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General Surgery Specialty
General Surgery (General) Subspecialty
Hernia Surgery Subspecialty
Mayo Clinic
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Past Notes
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<v ->My name is Dr. Michael Edwards.</v>
I am a Senior Associate Consultant
and Associate Professor at the
Mayo Clinic in Jacksonville, Florida.
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Our first patient today is going to be a 70 year old
gentleman with a symptomatic left inguinal hernia.
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We suspect that he may also have
a right sided inguinal hernia.
Nothing was felt on examination,
but he does describe some intermittent groin discomfort.
So we plan to explore both sides at the time of surgery.
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So we're gonna first, based on landmarks,
that's the xiphoid.
costal margin on the left,
costal margin on the right.
Pubis.
So we measure about 15, 20 centimeters
from our target organ.
So that is 15,
that is 20 centimeters.
Sometimes we use our hand as measurements.
The width of my hand is about eight centimeters.
So about eight centimeters off mid line,
And the right and left.
Our initial axis is gonna be via various needle
about eight centimeters from the the xiphoid,
laterally in about a finger width below the costal margin
our palmers point.
So about there.
So we just want to demonstrate that exaggerated drop test.
So plunger out, and you can see free flow fluid.
So we're pretty comfortable with that space.
<v ->Gas? Yes.</v>
<v ->Towel clip.</v>
Connect.
I'm gonna start pressure
<v ->15, 13.</v>
<v ->Yeah, so initial pressure three.</v>
Perfect. So we're in a good spot. Then we'll wait
for the abdomen to insufflate.
So we just below.
All right, let's hand it off to you, you ready?
So we use the eight millimeter optiview trocar.
Oh what a pre peroneum with that.
And there's peroneum,
and we are safely inside the abdomen.
So place in our lateral trocar on the right hand side
about eight centimeter lateral to our mid line trocar
and we're gonna proceed with docking.
Okay, here's your target. Towards the feet.
<v ->Okay</v>
<v ->Straighten up a little bit.</v>
Perfect.
So we target just in case
we need to change position
while the patient still docked to the robotic system.
So now we are docking the remaining arms.
So this is the gentleman that has a left sided
inguinal hernia that we care to see here.
We thought may also have a right sided inguinal
hernia based on examination and it does
in fact have a small right sided inguinal hernia.
So the first thing we do is inside our peroneum
about five centimeters above our defect.
Some outline in where we want inside our peroneum.
We're gonna incise just middle flow are
medium like a ligament.
We want it inside his perineum.
Step number one is really creation of our perineal flap
which we are doing here.
key with this is to make sure
that you stay just on top of that...
peritoneum.
Sometimes it is difficult to differentiate the peritoneum
from the pararectal fossa.
I find that one of the benefits
of doing these cases robotically....
is the view and be able to do most of this dissection
sharply with pottery and maintaining hemostasis.
So we're developing that preperitoneal flap,
immediately working our way towards pubis
and cooper's ligament.
There's no evidence of a direct hernia so far.
Camera view is still 30 up.
Find that this provided the best exposure
at this point in the case.
So once you're in the plane
much of the dissection can just be done
with gentle blunt dissection.
I like the curette because it maintains hemostasis.
So that's our pubis.
So now we're gonna extend dissection from medial collateral
and proceed to reducing our direct angular hernias sac.
So as we medialize our hernias sac
we are trying to find our core structures.
It seems to be coming in there.
We're trying to identify our gonadal vessels.
I find that the bipolar is very helpful for this dissection.
Allows you to maintain some hemostasis.
So there's our hernia sac.
Going into our deep inguinal ring
surrounded by quite a bit of hernial fat.
This is clearly a chronically incarcerated hernia sac.
We're gonna continue with medializing the hernias sac
until we plant our vas deference.
There's our gonadal vessels.
there's our vas.
Now that we've identified our vas.
We'll see if we can go ahead and reduce
the hernia sac itself
on the deep inguinal ring.
The difficulty here is just the extent of
pre perineal fat that we're having to deal with,
but again there is the edge of peroneum.
So we're gonna go ahead and expose pubis,
and cooper's ligament further
and then we'll complete a lateral dissection.
I'm gonna dissect our peritoneum SECALAB,
all our space for our...
mesh placement.
To provide a little bit of a better exposure
and safer perspective, we're gonna change our camera
to 30 down.
Starting to take advantage of using the robotic systems
for these cases is the exposure,
the extent of dissection that you can perform,
allowing you to place a larger piece of mesh
which I do think correlates with lower risk of occurrence.
Again, there's your vas deference,
quite a bit of visceral adiposity
above (inaudible) that you're seeing.
All right, so this completes our myopectineal dissection.
On the left you can see...
pubis,
coopers...
our bladders down here.
That's our space of red. Yes, that is dissected.
You can see our vas deference of vanital vessels.
That is our triangle of doom
formed by the vas difference immediately.
Then our vessels laterally the inferior edge
of the peritoneum interiorly
and that's our iliac artery,
pulsating away.
Our iliac vein is gonna be just behind
our vas difference here.
So before we proceed to the opposite side
I also like to create a little bit of a superior flap
on the peritoneum to accommodate the mesh size.
Gonna incise peritoneum again, few centimeters above.
We're gonna connect our dissection immediately.
The peritoneal dissection from the other side.
All right, so no direct hernia.
Epigastric is here.
We're gonna connect our left and right medial dissection.
This is a very high abdominal wall hernia.
Looks like our are another severe.
The vas is going to be there.
I like for Cooper's ligament to be exposed because
we do do suture fixation to coopers and to pubis.
Our iliac vein.
All right, we'll create our superior flap and then we'll
be done with our bilateral dissection.
So now our dissections are complete,
we're gonna proceed with...
Mesh appear.
I use PDS sutures for fixation of the mesh.
So several hernias can occur in this space where shown two
types of hernia.
This is quite and indirect link to abdominal wall hernia
like your deep inguinal ring is here
and the hernia is a little bit higher in the abdominal wall.
But this will be the indirect hernia space
direct medial to the epigastric and above
the umbilical tract.
Between umbilical trap and coopers will
be a femoral space.
You can see the iliac vein going into the femoral canal
and then below coopers will be operator face space.
You can see your operator canal there.
So I use hairteen all my robotic and more hundred appears.
It is a synthetic uncoded mesh.
So we're gonna position the mesh immediately first,
particularly for direct hernias, we wanna
make sure you have very good overlap to pubis.
In this case, this is a direct hernia.
So we're gonna focus on the lateral coverage.
I make sure we have adequate coverage inferiorly
and now that mesh is in front of the edge
of our peroneum and there is our mesh.
Very nice and deep.
Excellent.
So we always put a little bit of a curve
on the lateral aspect of the mesh to make sure
that this contour to fit this space we've dissected.
There is our indirect hernia with excellent coverage
of mesh at least five centimeters below.
There is no direct hernia but we still
have adequate coverage of both the femoral space
direct more hundred space as well as apyretic canal.
Now some surgeons will not do any fixation at all.
Some surgeon will use glue.
I like to use sutures for fixation.
Fix the coopers.
You can see the extended dissection
that this robotic platform that allows us to perform.
So media like to fix the coopers
as well as to the pubis, which was there right here.
All right. Here we'll fix the middle line
just above the pubis.
Sometimes when these needles are being taken out
we have an eight millimeter trocar.
The tip can get caught and suture can break
and you can potentially lose the needle.
So I straighten the needle out
fix the mesh immediately and securely.
Lower fixation, you wanna make sure that you are
above the cubic tract to prevent nerve entrapment.
All right.
So our mesh appears completed on this left hand side.
Mesh is well positioned to cover
all of mypec into the orps.
And all potential hernia sites.
The same thing.
We're gonna go ahead
and position the medial aspect of the mesh first.
And the dissect space is a perfect fit for the mesh.
For dissected space.
So We'll get that mesh
into that space that is deep to the edge of the peroneum.
Our small hernia is there.
So I wanna make sure we have adequate coverage.
We're most concerned
about our lateral coverage given the type of hernia here.
So I wanna make sure we fix the mesh laterally here
in a position that we're happy with.
Again, I'm not sure we are above the umbilical track.
Good overlap there.
That's pretty good.
Gotta put us a little bit higher because of
where that hernia is,
but we have a very good overlap.
All right, so mesh appears complete on this side.
So then we're gonna go ahead and re pertinalize
our peritoneum.
So we'll start laterally.
I use that tool V lock
absorb the suture as you can see here.
So a mesh appear on the left hand side.
Okay,
Looks good.
We'll do the same thing where you approximate our
peritoneum.
All right, so that completes our bilateral
robotic consist trans abdominal preparing to appear
of inguinal hernias.
So para name is completely approximated on the right
completely approximated on the left.
The same thing.
Never choke car up.
(not audible) if can see abdominal wall.
Okay all the trcors out.
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