easily go and the vision

04:29will be much better compared to simple telescopes

04:35so this is just the adhesiolysis with the left hand finger we are reducing the content inside

04:41and with the right hand slowly or slowly all the adhesion is separated out

04:47so far it is very easy only thing is that telescope will move with the instrument

04:52so you have to hold the telescope as well as instrument yourself

04:57assistant doesn't have much role in this surgery

05:00and if you will keep it STD then the instrument also will be under your control

05:08laparocator is a device which was used long back by the gynecologist to perform the single incision

05:13tubalization they were using single port tubalization but the same instrument we have modified

05:20and with the 45 centimeter instrument you can use single port surgery

05:24so this is the first time we have performed this surgery i have tried to search in the net there

05:32was no any surgery i could not find out any other surgeon performing single port of course single

05:38incision you can do and laparocator was never used for this surgery before

05:44we have started using laparocator for other procedure also like single port appendectomy

05:48single port ovary and drilling single port other surgery so this is adhesiolysis ergonomically it

05:56is little difficult than the double port or three port but simple procedures you can perform of course

06:02i will not recommend you this single port procedure to perform for advanced hernia surgery or

06:08inguinal hernia surgery but a small eye palm you can easily perform by single port

06:14so slowly slowly a stripping technique this is all this is a finger you are seeing this is our finger

06:21from above pressing so that you all the content is out and now we can see hernia is nicely visible

06:29and this is this is the hernia and this is the finger you can palpate and you can see the strips of

06:36the hernia after that mesh will be introduced with the same port and this is trans facial fixation of the

06:42corner of the mesh with the cobbler's needle you can do trans facial fixation one of the most

06:50important advantage of using trans facial fixation is that you don't have to be you know worry about

06:58the symmetry of the mesh it will bilateral symmetrically placed and other advantage is that

07:04you need less number of tackers so this is the cobbler's needle and we have already marked it before

07:12the corners was marked before the surgery itself and corners of the suture is pulled out with just

07:19one millimeter stab wound that not doesn't need any dressing post-operatively and you can just put a

07:25new aspirin powder and you can try to just rub it over to make a scar so most remote corner will be fixed

07:34first after that you can use so here we are using the right hypochondrium then right iliac fossa then left

07:42iliac fossa and last is the left hypochondrium you can see here the vision is not bad even with this

07:49laprocator and this laprocator already telescope and the instrument both is going with the same 10 mm

07:59so the telescope has effective only less because 5 mm will be taken by the

08:04instrument only so remaining you know diameter for the this telescope will be only 5 mm so the field of

08:12vision is small you can see as that it is not covering the entire screen it is only taking central

08:19part of the screen just like how the hysteroscope or hysteroscope is accumulating only central part of

08:25the skin but the vision is not bad and strikers 1688 camera is a 4k camera so resolution of that camera is

08:34also very good so you can perform it with the good vision and all the corners are getting transfixed as

08:42you know that transfixation of the trans facial fixation of the mesh need to go with the same

08:48skin prick and different facial prick and this instrument also sometime is controlling it and then

08:55it is coming out so this instrument channel is guiding sometime in the direction and then all the corner is

09:04fixed is fixed and after that tacker also will be introduced with the same laprocator the size we have

09:12little bit modified and we have attached a washer in the back of laprocator so that gas will not leak

09:17and instrument will be stable so this is now all the corner is transfacial fixation is done and after that

09:26here we will introduce the tracker so this is just stabilizing the sutures all around so that right

09:35now the suture is not tied outside it is only held by the artery forceps and then we will pull and push

09:41every corner to make the mesh bilateral symmetrical so that it will not be shagging down and it should

09:47be uniformly pulled up and once the corner sutures are fixed with the artery forceps then this is the

09:53tacker and then we will do the outer crowning as well you can see this is outer view this is the

09:59laprocator and tacker is also going and with the left hand you will stabilize the abdominal wall to keep

10:05the tacker perpendicular and then with the same laprocator you can fire the tacker and you can fix the

10:12mesh so this is a very innovative technique and patient has very faster recovery patient can discharge

10:19same day and you have the less pain also and this is fixation of the tacker by pushing the

10:27and fixing with the abdominal wall finger so that it should be perpendicular

10:31and here it is the outer crowning after outer crowning you will do inner crowning

10:37and this is a polyurethane mesh polyurethane mesh this is lotus 3d pro visc mesh it has dual mesh

10:45and the blue color is the polyurethane which we keep towards the bovel and white color is polyester

10:52which we keep towards the anterior abdomen wall pro visc 3d mesh is very good and we are using it for

10:59long time and it has a very good outcome it is not too much expensive also and these are few of the

11:06tackers for inner crowning and in this you when you go to fire the tacker your instrument also should be

11:13pushed together with the tacker this is the only difference between the two port and this is a

11:19single port single incision laparoscopic surgery is not the single port surgery in single incision

11:26actually 20 mm incision is required and then sills port is required but this is just a single port

11:33where 10 mm port is used with the laprocator and this is now outer crowning is done

11:40a little bit more inner crowning you can perform all around this one can be discharged same day

11:46after surgery we will put a small ball over the obliques to press the you know the shack and then

11:52we will fix it by the strapping and elastic adhesive so that it will give as a abdominal support

12:01for at least one week after that we can remove it

12:04and it is rare recurrence because it's a very small hernia and they are 15 by 20 size of the mesh is

12:11used so we can do the entire surgeries performed similarly as we do by two port or three port the

12:18vision is not compromised the transfixation is not compromised and mesh is nicely symmetrically placed all

12:27around so thank you very much for watching this video this was just a simple case of the umbilical

12:34hernia where a single instrument and 10 mm port is used to perform the entire surgery thank you very

12:42much for watching this video have a nice day thank you

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