Parth Sharma, MD, Georgios Orthopoulos, MD, PhD, Mazen Al-Mansour, MD. Baystate Medical Center
Case Presentation: A 67 year old male patient with a previous open right inguinal hernia repair, as well as previous robotic prostatectomy with pelvic lymph node dissection presented to the general surgery office with a painful right groin bulge, worsening over 2 years. He was taken to the operating room electively for robotic right recurrent inguinal hernia repair. The accompanying video demonstrates the technique used to repair the defect without injuring critical structures, especially considering the previously violated tissue planes.
Operation: A pre-peritoneal plane was created by incising the right lower quadrant peritoneum. Meticulous dissection was then conducted from medial to lateral along the pre-peritoneal space as significant post-operative adhesions were encountered. Notably, a three-way urinary catheter was used to distend the bladder with normal saline in order to protect it during the difficult dissection. An indirect hernia sac was encountered within the adhesions. The hernia sac was inadvertently entered, and although all attempts were made to fully reduce the hernia sac, the herniating peritoneum was ultimately transected and partially reduced into the intra-abdominal space. There were no bowel loops noted within the hernia. After confirming clearance of the internal inguinal ring, a 3DMax Light mesh was placed into the pre-peritoneal space. The medial portion of the mesh was buried deep near the Pubic Symphysis and Cooper’s Ligament, and adequate coverage was achieved laterally to close the defect. The peritoneal flap was then closed primarily with 2-0 V lock sutures in running fashion. The opened peritoneal defect was also primarily ligated with 2-0 V lock suture. The patient had no hernia recurrence on follow-up, and aside from a small post-operative seroma he did well thereafter.
Learning Points: Inguinal hernia repairs in patients with prior open inguinal canal and pre-peritoneal surgeries can be quite challenging. Prior operative reports can augment pre-operative planning. Infusing saline through a 3-way Foley catheter can also help define bladder borders in order to avoid injury. Transecting the indirect hernia sac is acceptable, especially to avoid spermatic cord structures and iliac vessels. The peritoneal defect must be closed if a non-barrier coated mesh is used, in order to separate mesh from bowel. Finally, the robotic platform is particularly advantageous due to enhanced visualization, surgeon-controlled camera movement, wristed instruments, and ergonomic benefits during prolonged cases (as if often the case when working with post-operative scarring and adhesions).
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95497
Program Number: V245
Presentation Session: Video Loop Day 2
Presentation Type: VideoLoop