Maricela123@gmail.com
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I need help in the following scenario: Preoperative diagnosis: Recurrent incarcerated strangulated left inguinal hernia._. Postoperative diagnosis: Recurrent sliding incarcerated strangulated left inguinal hernia. Recurrent right inguinal hernia. Umbilical hernia._ Procedure: Open robotic assisted repair of the left inguinal hernia with mesh. Assistant: none Anesthesia: General Endotracheal Anesthesiologist/CRNA: please, see anesthesia documentation. EBL:...2... ml Specimen: Hernia sac Complications: none Implants large 3D max mesh lightweight Findings: Giant sliding recurrent left inguinal hernia. No recognizable tissue planes. Overall very difficult procedure to take about 6 hours, high risk of complications. Indications: 49-year-old male_ with a clinical picture of incarcerated and strangulated left inguinal hernia _We discussed the natural course and management of the disease. We discussed indications for, including risks and benefits of a surgical procedure. We discussed possible complications, including infection, bleeding, damage to surrounding tissue, hernia at the incision site. The patient agreed to proceed with and signed the informed consent. Details of the procedure: The patient was identified in the holding area and brought to the operating room and positioned supine on the operating table. Sequential compression devices were applied to bilateral lower extremities to prevent deep venous thromboembolism. Subsequently, anesthesia was initiated without any complications. The surgical area was prepped and draped in a regular sterile fashion. TIME OUT: Immediately prior to procedure, time out was performed to include correct patient, agreement on the procedure to be performed, correct side, site, position, accurate procedure consent, relevant images, antibiotics, fluids. Everybody agreed. *** Incision was made above the umbilicus. Hernia was left intact. Abdominal cavity was entered and balloon trocar was placed. An additional 2 robotic trocars were placed in the right and left subcostal regions. Assistance 5 mm trocar was placed in the right lower quadrant. Robot was docked. Patient was positioned head down. There was obviously incarcerated small bowel in the hernia. By applying the traction to the bowel and external pressure, after some manipulation I was able to reduce the small bowel. Overall it appears viable, somewhat bruised but no evidence of any necrosis. After reduction of the bowel, the hernia became quite smaller however the rest of the hernia was sliding 1 with sigmoid: Completely disappearing in the hernia. There was reducible right inguinal hernia as well. I started with dissection in attempt to reduce the sliding inguinal hernia. There was a lot of scar tissue in the medial aspect of the dissection plane probably related to previous MAC of a repair. I was able to mobilize the colon off the retroperitoneum on the left side, however the part that was going inside the hernia opening I was not able to mobilize because of the very large size of the hernia and a lot of scar tissue on the medial side. I was able to identify iliac vessels and spermatic cord. Spermatic cord was distributed in the very thick and scarred area and it was difficult to dissected safely. After multiple attempts and significant amount of time spent, I decided to convert to open. The robot was undocked. Incision was made in the left inguinal area and carried down. Hernia sac was identified. It was dissected off the surrounding tissues and of the scrotum. Spermatic cord was identified in the scrotal part where it was intact and traced up to the internal ring. Again in this area it was involved in the very severe scalp process and it was difficult to tell where structures are. All attempts were made to preserve the spermatic cord intact, however because of the severe scarring I decided not to the expected in the medial part of the dissection where all the scarring was and just leave it alone attached to the abdominal wall. In this case I decided to use mesh intraperitoneally so I did need to dissect the cord all the way Reduce the chances of injury to spermatic vessels and or spermatic cord. The hernia was indeed a sliding hernia containing sigmoid colon. After the hernia sac was completely dissected, the hernia content was reduced back into the abdomen. At this time given the large defect in the abdominal wall from the giant hernia, I decided to proceed with intraperitoneal placement of the mesh as it will allow a larger overlap. I approximated internal oblique and transversalis fascia and muscles to the inguinal ligament with running PDS 0 suture. There was some tension on the repair, however tissue, together nicely. 1 cm opening was left for the spermatic cord. Subsequently aponeurosis of the external oblique was approximated over the repair. I used a wound 19 French drain to drain the scrotum. Skin was closed with staples. At this time the robot was docked again. I continued with dissection from the inside and finished visualization of the peritoneal flap. The colon was dissected completely of the retroperitoneum and moved cephalad and medially. Large mesh was introduced and placed in the left inguinal area with significant overlap over the closed defect. Mesh was secured to the pubis and to the rectus abdominis muscle with loose 0 Vicryl sutures. Peritoneal flap was closed with a running barbed 3-0 Monocryl. Before the closure, anterior area was irrigated with solution of vancomycin. All the solution was aspirated. The trochars were removed. Fascia at the abdominal incision was closed with 0 Vicryl. Skin was closed with staples. *** The needle, instrument and sponge counts were correct x 2. The patient tolerated the procedure well, was extubated in the OR and was transferred to the recovery in stable condition.