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Right femoral hernia repair with small segmental bowel resection

bda23054

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NAME OF OPERATION
1. Right femoral hernia repair with small bowel segmental resection.
2. Diagnostic laparoscopy.

ANESTHESIA
General.

SPECIMEN
Hernia sac and small bowel segment.

FINDINGS
This patient had a bulge in her right inguinal area that was consistent on ultrasound with unreducible hernia. After the patient was under general anesthesia, the bulge remained. It did not spontaneously reduce. Upon incision into the area, the inguinal ligament was attenuated and the defect did appear to be underneath the inguinal ligament consistent with femoral hernia medial to the femoral vessels. The hernia sac was thickened and had chronically inflamed appearance to it. There was no small bowel appreciated within the sac once the inguinal ligament that was constricting it was cut. Upon establishment of diagnostic laparoscopy, the segment that was incarcerated was obvious and photographic evidence was taken. It was a knuckle of small bowel about 6-8 cm in length that had inflamed thickened edematous appearance, questionably full thickness mesenteric border injuries, given the appearance it was resected. Side-to-side anastomosis was without tension. The hernia repair was found to be quite challenging with attenuated inguinal ligament and position of the defect.

DESCRIPTION OF OPERATION
The procedure as well as indications, benefits and potential risks were explained to the patient. All questions were answered. With consent obtained, the patient was taken to the operative suite, placed in the supine position and general anesthesia initiated. Anterior abdominal wall was then prepped and draped in the usual sterile fashion after Foley catheter was placed. Curvilinear incision over the right inguinal area was made over the neck of this inguinal mass. Electrocautery was used to carry dissection down through the superficial fascia, subcutaneous tissue, down to the external oblique. External oblique was opened and the inguinal canal was firm. The mass was appreciated within the subcutaneous tissue below the inguinal ligament. The inguinal ligament was ligated to release this
tension on this hernia sac. Apparently, the small bowel that was incarcerated had spontaneously reduced because I did not see any mass within the hernia sac. I then opt to look at the intraabdominal cavity. A 5-mm port was placed to the left upper quadrant using Visiport method. A right upper quadrant 5-mm port was placed as well as a left lower quadrant port was placed both under direct visualization. No intraabdominal injury was appreciated from the port placements. Local anesthetic was infiltrated at each of the pot sites prior to skin incision. The atraumatic graspers were used to identify the appendix and right colon. The ileocecal valve was then identified and working back a loop of small bowel and in the distal ileum was appreciated to be inflamed, indurated and questionable full thickness injury to the mesenteric border at this segment. I then placed a port through the hernia sac and grasped this segment of bowel, pulled it up through the hernia defect and dissect the sac away from this bowel segment. The bowel segment was then elevated with viable small bowel appreciated on either side of it. It was then removed segmentally with GIA-75 blue load stapling device. The mesentery was ligated with 2-0 silk stick ties. Hemostasis was visualized. The 2 limbs were placed side-to-side with 3-0 interrupted silk sutures along the antimesenteric border. About 1-2 cm below the ends of the segments, an enterotomy was made and the 75 blue load stapling device was fired to create a side-to-side anastomosis. The enterotomy was closed with a TA-60 stapling device and there was good bloody oozing at the staple line. One interrupted Lembert 3-0 silk suture was placed over the 2 corners of one side of the anastomosis to control bleeding. 3-0 silk suture was placed in crotch of the anastomosis to keep tension off the limbs. The mesenteric defect was closed with figure-of-eight 2-0 Vicryl. The anastomosis was then dropped back into the abdomen. The fascial defect as noted above was technically difficult to close given the proximity of the vessels and the lack of strong connective tissue to secure the fascia to anteriorly and given the bowel resection not able to place a mesh. 0-Prolene sutures used in interrupted fashion to close this defect along the transversalis and rebuild the attenuated inguinal ligament. Some bleeding along the rectus muscle medially was controlled with 3-0 silk stick-tie suture. No significant retroperitoneal bleeding appreciated, with the interrupted 0-Prolene figure-of-8 sutures in place to reinforce this closure. After the hernia sac was removed the pneumoperitoneum was established to visualize any holes in the repair and this was reinforced. Care was taken not to injure the underlying femoral vessels. The pneumoperitoneum was then released and accessory ports removed. The site was irrigated with polymyxin/Bacitracin/normal saline mixture and padded dry. No bleeding was appreciated, though earlier there was a little bit of bloody oozing, so I opted to place some Avitene in this bed. The external oblique fascia was closed with 2-0 Vicryl sutures interrupted fashion. The superficial fascia was closed with a running 3-0 Vicryl. Interrupted inverted deep dermal 3-0 Vicryl sutures were also used to reapproximate the skin edges loosely, and skin staples were used to reapproximate skin edges at each of the port sites and the right inguinal incision. Silvercel, 4 x 4's, Medipore tape were applied to each of the port sites. All sponge and instrument counts were correct. Instruments were not counted at the beginning of the procedure, so we will obtain an abdominal x-ray to make sure she has no foreign bodies. The patient was awakened and taken to the recovery room in stable and satisfactory condition.
 
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