Laparoscopic Repair of LeftSided Complete Indirect Inguinal Hernia Skin to Skin Surgery Video

Aaradhya Sharma

https://www.laparoscopyhospital.com/SERV01.HTM  Laparoscopic Repair of Left-Sided Complete Inguinal Hernia: An Overview for Surgeons. Inguinal hernias are among the most common conditions managed in general surgery, with left-sided complete inguinal hernias presenting unique challenges and considerations. The laparoscopic approach has gained popularity due to its minimal invasiveness, reduced postoperative pain, and quicker recovery times compared to open repair methods. This article explores the laparoscopic repair of left-sided complete inguinal hernias, highlighting the techniques, benefits, and outcomes based on current surgical practices and research.  Understanding Left-Sided Complete Inguinal Hernia A left-sided complete inguinal hernia occurs when abdominal contents protrude through the inguinal canal on the left side of the groin. These hernias can be direct, where the hernial sac pushes through a weak spot in the abdominal wall, or indirect, where the hernia follows the pathway that the testicles made during pre-birth development. Complete hernias are those that have traversed the entire inguinal canal.  Indications for Laparoscopic Repair Laparoscopic repair is particularly indicated in patients who prefer a cosmetic solution with minimal scarring and those requiring a faster return to daily activities or work. It is also advantageous in bilateral hernias or in the recurrence of a hernia after open repair.  Surgical Techniques Preoperative Preparation Patients undergo a thorough preoperative assessment including a detailed history and physical examination, alongside imaging studies if required. Preoperative instructions typically include fasting and the administration of prophylactic antibiotics.  Operative Procedure The laparoscopic repair of a left-sided inguinal hernia generally follows these steps:  Anesthesia: General anesthesia is commonly used to ensure patient comfort and muscle relaxation, which facilitates the creation of the pneumoperitoneum.  Access and Port Placement: Three incisions are typically made in the lower abdomen to insert the laparoscope and surgical instruments. The camera port is usually placed at the umbilicus, with two working ports placed laterally.  Creation of Pneumoperitoneum: Carbon dioxide is insufflated into the abdominal cavity to enhance visualization and provide space for instrument manipulation.

Transcript

00:00hello friends this is a case of complete indirect inguinal hernia this

00:07patient has left sided complete inguinal hernia since childhood and the

00:13content we are going to the scrotum so we will do the laparoscopic repair by

00:20transabdominal prepaternally repair and here we will use ipsilateral port

00:25generally I perform the inguinal hernia surgery ipsilateral port that gives us the

00:31better ergonomics although sometimes shorting of the instrument happens but

00:36that can be minimized if you will use the two graspers and you do the blunt

00:41dissection we generally give only sharp dissection to peritoneum and then all

00:46the separation of sac and the lateral and medial dissection we do by two atraumatic

00:52rasper so here various needle is introduced and pneumopetoneum is started

00:57and here we are using preset pressure 15 waiting for actual pressure to reach to

01:04the preset pressure pneumopetoneum is created now and now we will enlarge the

01:09incision and we will put the first port here we have to stand near the right

01:15shoulder and the camera person will be almost near the head of the patient so

01:20that he can not interfere in your movement so this is the trocar generally we

01:26apply little betadine over the cannula so that any port site infection can be

01:31minimized so now the tubing of the insufflator is inserted and now the flow

01:38rate is increased to maximum flow rate to 10 liter per minute now we will enter

01:42inside here we can see this is the complete inguinal scrotal large hernia sack and we are

01:48inside the sack to show you and sigmoid colon is also adhered so we will start from the

01:55medial umbilical ligament and slowly we will go up to 10 o'clock position we can

02:00see here in front of us there is inferior epigastic vessel so you should cut the

02:04plutonium this is inferior epigastic vessel so we should cut the plutonium in

02:09such a way that inferior epigastic vessel should not be injured and these are two

02:14ipsilateral port ipsilateral port are little difficult little swadding happens but your

02:20movement is and your arm is fully adducted so this is started at median umbilical medial

02:27umbilical ligament and then it will go at 10 o'clock position and here we are using harmonic

02:32to cut the plutonium you may use scissors and some people they even use hook also and now

02:38we will go little down so that lateral dissection will be easy so incision is over and after that

02:47there is no need of any scissors or any other instrument we will just use two atraumatic

02:52rasper to do all the dissection so this only petonial incision is given by the sharp dissection

03:00or either by the scissors or with the harmonic now first we will do the lateral dissection over

03:06the triangle of pain and left hand will pull the plutonium and right will do the separation of the

03:13transversalis fascia so this pocket has to be made it is better to make a bigger pocket rather than

03:20bigger incision so this is separating and making the pocket laterally

03:31so inferomedial traction will be given to the plutonium and blunt separation of the transversalis fascia will

03:42be done and this is now you can see the nerve also is visible and this is the triangle of pain dissection

03:49is over sigmoid doesn't need to be touched once you will separate the plutonium sigmoid will retract itself

03:56now this is medial dissection to the sac and then we will medialize the medial umbilical ligament and

04:02medialize the bladder bluntly to find out the cooper ligament that is the pectineal ligament and

04:09slowly slowly by the two grasper it is separating the medial umbilical ligament and mobilizing the

04:16bladder more medially and here we can see lighthouse that is the cooper ligament started visible

04:23this is the pectineal ligament or cooper ligament and space of radius also is visible

04:29so this is also called lighthouse so after lateral and medial dissection now this sac dissection is just

04:35started and slowly slowly you should hold it nearer to the plutonium and with the right hand you can

04:42push the transversalis fascia this is inferior epigastric vessel above so it is a indirect hernia

04:48so it will be lactal to inferior epigastric vessel care should be taken that you should not use

04:54maryland maryland often creates

05:04maryland often creates the button hole in the plutonium so with two atraumatic rasper we should

05:11try to separate the sac in cases of complete indirect inguinal hernia there is a tendency of the testes

05:20to come into the inguinal canal so it is better that you ask one assistant to hold the testes back

05:26into the escrotum he will keep it holding it so that when you pull it should not displace into the

05:32canal so this is now we can see this is puckering and that is the complete sac

05:40so slowly slowly ambidexity is required and by manually you can start pulling the sac

05:47taking care of that vas and spermatic vessels should not be injured

05:58so this is separating now and sac is slowly coming out

06:04in complete inguinal escrotal hernia as soon as your grasper will leave this sac has a tendency to go

06:10back into the canal so this is very important that you should remain as nearer as possible to the

06:17plutonium and try to separate the transversalis fascia away from that

06:23so in this we put the port one port supra umbilical and another port 7.5 centimeter lateral and below the

06:41umbilicus on the right side and again another 7.5 centimeter lateral and below

06:47and you can see this is a sac which is coming out and slowly you will separate it from transversalis fascia

06:58but in case of the complete inguinal escrotal hernia it is not very good to separate the entire sac

07:05that will unnecessarily you will do a lot of a struggle so we are separating it and then it should

07:10be separated from vas and spermatic vessel so you have to make a window just below it

07:17here you can see vase and spermatic vessel is pushed down and a window is created in between

07:22the vase and the sac after that we will just cut it with the harmonic scalpel and then remaining

07:30transversalis fascia will be left into the escrotum so this is now the maximum you know

07:40separation of the sac is over and here we can see this is transversalis fascia

07:45which is very tightly adhered and it will not be separated so in those situation it is not wise to

07:52just try to retract it anyhow otherwise you have a lot of seroma and unnecessarily you have a uging

08:00so now this is a vase and a spermatic vessel which is separated from the sac

08:05and now we will cut it here with the harmonic scalpel

08:13you may use scissors also take care that the sac which is going in the escrotum should be open

08:20it should not be sealed by the harmonic you may use rodders not also here but here because we are using

08:27harmonic and now we can see again we are going into the sac and now there is no peritoneum inside the

08:34defect you can see only transversalis fascia so that means there is no bleeding no oozing

08:40further dissection will be done on the triangle of dome so at least six centimeters this is the sac

08:45is reverting and you will pull it out and then further dissection of the triangle of dome should be

08:52done so that at least six centimeter all around the margin of the defect you have a pocket to spread

08:59the mesh nicely and mesh should not be crumbled so this is the triangle of dome dissection and it is

09:07peytonium pocket is pulled down it is at the level of the iliac vessel so you have to be careful

09:13if you have some septa on the space of ball gauss or if you have any lateral dissection that also should be

09:21completed we can see the lfcn nerve is also visible

09:26so pocket is enlarged sigmoid will automatically drop with the your peytonial dissection you don't

09:33need to separately immobilize the sigmoid colon and now this is the triangle of doom

09:38so dissection part is over and now we are ready to put a mesh here so this is the spermatic vessel

09:46vast difference this is triangle of pain triangle of doom trebuchad of disaster now we are using here

09:52polypropylene mesh and this mesh will be introduced and it should

10:04mesh should be nicely esterated it should esterated all around so that it should not crumble and you can

10:10push it over the pockets of the peytonium and this is super lateral and super inferior inferior

10:19medial all has to be separated so that it should cover the entire myopectinial orifice

10:26and it should go all around and center of the mesh should be in the center of defect

10:31that is important so that recurrence will not happen and this inferomedial end of the mesh we are seeing

10:37it is over the pectinial ligament and that is lighthouse and then we will fire the tracker

10:44generally we use only two tracker because excessive tracker will you know create the pain also

10:50and it doesn't have any advantage so many of the literatures are showing that no fixation is also

10:58good but we generally fix two tackers one inferomedial on the cooper another supra lateral over the arc of

11:05transversus abdominis so here we are using the covedian pro tack that is a titanium tacker and it is the first is

11:13fire over the pectinial ligament and now the second is over supra lateral over the arc of the transversus

11:22abdominis and this will be pushed and it should be fired over the your finger so that you can give the

11:29counter and then fire and now the pressure will be decreased to eight millimeter of mercury and this

11:35by double brushing technique we will fix the peritonium above this is fixing over the rectus abdominis take care

11:41of infiapigastic we are medial to infiapigastic air and infiapigastic is visible after that you can go

11:49supra lateral and lateral to infiapigastic here we are using the extra petroleum which came out with

11:56the sac that also will help you to reinforce the peritonization of the entire defect take care that

12:04accidentally you should not fire over the infiapigastic vessel and the pressure of the pneumo

12:09plutonium should be only eight millimeter of mercury pressure because it will not tear here we can see

12:16this is below is a sigmoid right now percent is head down and left up once the percent will become

12:22supine then this sigmoid will also help you to this is sigmoid it is also will help you to press over the

12:28plutonium so this is now fixed laterally medially everywhere any part of the mesh should not be visible

12:37and now surgery is over and slowly you should reduce the gas and under vision you will see that now this

12:43sigmoid is reinforcing the your peritonial repair so thank you very much for watching this video

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