nlbarnes
Expert
Any recommendations other than 15835, 49654-22, & 49568?
PROCEDURE:
Robotic perineal herniorrhaphy with mesh.
INDICATION:
who approximately a year ago had a
laparoscopic abdominoperineal resection for rectal cancer. He had had
preoperative chemotherapy and radiation. He had done well
postoperatively and has no evidence at the present time of recurrent
cancer. However, he has developed an enlarging perineal mass such
that when he stands up, it protrudes like a tail from his perineum.
It is uncomfortable in a pressure sense and on CT scan appears to
contain the omentum that we put down in the pelvis to try to keep the
small bowel out of the pelvis. The skin over the perineum is also
thinning out and he therefore is taken for perineal hernia repair.
DESCRIPTION OF PROCEDURE:
After the induction of suitable general endotracheal anesthesia, with
the patient in the lithotomy position, the abdomen was prepped and
draped in usual sterile fashion with ChloraPrep and the stoma was
prepped with Betadine. We placed a Gelfoam in the stoma and then
placed a sponge over the ostomy and then placed an Ioban over all of
that to make sure to keep the ostomy separate from the field. A left
upper quadrant incision was made. The Veress needle was passed. The
pressure read high twice and so then we went to the supraumbilical
position and performed a cutdown and passed a robot 8 port, but we had
difficulty maintaining pressure, so we got a Hasson trocar with a
balloon and passed that and then we were able to insufflate the
abdomen to 15 mm pressure of CO2. We looked at the left upper
quadrant and could not see any evidence of injury to bowel or blood
vessels or spleen. A #5 trocar was placed in the left upper quadrant
and then we were using the 5, 30-degree laparoscope via these two
ports to place a #8 robot port in the right lower quadrant and a #8
robot port in the left lower quadrant inferior and lateral to the
ostomy. We assessed that the robot arms would not cause any injury to
the ostomy with the necessary rotation that we would need to make to
work in the pelvis. We swept the small bowel out of the pelvis with
laparoscopic soft touch babcocks. It was not adhesed there at all. The
omentum was stuck in the pelvis. We then docked the robot with the patient in
the trendelenberg position. We started with a #8 camera, but eventually
changed to a #12 camera as the patient had a very long deep pelvis and the #8
camera would not allow the robot camera to go down deep enough to see to the
bottom of the pelvis, but the 12 did. We placed a scissor in the #1 port on
the patient's right hand side, we placed a Cartier in the #2 port on the
patient's left hand side, and we also added another 5 port in the right upper
quadrant for an extra assist port. There were no anterior abdominal wall
adhesions. We could see the big flap of omentum going all the way down into
the pelvis. It was not significantly adhesed in the upper pelvis, but down
distally and through the levators, it was adhesed. We used the scissors with
cautery to take down most of these adhesions. I did look both for both the
left and right ureter, I believe I identified both of them through the white
scarred peritoneum by visualizing them moving and care was taken to avoid
injury to them. Due to the smooth white scarring that was somewhat thick over
the areas of the previous pelvic dissection including over the surfaces of the
ureters, I did not wish to individually dissect out each ureter lest I injure
it. Once I divided all the omental adhesions in the pelvis with the scissor
and cautery, I pulled the omentum up out of the pelvis. We achieved
hemostasis on the end of the omentum with the fenestrated bipolar, which was
placed in the #2 port and also I should note that some of the hernia sac also
was divided and came up with the omentum. We were then looking at a smooth
pelvic inlet and we got a 10 x 15 cm ProGrip mesh. The rep was here as this is
not typical location to use it, of course, these hernias are very rare so
there is no typical recommendation for mesh type. The idea was that mesh is
somewhat challenging to fixate in the pelvis and we are hoping that the
overlap of the ProGrip on the surrounding peritoneal surfaces would lead to
sticking of the mesh there as well, which would help fixate it in place. We
cut the ProGrip mesh to the largest circle we could make it and then we folded
it and placed it through the #1 port down into the pelvis. We then unfolded
it in the pelvis and centered it, so that it overlapped the presacral
peritoneum posteriorly and anteriorly it overlapped the preperitoneal fat that
lies over the bladder. We were able to occlude the entire hole with about 2
cm of overlap at the least overlapped portion. We then considered how to
fixate the mesh, any suturing into the retroperitoneum of the pelvic
sidewalls clearly can lead to significant bleeding. We knew we would not be
able to tack anteriorly though because really there was very little to sew to
anteriorly, so I got a 3-0 absorbable barbed Stratafix suture and we using the
robot needle driver, sewed the mesh initially posteriorly to the presacral
fascia with the running barbed suture. When we got close to where the ureter
would cross the pelvis, we stopped the suturing and then went anteriorly
sewing to the peritoneum and peritoneal fat anterior to the bladder without
picking up the bladder anteriorly and ran this laterally once again sewing out
a little more laterally to get the mesh to sit up and overlap the lateral side
of the pelvis where the ureter would pass underneath. Care was taken to avoid
injury to the ureter and to the best of our ability, we did not injure it. We
completed the suturing and while the mesh was nicely seated, I was concerned
about the weight of this patient's omentum and whether it was wise to have
used only absorbable suture, so we went ahead and got a ProTack and we were
able to add tack posterolaterally, again staying inferior and posterior to the
site of the ureter along the pelvic brim. Anteriorly though we had nowhere to
place the secure tack and so we actually ran another barbed suture, so we had
two layers of suturing anteriorly. The mesh appeared to be fixated and with
some overlap, and I was hoping the ProGrip will stick as it usually does to
the underlying tissue adding further fixation. We then dropped the omentum
back down in the pelvis making sure the small bowel was not under the omentum
and it was not. There was really a remarkably large amount of healthy omentum
and due to its weight, I elected to drop it mid to distal portion down to the
depths of the pelvis and then take the most distal portion and sewed that with
the robot with another barbed suture to the anterior pelvic peritoneum
sewing back and forth to try to suspend the full weight of the omentum and
make it less likely to prolapse in the future. We did have some bleeding
while we are performing the all this suturing, but from the abdominal cavity
at least hemostasis appeared excellent at the conclusion of this portion of
the surgery. We checked the mesentery to the colostomy and that appeared
nicely intact. We removed the midline 12 port and placed a 0 Vicryl Endo
Close there and then, we removed the remaining ports under direct vision.
There was no evidence of bleeding at any port site. The skin of all ports was
closed with 4- 0 Monocryl subcuticular stitch. Dermabond was placed and then
we turned our attention to the perineum. We raised the patient in very high
lithotomy and scooted his butt off the end of the bed a little bit, so that we
would be able to work with the perineal tissues without contaminating our
dissection. Consideration was given to simply leaving the perineal hernia sac
in the hopes that it might involute with the omentum not going down into it.
However, we put the table in reverse Trendelenburg and still the patient had
a significant enough bulge there that I felt that he would be very unhappy
with the result if I did not excise it. The concern of course with excising
it is any wound infection at this point could lead to a mesh infection, which
would be a very big problem. I finally decided that this patient
would prefer me to go ahead and have us excise the excess tissue in his
perineum, so we clipped the hair on the perineum with the clippers and
then we prepped with ChloraPrep, let that completely dry and then
prepped again with ChloraPrep and let that completely dry and then we
draped out the perineum and grasping the excess tissue. I used the
electrocautery to make an elliptical skin incision around it. We
inevitably entered the hernia sac and there was about 200 cc of blood
that came out that looked old and dark. We excised as much of the
hernia sac as we could and then we cauterized the remainder of it with
the Bovie, so that its surface was not as smooth. We could see the
mesh up at the top of our dissection. We placed a clean lap pad up
there and removed it and we had no evidence of further bleeding. I think the
blood in this space was simply run down from when we were performing the
surgery on the abdominal side. The mesh was probably 15 cm away from the skin
incision because this patient had a very long narrow pelvis. We were able to
reapproximate the levators which I did with interrupted 2-0 Vicryl suture and
then I closed the subcutaneous fat in three more layers of interrupted 2-0
Vicryl suture. Then, we closed the skin with interrupted 3-0 Vicryl subdermal
sutures followed by running 4-0 Monocryl subcuticular stitch. Dermabond was
placed. The hernia sac was sent to Pathology - PATH: FIBROMEMBRANOUS TISSUE W/ ATTACHED YELLOW UNREMARKABLE ADIPOSE TISSUE & SKIN. Sponge, needle, and instrument
counts were correct. Blood loss was 250 mL. The patient tolerated the
procedure well and went in good condition to the recovery room. A total of 42
mL of 0.25% Marcaine with epinephrine were injected for postoperative
pain relief. I forgot to state that obviously, we did undock the robot when
we completed using it on the abdominal side and also when we finished the
abdominal surgery, we placed a new stoma bag on still a very pink normal-
appearing colostomy. I should note looking at the colostomy, there was no
evidence of a parastomal hernia either. This was a challenging surgery for
a rare hernia and the surgery required at least 3 hours, closer to 4 hours
to perform and was much more difficult than a standard abdominal wall ventral
hernia repair.
610160231 02_08
PROCEDURE:
Robotic perineal herniorrhaphy with mesh.
INDICATION:
who approximately a year ago had a
laparoscopic abdominoperineal resection for rectal cancer. He had had
preoperative chemotherapy and radiation. He had done well
postoperatively and has no evidence at the present time of recurrent
cancer. However, he has developed an enlarging perineal mass such
that when he stands up, it protrudes like a tail from his perineum.
It is uncomfortable in a pressure sense and on CT scan appears to
contain the omentum that we put down in the pelvis to try to keep the
small bowel out of the pelvis. The skin over the perineum is also
thinning out and he therefore is taken for perineal hernia repair.
DESCRIPTION OF PROCEDURE:
After the induction of suitable general endotracheal anesthesia, with
the patient in the lithotomy position, the abdomen was prepped and
draped in usual sterile fashion with ChloraPrep and the stoma was
prepped with Betadine. We placed a Gelfoam in the stoma and then
placed a sponge over the ostomy and then placed an Ioban over all of
that to make sure to keep the ostomy separate from the field. A left
upper quadrant incision was made. The Veress needle was passed. The
pressure read high twice and so then we went to the supraumbilical
position and performed a cutdown and passed a robot 8 port, but we had
difficulty maintaining pressure, so we got a Hasson trocar with a
balloon and passed that and then we were able to insufflate the
abdomen to 15 mm pressure of CO2. We looked at the left upper
quadrant and could not see any evidence of injury to bowel or blood
vessels or spleen. A #5 trocar was placed in the left upper quadrant
and then we were using the 5, 30-degree laparoscope via these two
ports to place a #8 robot port in the right lower quadrant and a #8
robot port in the left lower quadrant inferior and lateral to the
ostomy. We assessed that the robot arms would not cause any injury to
the ostomy with the necessary rotation that we would need to make to
work in the pelvis. We swept the small bowel out of the pelvis with
laparoscopic soft touch babcocks. It was not adhesed there at all. The
omentum was stuck in the pelvis. We then docked the robot with the patient in
the trendelenberg position. We started with a #8 camera, but eventually
changed to a #12 camera as the patient had a very long deep pelvis and the #8
camera would not allow the robot camera to go down deep enough to see to the
bottom of the pelvis, but the 12 did. We placed a scissor in the #1 port on
the patient's right hand side, we placed a Cartier in the #2 port on the
patient's left hand side, and we also added another 5 port in the right upper
quadrant for an extra assist port. There were no anterior abdominal wall
adhesions. We could see the big flap of omentum going all the way down into
the pelvis. It was not significantly adhesed in the upper pelvis, but down
distally and through the levators, it was adhesed. We used the scissors with
cautery to take down most of these adhesions. I did look both for both the
left and right ureter, I believe I identified both of them through the white
scarred peritoneum by visualizing them moving and care was taken to avoid
injury to them. Due to the smooth white scarring that was somewhat thick over
the areas of the previous pelvic dissection including over the surfaces of the
ureters, I did not wish to individually dissect out each ureter lest I injure
it. Once I divided all the omental adhesions in the pelvis with the scissor
and cautery, I pulled the omentum up out of the pelvis. We achieved
hemostasis on the end of the omentum with the fenestrated bipolar, which was
placed in the #2 port and also I should note that some of the hernia sac also
was divided and came up with the omentum. We were then looking at a smooth
pelvic inlet and we got a 10 x 15 cm ProGrip mesh. The rep was here as this is
not typical location to use it, of course, these hernias are very rare so
there is no typical recommendation for mesh type. The idea was that mesh is
somewhat challenging to fixate in the pelvis and we are hoping that the
overlap of the ProGrip on the surrounding peritoneal surfaces would lead to
sticking of the mesh there as well, which would help fixate it in place. We
cut the ProGrip mesh to the largest circle we could make it and then we folded
it and placed it through the #1 port down into the pelvis. We then unfolded
it in the pelvis and centered it, so that it overlapped the presacral
peritoneum posteriorly and anteriorly it overlapped the preperitoneal fat that
lies over the bladder. We were able to occlude the entire hole with about 2
cm of overlap at the least overlapped portion. We then considered how to
fixate the mesh, any suturing into the retroperitoneum of the pelvic
sidewalls clearly can lead to significant bleeding. We knew we would not be
able to tack anteriorly though because really there was very little to sew to
anteriorly, so I got a 3-0 absorbable barbed Stratafix suture and we using the
robot needle driver, sewed the mesh initially posteriorly to the presacral
fascia with the running barbed suture. When we got close to where the ureter
would cross the pelvis, we stopped the suturing and then went anteriorly
sewing to the peritoneum and peritoneal fat anterior to the bladder without
picking up the bladder anteriorly and ran this laterally once again sewing out
a little more laterally to get the mesh to sit up and overlap the lateral side
of the pelvis where the ureter would pass underneath. Care was taken to avoid
injury to the ureter and to the best of our ability, we did not injure it. We
completed the suturing and while the mesh was nicely seated, I was concerned
about the weight of this patient's omentum and whether it was wise to have
used only absorbable suture, so we went ahead and got a ProTack and we were
able to add tack posterolaterally, again staying inferior and posterior to the
site of the ureter along the pelvic brim. Anteriorly though we had nowhere to
place the secure tack and so we actually ran another barbed suture, so we had
two layers of suturing anteriorly. The mesh appeared to be fixated and with
some overlap, and I was hoping the ProGrip will stick as it usually does to
the underlying tissue adding further fixation. We then dropped the omentum
back down in the pelvis making sure the small bowel was not under the omentum
and it was not. There was really a remarkably large amount of healthy omentum
and due to its weight, I elected to drop it mid to distal portion down to the
depths of the pelvis and then take the most distal portion and sewed that with
the robot with another barbed suture to the anterior pelvic peritoneum
sewing back and forth to try to suspend the full weight of the omentum and
make it less likely to prolapse in the future. We did have some bleeding
while we are performing the all this suturing, but from the abdominal cavity
at least hemostasis appeared excellent at the conclusion of this portion of
the surgery. We checked the mesentery to the colostomy and that appeared
nicely intact. We removed the midline 12 port and placed a 0 Vicryl Endo
Close there and then, we removed the remaining ports under direct vision.
There was no evidence of bleeding at any port site. The skin of all ports was
closed with 4- 0 Monocryl subcuticular stitch. Dermabond was placed and then
we turned our attention to the perineum. We raised the patient in very high
lithotomy and scooted his butt off the end of the bed a little bit, so that we
would be able to work with the perineal tissues without contaminating our
dissection. Consideration was given to simply leaving the perineal hernia sac
in the hopes that it might involute with the omentum not going down into it.
However, we put the table in reverse Trendelenburg and still the patient had
a significant enough bulge there that I felt that he would be very unhappy
with the result if I did not excise it. The concern of course with excising
it is any wound infection at this point could lead to a mesh infection, which
would be a very big problem. I finally decided that this patient
would prefer me to go ahead and have us excise the excess tissue in his
perineum, so we clipped the hair on the perineum with the clippers and
then we prepped with ChloraPrep, let that completely dry and then
prepped again with ChloraPrep and let that completely dry and then we
draped out the perineum and grasping the excess tissue. I used the
electrocautery to make an elliptical skin incision around it. We
inevitably entered the hernia sac and there was about 200 cc of blood
that came out that looked old and dark. We excised as much of the
hernia sac as we could and then we cauterized the remainder of it with
the Bovie, so that its surface was not as smooth. We could see the
mesh up at the top of our dissection. We placed a clean lap pad up
there and removed it and we had no evidence of further bleeding. I think the
blood in this space was simply run down from when we were performing the
surgery on the abdominal side. The mesh was probably 15 cm away from the skin
incision because this patient had a very long narrow pelvis. We were able to
reapproximate the levators which I did with interrupted 2-0 Vicryl suture and
then I closed the subcutaneous fat in three more layers of interrupted 2-0
Vicryl suture. Then, we closed the skin with interrupted 3-0 Vicryl subdermal
sutures followed by running 4-0 Monocryl subcuticular stitch. Dermabond was
placed. The hernia sac was sent to Pathology - PATH: FIBROMEMBRANOUS TISSUE W/ ATTACHED YELLOW UNREMARKABLE ADIPOSE TISSUE & SKIN. Sponge, needle, and instrument
counts were correct. Blood loss was 250 mL. The patient tolerated the
procedure well and went in good condition to the recovery room. A total of 42
mL of 0.25% Marcaine with epinephrine were injected for postoperative
pain relief. I forgot to state that obviously, we did undock the robot when
we completed using it on the abdominal side and also when we finished the
abdominal surgery, we placed a new stoma bag on still a very pink normal-
appearing colostomy. I should note looking at the colostomy, there was no
evidence of a parastomal hernia either. This was a challenging surgery for
a rare hernia and the surgery required at least 3 hours, closer to 4 hours
to perform and was much more difficult than a standard abdominal wall ventral
hernia repair.
610160231 02_08