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Laparoscopic lumbar hernia repair

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Laparoscopic   lumbar   hernia   repair

作者群
F Jamali, D Mutter, J Marescaux
關鍵字
hernias,operation,hernia repair surgery
媒體類型
期間
10'00''
刊物
2004-09
普通的
最愛
Favorites Media
音訊
en
副標題
en
數位出版
WeBSurg.com, Sept 2004;4(09).
URL: http://www.websurg.com/doi-vd01en1004e.htm

Laparoscopic   lumbar   hernia   repair

1. Case presentation 00'15''
This video illustrates the laparoscopic surgical approach to the repair of an uncommon type of hernia, namely a lumbar hernia. The case at hand is a 40-year-old female patient who in 1996 had undergone a left mastectomy with a delayed latissimus dorsi flap reconstruction. Here we can see the scar of the flap reconstruction. Three months ago, prior to the current presentation, the patient noted the sudden onset of pain as well as a bulge following a lifting effort. This bulge is centred around the area that is marked for you. CT-scanning demonstrates the presence of this lumbar hernia defect measuring 5cm in size with loss of the latissimus dorsi muscle. The defect is lateral to the psoas and the quadratus lumborum muscle noted by the blue area. Physical examination reveals the presence of a muscular well-defined defect. The defect has been marked for you on the abdominal wall. The landmarks that have been chosen are the costal margin and the anterior superior iliac spine. The goal will be to place a large Onlay mesh in the retroperitoneal area to cover well beyond the edges of the marked defect. A laparoscopic exploration is begun with the patient in full lateral position. As we can see, the white line of Toldt is clearly visualized and the defect is hereby seen by applying pressure from the outside. In addition to the 12mm optical trocar, we have placed two operating 5mm trocars on either side for an optimal ergonomic position. The dissection is begun by incising the peritoneum. This incision is done proximal to the site of the operation. This will allow for the development of a large operating field similar to the approach that is used for the treatment of trans-abdominal preperitoneal repair of inguinal hernias. Once the incision of the peritoneum is complete, the dissection plane is begun in close contact to the peritoneum by sweeping away some of the retroperitoneal fat. The dissection is then continued along the loose areolar tissue in close contact to the peritoneum until the hernial sac and defect are revealed. During the course of the dissection, the psoas muscle is identified along with the ilio-inguinal nerve, which is here visualized. Care is exercised throughout the procedure to preserve this nerve as well as all the other femoral cutaneous nerves that will be identified. The dissection is therefore continued in the retroperitoneal fatty plane above the psoas muscle, then in contact with abdominal wall to reveal the defect. This dissection is taken all the way to the lateral abdominal wall with identification of the lateral musculature of the abdominal wall and the cleavage plane between the Gerota’s fascia and this lateral abdominal wall musculature. Here we begin to identify the hernial defect with a lipoma-like structure that seems to be identified at this level. The hernial defect is now clearly visualized. Vascular clips are applied on any vessels that are encountered, which are then divided. We now proceed to the division of the attachments of Toldt’s fascia to the inferior edge and lateral edge of this hernial defect. This will allow for the placement of the mesh to cover the defect posteriorly in a large fashion. During the course of dissection, we can again see the ilio-inguinal nerve clearly identified running along the lateral edge of the psoas muscle and over the quadratus lumborum. The nerve is seen next to the scissors in the background. The plane between the psoas muscle and the quadratus lumborum is hereby developed. The ilio-inguinal nerve running along the quadratus lumborum muscle can now be clearly seen. Completion of dissection over the psoas muscle is then undertaken with the ilio-inguinal nerve clearly visualized and very soon the appearance of the genital femoral nerve along the psoas muscle itself. Here we can begin to see the genital femoral nerve appearing. This nerve again will be well identified and spared. The proximal dissection is then taken as high up as necessary to make sure that the large mesh that will be laid will amply cover the hernial defect from all aspects. Here we can see the hernia defect measuring 5cm. An 18 by 15cm piece of mesh will be used to reconstruct this defect. It is rolled and then sutured with 2 sutures to anchor it in place. It will be tacked along its inferior border and rolled backwards into position. It is introduced into the abdominal cavity via the 12mm optical port. The mesh is then easily positioned in place. We begin by tacking the inferior border of the mesh to the psoas and the quadratus lumborum muscle. Once the mesh is anchored at this level, we will divide the sutures holding the mesh and unroll it. Here you can see the tackers being placed against the psoas muscle. Once the inferior edge of the mesh is well secured and tacked in place, we will divide the sutures, which will now allow us to unroll the mesh without any undue hassles. The mesh is then being unrolled, care being taken to keep it flat and properly positioned. Once the mesh is unrolled into position, the tackers are used to anchor it to the anterior abdominal wall. Counter-pressure is exerted during the process by the hand of the assistant. Care is being taken so that the mesh will be fully covered by the peritoneum at the end of the procedure. The picture in picture image shows you the counter-pressure being applied by the assistant. At the end of the procedure, the peritoneal defect is then closed using the tacker device. This will ensure that the mesh is completely covered to minimize the risk of adhesions. The picture in picture image again shows you the counter-pressure being exerted by the hand of the assistant. The panoramic view demonstrates here complete closure of the peritoneal defect.