Task Analysis of Laparoscopic Procedures

Laparoscopic Repair of Ventral Hernia by IPOM Technique : Task Analysis
General Surgery / Jan 22nd, 2018 1:36 pm     A+ | a-
Laparoscopic Repair of Ventral Hernia by IPOM Technique : Task Analysis
Dr. Jeevan G.S. MBBS, DNB (Gen Surg), MRCS (Eng), F.MAS
 
Introduction
 
Any protrusion of viscera through anterior abdominal wall is called as Ventral hernia. It is categorised as spontaneous or acquired 
Spontaneous –primary defects in abdominal fascia includes.
 
1. Umbilical & paraumbilical hernia 
2. Epigastric hernia 
3. Spigelian hernia  
 
Acquired 
 
1. Incisional hernia 
2. parastomal hernia
 
The laparoscopic approach shortens the operating time and the hospitalisation of the patient while the incisions cause less pain and there is a faster return to normal daily activities. Relative contraindications of this surgery include extremely large hernias with loss of abdominal domain or those associated with extensive, dense intra- abdominal adhesions.
 
Approach Considerations
 
The basic surgical principles of laparoscopic repair include the following: no tension technique, appropriate trocar placements and the use of mesh. The number of trocars used and their placement are related to the location and the size of the hernia, as well as the surgeon’s experience and choice. 
 
Preoperative Preparation
 
The patient must be free of skin infections and the respiratory function must be evaluated and optimised before the operation. If the hernia contains parts of the gastrointestinal tract such as bowel, appropriate imaging and endoscopy may be performed in order to avoid any intraoperative complications. The patient may be given a bowel preparation prior to surgery.
 
Anesthesia
 
General Anesthesia with endotracheal tube is required.
 
Operative Preparation
 
Perioperative antibiotics should be given according to the most recent national guidelines. The stomach must be decompressed with an orogastric tube, a Foley catheter must be placed and stockings are applied. The skin is prepared in a routine manner using antiseptics.
 
Position
 
The patient is placed in a supine position.
 
Instruments and Surgeon Position
 
All devices and instruments needed for the operation must be checked for proper function. The surgeon’s position must follow the principles of ergonomics in laparoscopic surgery i.e. suitable table height at 0.49 of surgeon’s height, alignment of surgeon, hernia and monitor, placement of monitor at a distance of 5 times its diagonal diameter and at a height no less than approximately 20cm from his/her visual axis.
 
 Incision and Exposure
 
The 10mm port of the laparoscopic telescope and the 5mm instrument ports are a function of the position of the hernia defect and the preference of the surgeon. The “Diamond-Baseball” principle of port placement should be followed for better ergonomics. Good exposure, traction, counter traction and good working angles between the instruments and the patient must never be compromised in an attempt to use fewer trocars. The ports need to be placed at a distance no less than 5cm with each other. One of the operating ports could be 10mm in size. 
 
The surgeon must decide where the entrance to the peritoneal cavity should be. A safe site for primary entrance would be Palmer’s point at 2-3 cm below the left costal margin in the mid-clavicular line. Access to the peritoneal cavity is gained using either the closed or the open technique.
 
 Closed technique access
 
• Make an incision on the skin, 2mm using a scalpel blade No. 11
• Lift the abdominal wall and insert the Verres needle through the    incision at a 45o elevation angle but perpendicular to the abdominal wall.
• After you hear the three click sounds, do ascertainment tests (irrigation, aspiration and hanging drop tests) to check the correct placement of the needle
• Insufflate the peritoneal cavity with CO2 through the Verres needle according to the principles of insufflation.
• Observe the rise of the intra-abdominal pressure and the total volume of gas as the abdomen distends uniformly and hernia pops out.
• Take the needle out of the abdomen.
• Enlarge the incision upto 10mm.
• Slowly screw the cannula with the trocar into the peritoneal cavity.
• The camera is white-balanced and focused.
• The telescope is advanced down the port into the abdomen
•  All four quadrants of the abdomen are explored
•  The hernia and its contents are evaluated
•  Additional unrecognised hernia defects may be found
•  Omental and other adhesions to the abdominal wall are visualized
•  The 5mm instrument ports are placed after transillumination of the abdominal wall using the telescope, to show any regional  vessels within the abdominal musculature
 
Procedure
 
Adhesiolysis and reduction of contents of the hernia sac:
Typically, If the content is bowel it would assume a pyramidal shape or a flyover shape and if the content is momentum, it would appear as a treetop.
 
If Omentum as contents
 
• Grasp the omentum near the abdominal wall with the grasper.
• Apply gentle traction.
• Incise sharply the junctions of the omentum with the peritoneum of the abdominal wall using laparoscopic scissors or using monopolar hook or else with harmonic scalpel.
• Reduce the sac into the abdominal cavity.
• Any bleeding that might occur should be controllled.
 
If bowel as contents use laparoscopic scissors for a sharp dissection and avoid electrosurgical devices as far as possible.
 
Mesh Placement 
 
• A dual mesh would be ideal choice to prevent bowel adhesions.
• Make a measurement of the perimeter of the defect and make sure there is clear zone for attachment of the mesh and for applying the sutures or tackers.
• Deflate the abdomen and identify/mark the edges of the defect on the abdominal wall. If measurements are made with the abdomen fully inflated, the mesh will be too large
• Measure the defect’s size
• Choose the size of the mesh as defect + 12 cm on all sides.
• Place anchoring sutures at four corners of the mesh or four sutures each at 12,3,6,9 o clock positions in case of circular mesh.
• Tie each suture in its midpoint and leave the long tails intact
• Mark the sites of the skin corresponding to the sutures
• Roll the mesh
• Introduce the mesh to the abdominal cavity through the 10mm 
• Unfold and orient the mesh by making sure the right surfaces are facing towards the hernia and the abdomen
• Make a 2mm skin stabs at the marked sites using No.11 blade.
• Pull the sutures through the abdominal wall muscles with a suture passer instrument
• Secure the preattached sutures at the four quadrants setting the knot deeply
• Use an endoscopic stapling device such as a tacker to secure the   exposed perimeter of the mesh
• Place the tacks 1 cm apart, applying external counterpressure with the hand while tacking best approach is to create a double-circle configuration with the outer line located close to the edge, to prevent the mesh from folding on itself and inner crowning around the fascial defect.
• Do not apply tackers over the fascial defect.
 
Upon completion of the procedure:
 
• Inspect the abdomen for any bleeding sites
• Remove the operating ports under direct vision checking for bleeding sites
• Release the pneumoperitoneum
• Close the fascia of the 10mm trocar site with NO.1 absorbable sutures
• Approximate the skin with subcuticular sutures
• Apply dry sterile dressings.
 
Postoperative Care
 
• Remove the orogastric tube before the patient awakens
• Discontinue the Foley catheter when the patient is able to void
• Give Painkillers
• Advance diet as tolerated by the patient, starting with fluids within 1 day
• The use of an abdominal binder for 1 month is recommend by some surgeons
 
Complications
  • Intra operative bleeding
  • Bowel perforation
  • Prolonged ileus
  • Hematoma at Port site / Tacker site
  • Seroma
  • Port site infection
  • Abscess
  • Mesh Infection
  • Bowel adhesion and obstruction
 
Bibliography 
 
1. Task Analysis of Laparoscopic procedures, World Laparoscopy Hospital Retrieved from: https://www.laparoscopyhospital.com/index.htm
 
2. Guidelines for laparoscopic ventral hernia repair, SAGES. Retrieved from:
 https://www.sages.org/publications/guidelines/guidelines-for-laparoscopic-ventral-hernia-repair/
 
3. Laparoscopic Ventral Hernia Repair, WebSurg. Mar 2014; 14(03) Retrieved from:
http://www.websurg.com/Laparoscopic_ventral_hernia_repair_(LVHR)-vd01en4221.htm 
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