Para-umbilical Hernia IPOM Repair

Aaradhya Sharma

https://www.laparoscopyhospital.com/SERV01.HTM  This video demonstrates the laparoscopic repair of a paraumbilical hernia. A paraumbilical hernia is an area of weakness around your umbilicus that adults are more likely to develop. An umbilical hernia is an area of weakness in your umbilicus (naval) that often develops in children. A paraumbilical or umbilical hernia is a common type of abdominal hernia. Paraumbilical hernias usually develop later in life and are often caused by acquired abdomen openings linked to intra-abdominal pressure from carrying excess body weight, ascites, cancer, or other intra-abdominal malignancy, or multiple pregnancies. Hernias don't go away on their own. Only surgery can repair a hernia. Many people are able to delay surgery for months or even years but there is always a chance of incarceration.  For more information please contact:  World Laparoscopy Hospital  Cyber City, Gurugram, NCR DELHI INDIA 122002  Phone & WhatsApp: +919811416838, + 91 9999677788

Transcript

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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