00:01hello friends this is a case of para-umblycal hernia this patient has
00:07previous surgeries and the problem of the incisional hernia was not there but
00:14later she has developed the para-umblycal hernia which according to history it was
00:18present since long it was already present before so we are going to
00:23perform the surgery of para-umblycal hernia with the eye palm technique and
00:27here we will use the polyurethane mesh that is one of the best mesh which is
00:31possible this is the marking which you can see this is palmer's point and you
00:36can give the marking of the palmer's and then this is the mid clavicular line
00:41just below the costal margin and after that you can stretch the abdominal wall
00:46little down to introduce the various needle and various needle should be just
00:51pointed towards the stomach so this is lifted and stretched down and now this is
00:57the various needle which is pointed towards the stomach once it is in after
01:02that you can do irrigation test this is irrigation test and then followed by
01:07suction test and after that this is hanging drop test so all these three
01:12tests is performed and then you can attach the tubing of the insufflator and then
01:18you can start waiting for the quadro-manometric indicator to be according to
01:24the setting and here we have put the preset pressure 15 and actual pressure is
01:29slowly reaching to the 15 your eye should be over the insufflator and slowly
01:35this tympanic sound will come all over the abdomen and you should wait till here
01:40we can see that actual pressure is slowly increasing and will reach up to the 15
01:45and our preset is 15 and after few minutes flow rate is 3 liter per minute so this 15 is
01:52now reached and pneumopetodium as you can see is achieved now various needle should be taken
01:58out enlarge the incision and this is the 11 mm trocar which will be introduced to the
02:03palmer's point by screwing movement you should introduce it and then attach the tubing of the
02:09insufflator during this introduction you have to be very careful because there may be suspected
02:15adhesion in many cases and then attach the tubing of the insufflator again and then you can
02:21increase the flow rate to 6 to 10 liter per minute now everything is fine and we will introduce the
02:27telescope to have a look that what is inside and how it looks like and here we are in and just the
02:34light cable you will put the light cable down so that you can see the ventral abdominal wall and
02:41surprisingly this is the hernia but there is no any adhesion this is the black hole of the hernia which
02:47is visible but surrounding absolutely there is no adhesion so it is very good and this is a
02:54para umbilical hernia that is you can say supra umbilical now this is the falsiform ligament
03:00you can just do the adhesive lysis of the falsiform ligament because we need to have at least six
03:07centimeters free area all around to put the mesh because the mesh is required and here we will do the
03:14ipoam intra-patural only mesh repair without repair of the defect because it's not a very big defect
03:21it's a small defect so it can be done without any need of doing the primary repair with the proline or
03:29ethibond but we need at least six centimeters all around the margin of the defect free area so this is
03:36the harmonic and this is the fatty part of the falsiform ligament which is slowly getting separated with the
03:42harmonic and then you will reach to the membranous part of the falsiform ligament now we are reaching
03:48to the membranous part of the falsiform ligament so at least the domain of the mesh generally we use 12
03:57plus defect if defect is 3 centimeter mesh will be 15 by 15 so the domain of the defect if it is large
04:04then at least 6 centimeter all around the margin of the defect we should have the free area now this is
04:10mesh and just fold the mesh like a plated shari like plated and corner of the mesh it has a
04:17suture already tightened and now obliquely we should hold it by a grasper and you can apply a little
04:23gylocaine over the tip of the this mesh this is gylocaine and just you can put little gylocaine so that
04:31it will slip nicely into the cannula and then with the palmer's point you will remove the valve of the
04:38cannula of the palmer's point here valve is getting removed and then directly you will pass through
04:45the cannula pointing towards the nta abdominal wall so that because it's a blind injury so that it should
04:51not touch the bowel and now slowly it has been introduced in now this is out in and after that
04:58take the grasper out and here we can see this is our entire message inside now we will do trans facial
05:05fixation you should must take care of inferior epigastic vessel and two centimeter lateral to
05:11the corner of the mesh you will do trans facial fixation and slowly the suture will be taken out
05:18and the second suture should be two centimeter lateral to the first one and slowly slowly all the
05:24corners first we should must fix the most remote corner like here this is the right iliac fossa
05:31corner is getting fixed and mapping should be done before putting the mesh inside so that you will be
05:39bilateral symmetrical and symmetrically mesh will be used now this is the right hypochondric
05:45mesh fixation trans facial and both the suture has to be pulled separately one by one not both together
05:52now this is the left iliac fossa mesh coordinate which is fixed and this thread is already tightened before
05:59so you don't have a problem of asymmetry it will be nicely pulled only the inferior epigastic vessel
06:07should be kept in mind that accidentally it should not be pricked so the last fixation will be
06:13on the left hypochondrium and that is your palmer's point and after that this is tacker and tacker will do
06:20the outer as well as inner crowning outer crowning first should be in the middle and all the four
06:27cornered in the middle it should be fixed and left hand should must give support to the tip of the
06:33tacker so that when you fire it it should be perpendicular it should not be oblique so this is
06:39outer crowning which is going on and the left hand will support and then you will fire so this is here
06:46we are using absorbable suture attacker that is polygalactane tacker so it is absorbable and this
06:52is the falsiform ligament area that is the superior area and again in the middle of the corners you
06:59will do first outer crowning fixation and just left hand finger will support and then you will keep on
07:06firing and now again this is at the two-third junction of two-third and one-third of the corner again outer
07:14crowning should be done so it should be bilateral symmetrical it should not be at a uneven distance
07:21and approximately two two centimeter away this is the outer we can see three ports has been used
07:27and this is the outer view how you will introduce the ports and the tackers and you can keep the
07:36telescope into the palmer's point and with the left hand you will use the on the abdominal wall and with
07:43the right hand you can fire the tacker or you can make it sure that the abdominal wall should be folded
07:49so this is inferior apagastic vessel here you can see this is inferior apagastic vessel so we should
07:54must fire the tacker lateral to the inferior apagastic vessel and this should be very careful so this is
08:02done and now this is again the in between the outer crowning few more tackers has been fired
08:11so this eye balm technique of the laparoscopic inguinal hernia repair is a very easy surgery
08:16it is not difficult and especially if you have mapping of the hardina site is careful then it
08:23won't be any problem of asymmetry now this mess is polyurethane mess it has dual mess 3d dual mess
08:31and in this mess there are two color white and blue so white one this is just cleaning of the telescope
08:38telescope was taken out to clean it so yes and again telescope is in so white color is
08:45basically polyester that will be parietal side that should be towards the anterior abdominal wall
08:51and the blue color is visceral color that will be towards the viscera and blue color is polyurethane
08:59so this is very good and now this is inner crowning so inner crowning should be on the margin of the defect
09:06accidentally you should not fire over the defect otherwise it will come out of the skin and unnecessarily
09:13there will be infection so we can see here again the vision is that the left hand is just supporting
09:20it and with the right hand you will fire the tacker so now once the all the tacker will be fired after
09:26that at last you will do the trans facial fixation of the corner suture so this is how you will just
09:33support it and the all the fixation of the absorbable tacker will be done so this is now you have to do
09:42and this is the last few of the pharynx in the inner crowning which is almost over and generally we should
09:52give a tight strapping postoperatively so that patient should not develop any chiroma so it is
09:58almost over and now we will come out and this trans facial fixation of the suture will be done so that
10:05it will go subcutaneous so thank you very much for watching this video this was just a simple case of
10:11eye pump technique of ventral hernia thank you and have a nice day
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