philnamba
Contributor
Any guidence?
PROCEDURE:
The patient was taken to the operating room after emptying her urinary
bladder in the preoperative area. She was placed in a supine position on a
standard operating room table. Time out was done. She was administered a
suitable general anesthetic. The abdomen was then prepped with Hibiclens.
This was allowed to dry. An Ioban drape was then placed. The abdomen was
then squared off widely. Starting on the left anterior axillary line at
the level of the umbilicus, a small area was anesthetized with Marcaine
0.5% with epinephrine. The skin was incised transversely, and a disposable
Veress needle was inserted through the incision into the peritoneal
cavity. Saline drop test initially appeared to show adequate position, but
it was apparent it not in the peritoneal cavity. A left subcostal site
was then selected just lateral to the mid clavicular line. Again, Marcaine
was infiltrated. The skin was incised transversely, and a disposable
Veress needle was inserted easily. Again, saline drop test did confirm
appropriate position. CO2 was then allowed to insufflate the peritoneal
cavity. After creating an adequate pneumoperitoneum, the Veress needle was
removed, and a disposable bladed 5 mm sharp port and trocar assembly with
a balloon was inserted. The laparoscope was then introduced, and we
performed the abdominal exploration laparoscopically. A bariatric 5 mm
sharp port was then placed in the initial Veress needle site under
laparoscopic visualization. The balloon on the port was inflated, and the
height was adjusted with the O-ring.
A right upper quadrant port was then placed in the lateral subcostal area
again using the same technique.
Working through the left subcostal port, I attempted to reduce the small
bowel from the main hernia unsuccessfully after several attempts. I then
proceeded with the open portion of the procedure. Incision was made over
the right lower quadrant hernia with scalpel. The incision was made
transversely and then extended through the subcutaneous tissues and dermis
with cautery. Cautery was used to control bleeders. The incision was
extended down to the hernia sac, which was dissected from the surrounding
subcutaneous tissue circumferentially. The hernia sac was then opened and
small bowel was adherent to the surface of the sac where it was carefully
lysed as was omentum. Omentum extended into the smaller hernia defects
cephalad and medial to the main defect. Again, there were at least four of
the small defects that were opened and reduced. A partial omentectomy was
carried out with the cautery. After clearing the peritoneum around the
main hernia defect as well as the smaller defects, we prepared a
Ventralight ST mesh and placed this in the wound and closed the fascia
with interrupted figure-of-eight stitches of #1 Prolene. Then reinserting
the scope, it was apparent that the left subcostal port was in the colon,
and adhesions were lysed in order to expose the area of the injury. The
adhesions were taken down on the left mid and upper abdominal wall using
LigaSure with adequate hemostasis. The colotomy and the anterior surface
of the bowel was then identified. It was grasped with Maryland clamp. The
5 mm port was exchanged for a 12 mm sharp port after lengthening the
incision, and an Endo GIA 45 mm staple length, 3.5 mm staples were was
then placed across the base of the colotomy and fired and closed. A small
portion of the colotomy wound was then removed.
Because of the injury to the colon, the hernia defect was opened. Those
sutures were removed, and the Ventralight mesh was removed. The colon was
then brought up through the operative field, and the other defect in the
lower portion of the bowel wall was identified. This was closed with
interrupted stitches of 2-0 Polysorb and then imbricated with 3-0 silk
interrupted stitches. The staple line from the GIA was also imbricated
with interrupted stitches of 3-0 silk. The bowel was then returned to the
peritoneal cavity.
We then selected a XenMatrix graft. This was cut to the appropriate size
to cover all the defects. It was then placed into the peritoneal cavity
after placing stay sutures of 2-0 Prolene. The corresponding sites of the
abdominal wall were marked. Again, the defect at the large hernia was
closed again with interrupted stitches of #1 Prolene. Stab wounds were
then placed for the stay sutures. They were grasped with the Endo close
instrument and brought out through the abdominal wall. We then tried to
affix the graft to the abdominal wall. However, both the SorbaFix and endo
tacks were not able to penetrate the graft and secure enough purchase in
the abdominal wall. An endostapler was then applied, and the lower portion
of the mesh was secured to the lower portion of the abdominal wall.
Attempts to bring the mesh up and close this to the cephalad portion of
the mesh, however, was not successful. Therefore, an epigastric incision
was made, and using 0 Prolene, the mesh was secured to the abdominal wall
in interrupted fashion. This way the mesh completely covered all the
hernia defects. This wound was then closed with figure-of-eight stitches
of #1 Prolene. We then reintroduced the pneumoperitoneum and inspected the
mesh. Some adhesions of fatty tissue and omentum were included in the
closure of the mesh. These were carefully taken down fairly easily. The
left upper quadrant subcostal port defect was then closed with 0 Polysorb
using Carter-Thompson closure device. After assuring adequate hemostasis,
the final ports were removed. CO2 was allowed to escape the peritoneal
cavity before removing the final port. The subcutaneous tissue in the
right lower quadrant hernia defect was approximated with interrupted
stitches of 2-0 chromic. All the wound edges of all the port wounds and
epigastric wound were closed with skin staples. Telfa and Tegaderm were
then used to dress all the incisions. An abdominal wall binder was placed.
The patient was returned to recovery in satisfactory condition. She
tolerated the procedure well.
The patient will be admitted to the hospital for IV antibiotics. She has
been receiving both Ancef and Flagyl, which we will continue for the next
few days. We will await bowel function before starting her diet. I will
inform the patient regarding the iatrogenic colotomy as well as placement
of the XenMatrix mesh. Possibility of recurrent hernia is significant. I
will discuss this with her further.
PROCEDURE:
The patient was taken to the operating room after emptying her urinary
bladder in the preoperative area. She was placed in a supine position on a
standard operating room table. Time out was done. She was administered a
suitable general anesthetic. The abdomen was then prepped with Hibiclens.
This was allowed to dry. An Ioban drape was then placed. The abdomen was
then squared off widely. Starting on the left anterior axillary line at
the level of the umbilicus, a small area was anesthetized with Marcaine
0.5% with epinephrine. The skin was incised transversely, and a disposable
Veress needle was inserted through the incision into the peritoneal
cavity. Saline drop test initially appeared to show adequate position, but
it was apparent it not in the peritoneal cavity. A left subcostal site
was then selected just lateral to the mid clavicular line. Again, Marcaine
was infiltrated. The skin was incised transversely, and a disposable
Veress needle was inserted easily. Again, saline drop test did confirm
appropriate position. CO2 was then allowed to insufflate the peritoneal
cavity. After creating an adequate pneumoperitoneum, the Veress needle was
removed, and a disposable bladed 5 mm sharp port and trocar assembly with
a balloon was inserted. The laparoscope was then introduced, and we
performed the abdominal exploration laparoscopically. A bariatric 5 mm
sharp port was then placed in the initial Veress needle site under
laparoscopic visualization. The balloon on the port was inflated, and the
height was adjusted with the O-ring.
A right upper quadrant port was then placed in the lateral subcostal area
again using the same technique.
Working through the left subcostal port, I attempted to reduce the small
bowel from the main hernia unsuccessfully after several attempts. I then
proceeded with the open portion of the procedure. Incision was made over
the right lower quadrant hernia with scalpel. The incision was made
transversely and then extended through the subcutaneous tissues and dermis
with cautery. Cautery was used to control bleeders. The incision was
extended down to the hernia sac, which was dissected from the surrounding
subcutaneous tissue circumferentially. The hernia sac was then opened and
small bowel was adherent to the surface of the sac where it was carefully
lysed as was omentum. Omentum extended into the smaller hernia defects
cephalad and medial to the main defect. Again, there were at least four of
the small defects that were opened and reduced. A partial omentectomy was
carried out with the cautery. After clearing the peritoneum around the
main hernia defect as well as the smaller defects, we prepared a
Ventralight ST mesh and placed this in the wound and closed the fascia
with interrupted figure-of-eight stitches of #1 Prolene. Then reinserting
the scope, it was apparent that the left subcostal port was in the colon,
and adhesions were lysed in order to expose the area of the injury. The
adhesions were taken down on the left mid and upper abdominal wall using
LigaSure with adequate hemostasis. The colotomy and the anterior surface
of the bowel was then identified. It was grasped with Maryland clamp. The
5 mm port was exchanged for a 12 mm sharp port after lengthening the
incision, and an Endo GIA 45 mm staple length, 3.5 mm staples were was
then placed across the base of the colotomy and fired and closed. A small
portion of the colotomy wound was then removed.
Because of the injury to the colon, the hernia defect was opened. Those
sutures were removed, and the Ventralight mesh was removed. The colon was
then brought up through the operative field, and the other defect in the
lower portion of the bowel wall was identified. This was closed with
interrupted stitches of 2-0 Polysorb and then imbricated with 3-0 silk
interrupted stitches. The staple line from the GIA was also imbricated
with interrupted stitches of 3-0 silk. The bowel was then returned to the
peritoneal cavity.
We then selected a XenMatrix graft. This was cut to the appropriate size
to cover all the defects. It was then placed into the peritoneal cavity
after placing stay sutures of 2-0 Prolene. The corresponding sites of the
abdominal wall were marked. Again, the defect at the large hernia was
closed again with interrupted stitches of #1 Prolene. Stab wounds were
then placed for the stay sutures. They were grasped with the Endo close
instrument and brought out through the abdominal wall. We then tried to
affix the graft to the abdominal wall. However, both the SorbaFix and endo
tacks were not able to penetrate the graft and secure enough purchase in
the abdominal wall. An endostapler was then applied, and the lower portion
of the mesh was secured to the lower portion of the abdominal wall.
Attempts to bring the mesh up and close this to the cephalad portion of
the mesh, however, was not successful. Therefore, an epigastric incision
was made, and using 0 Prolene, the mesh was secured to the abdominal wall
in interrupted fashion. This way the mesh completely covered all the
hernia defects. This wound was then closed with figure-of-eight stitches
of #1 Prolene. We then reintroduced the pneumoperitoneum and inspected the
mesh. Some adhesions of fatty tissue and omentum were included in the
closure of the mesh. These were carefully taken down fairly easily. The
left upper quadrant subcostal port defect was then closed with 0 Polysorb
using Carter-Thompson closure device. After assuring adequate hemostasis,
the final ports were removed. CO2 was allowed to escape the peritoneal
cavity before removing the final port. The subcutaneous tissue in the
right lower quadrant hernia defect was approximated with interrupted
stitches of 2-0 chromic. All the wound edges of all the port wounds and
epigastric wound were closed with skin staples. Telfa and Tegaderm were
then used to dress all the incisions. An abdominal wall binder was placed.
The patient was returned to recovery in satisfactory condition. She
tolerated the procedure well.
The patient will be admitted to the hospital for IV antibiotics. She has
been receiving both Ancef and Flagyl, which we will continue for the next
few days. We will await bowel function before starting her diet. I will
inform the patient regarding the iatrogenic colotomy as well as placement
of the XenMatrix mesh. Possibility of recurrent hernia is significant. I
will discuss this with her further.