PREOPERATIVE DIAGNOSIS: Recurrent right inguinal hernia.
*
POSTOPERATIVE DIAGNOSIS: Right femoral hernia with a large incarcerated hernia sac.
Intra-abdominal adhesions.
*
PROCEDURE PERFORMED:
1. Laparoscopic right femoral hernia repair.
a. TEPP and TAP approach.
b. Resection of the hernia sac.
2. Laparoscopic lysis of adhesions.
3. "Difficult" surgery
*
ANESTHESIA: General endotracheal.
*
ESTIMATED BLOOD LOSS: Minimal.
*
FLUIDS GIVEN: Crystalloid.
*
INDICATION: The patient is a **, status post open right inguinal hernia repair years ago who now has a supposed recurrence with a large bulging mass in the inguinal region. The patient presents for a laparoscopic approach for preperitoneal repair.
*
FINDINGS: There were adhesions intra-abdominally, these had to be lysed in order to have appropriate visualization from within the abdominal cavity.
*
The mass in question was eventually noted to be a hernia sac that was enlarged, distended, and chronically inflamed (thickened walls). The sac was eventually suture-ligated and resected. We had to make sure that this was not a different entity such as mass lesion, bladder herniation, or testicle.
*
The mesh was placed in the preperitoneal space.
*
This case will be labeled as "difficult" due to the ambiguity of the identity of the mass lesion and the time it took to complete the procedures, especially laparoscopically.
*
TECHNIQUE: Patient was taken to the operating room and placed in supine position. SCD stockings were placed on both legs. General anesthesia was induced. The abdomen was prepped and draped in the usual sterile fashion using a ChloraPrep solution. Incision was made in approximately the umbilical area. The patient has distorted skin anatomy from surgery as a child (open appendectomy). Dissection was carried to the intra-abdominal fascia. An incision was made on the anterior abdominal fascia just right of midline. The medial border of the rectus muscle was identified and retracted laterally to reach the preperitoneal space. Blunt dissection was carried out and access to the preperitoneal space was gained. A Hassan type of trocar was placed. The preperitoneal space was insufflated with CO2 gas to a pressure of 15 mmHg. Eventually, 2 other working trocars were placed just left of midline, one above the pubis and one halfway between the pubis and the umbilicus. Further dissection of the preperitoneal space was pursued. The herniation was noted. It appeared to be a femoral type of hernia, although this was difficult to tell exactly. Reduction of the hernia sac was not going well. The patient still had the large bulging mass in the right inguinal region. The case was turned to the intraabdominal approach. A Veress needle was placed into the abdominal cavity in the left upper quadrant away from previous surgery site. A couple of 5 mm trocars were placed, one for camera and one for instrumentation. It was noted there were a lot of adhesions from the omentum to the abdominal wall from his previous surgery. These adhesions had to be lysed and taken down in order to get adequate visualization of the right groin region. There were also adhesions of the cecum to the peritoneum a bit anteriorly and medially. That would have made for difficult taking down of the peritoneum. We kept going back and forth between transabdominal and extraperitoneal approach in order to gain adequate visualization and access to our operative site. It was noted that there was a femoral hernia looking from within the abdominal cavity. There was nothing traversing this defect from the intra-abdominal site. The mass was still present, however, in the right groin region.
*
Eventually, "open approach" was used. Skin incision was made over the right groin region over the mass. Dissection was carried through subcutaneous tissue and through the anterior oblique fascia. The inguinal canal was reached working toward a mass lesion that was very well palpable. Initially I was not sure what this was exactly. Eventually, it was noted that this was a hernia sac that was enlarged, filled with fluid, and had to have been a bit irritated, for the walls were thickened. A Foley catheter was placed on table to make sure that this was not a part of a bladder herniation. Once we were assured that this was not anything but a hernia sac, dissection was carried around the sac down to its exit site at the femoral space. The sac was eventually suture ligated. The excess was resected and sent to Pathology for analysis. The stump of the sac was seen to be contracting a bit into the femoral space. Hemostasis was assured at the open incision site. The external oblique fascia was reapproximated with Vicryl sutures. Subcutaneous tissue was reapproximated with Vicryl sutures as well. Skin incision was closed with 4-0 Vicryl suture in a running subcuticular fashion.
*
Return back to transabdominal and preperitoneal approaches. Working from the preperitoneal space, the peritoneum/hernia sac was completely reduced at the femoral space. There was no injury to any other structures. Further dissection and inspection were carried out to make sure there was not another hernia through the internal inguinal ring. At this point, a polypropylene mesh was brought onto the field. It was cut to the appropriate size and shape. This was placed into the preperitoneal space and laid across the inguinal floor. Care was taken to make sure that the femoral space was well covered with good margins. The internal ring was also well covered with this mesh. The mesh was secured to the pubic tubercle with tacks. A couple other tacks were used against the abdominal wall to secure the mesh in place. Hemostasis was adequate. The preperitoneal space was filled with a ropivacaine anesthetic solution for postoperative analgesia. The trocars were removed from the preperitoneal space. Dissection was carried from within the abdominal cavity as well. There was no evidence of any other herniation. Trocars removed and abdomen desufflated of CO2 gas. The larger fascial defects were closed with 0 Vicryl sutures. All the skin incisions were closed with 4-0 Vicryl sutures in a running subcuticular fashion. Dermabond skin closing solution was applied to the incisions. The patient tolerated the procedure well. Pt was transferred to the recovery room in stable condition.

PREOPERATIVE DIAGNOSIS: Recurrent right inguinal hernia.
*
POSTOPERATIVE DIAGNOSIS: Right femoral hernia with a large incarcerated hernia sac.
Intra-abdominal adhesions.
*
PROCEDURE PERFORMED:
1. Laparoscopic right femoral hernia repair.
a. TEPP and TAP approach.
b. Resection of the hernia sac.
2. Laparoscopic lysis of adhesions.
3. "Difficult" surgery
*
ANESTHESIA: General endotracheal.
*
ESTIMATED BLOOD LOSS: Minimal.
*
FLUIDS GIVEN: Crystalloid.
*
INDICATION: The patient is a **, status post open right inguinal hernia repair years ago who now has a supposed recurrence with a large bulging mass in the inguinal region. The patient presents for a laparoscopic approach for preperitoneal repair.
*
FINDINGS: There were adhesions intra-abdominally, these had to be lysed in order to have appropriate visualization from within the abdominal cavity.
*
The mass in question was eventually noted to be a hernia sac that was enlarged, distended, and chronically inflamed (thickened walls). The sac was eventually suture-ligated and resected. We had to make sure that this was not a different entity such as mass lesion, bladder herniation, or testicle.
*
The mesh was placed in the preperitoneal space.
*
This case will be labeled as "difficult" due to the ambiguity of the identity of the mass lesion and the time it took to complete the procedures, especially laparoscopically.
*
TECHNIQUE: Patient was taken to the operating room and placed in supine position. SCD stockings were placed on both legs. General anesthesia was induced. The abdomen was prepped and draped in the usual sterile fashion using a ChloraPrep solution. Incision was made in approximately the umbilical area. The patient has distorted skin anatomy from surgery as a child (open appendectomy). Dissection was carried to the intra-abdominal fascia. An incision was made on the anterior abdominal fascia just right of midline. The medial border of the rectus muscle was identified and retracted laterally to reach the preperitoneal space. Blunt dissection was carried out and access to the preperitoneal space was gained. A Hassan type of trocar was placed. The preperitoneal space was insufflated with CO2 gas to a pressure of 15 mmHg. Eventually, 2 other working trocars were placed just left of midline, one above the pubis and one halfway between the pubis and the umbilicus. Further dissection of the preperitoneal space was pursued. The herniation was noted. It appeared to be a femoral type of hernia, although this was difficult to tell exactly. Reduction of the hernia sac was not going well. The patient still had the large bulging mass in the right inguinal region. The case was turned to the intraabdominal approach. A Veress needle was placed into the abdominal cavity in the left upper quadrant away from previous surgery site. A couple of 5 mm trocars were placed, one for camera and one for instrumentation. It was noted there were a lot of adhesions from the omentum to the abdominal wall from his previous surgery. These adhesions had to be lysed and taken down in order to get adequate visualization of the right groin region. There were also adhesions of the cecum to the peritoneum a bit anteriorly and medially. That would have made for difficult taking down of the peritoneum. We kept going back and forth between transabdominal and extraperitoneal approach in order to gain adequate visualization and access to our operative site. It was noted that there was a femoral hernia looking from within the abdominal cavity. There was nothing traversing this defect from the intra-abdominal site. The mass was still present, however, in the right groin region.
*
Eventually, "open approach" was used. Skin incision was made over the right groin region over the mass. Dissection was carried through subcutaneous tissue and through the anterior oblique fascia. The inguinal canal was reached working toward a mass lesion that was very well palpable. Initially I was not sure what this was exactly. Eventually, it was noted that this was a hernia sac that was enlarged, filled with fluid, and had to have been a bit irritated, for the walls were thickened. A Foley catheter was placed on table to make sure that this was not a part of a bladder herniation. Once we were assured that this was not anything but a hernia sac, dissection was carried around the sac down to its exit site at the femoral space. The sac was eventually suture ligated. The excess was resected and sent to Pathology for analysis. The stump of the sac was seen to be contracting a bit into the femoral space. Hemostasis was assured at the open incision site. The external oblique fascia was reapproximated with Vicryl sutures. Subcutaneous tissue was reapproximated with Vicryl sutures as well. Skin incision was closed with 4-0 Vicryl suture in a running subcuticular fashion.
*
Return back to transabdominal and preperitoneal approaches. Working from the preperitoneal space, the peritoneum/hernia sac was completely reduced at the femoral space. There was no injury to any other structures. Further dissection and inspection were carried out to make sure there was not another hernia through the internal inguinal ring. At this point, a polypropylene mesh was brought onto the field. It was cut to the appropriate size and shape. This was placed into the preperitoneal space and laid across the inguinal floor. Care was taken to make sure that the femoral space was well covered with good margins. The internal ring was also well covered with this mesh. The mesh was secured to the pubic tubercle with tacks. A couple other tacks were used against the abdominal wall to secure the mesh in place. Hemostasis was adequate. The preperitoneal space was filled with a ropivacaine anesthetic solution for postoperative analgesia. The trocars were removed from the preperitoneal space. Dissection was carried from within the abdominal cavity as well. There was no evidence of any other herniation. Trocars removed and abdomen desufflated of CO2 gas. The larger fascial defects were closed with 0 Vicryl sutures. All the skin incisions were closed with 4-0 Vicryl sutures in a running subcuticular fashion. Dermabond skin closing solution was applied to the incisions. The patient tolerated the procedure well. Pt was transferred to the recovery room in stable condition.