Lap Gastrojejunostomy - Way s1

TEP repair - Duh last updated February 2007

Patient Preparation: Preoperative note completed. Generally lap hernias only performed in bilateral or recurrent hernias that are symptomatic

Key Equipment and Instruments: 10mm 30deg scope 2 x 5mm VersaSTEP ports 11mm structured-balloon trocar with pump (NOT balloon dissector, which Dr. Duh does not use) basic laparoscopic set Protack instrument Bard 3D Max mesh (comes in left and right, pointed side is lateral, always use large. If too big, overlap medially) in room, not opened 6in x 4.5in mesh (thin wide-woven mesh preferred, polyester or polypropylene) Setup Iodine prep (no chloroprep), no Foley: void before OR, no TEDS or SCDs, seatbelt, supine, both arms tucked, monitor directly off patients feet (inferiorly), antibiotics, shave in band along port sites, kefzol 1g IV.

Port Placement assuming right hernia, use mirror image for left hernias:

10mm camera 5mm working 5mm working

Procedure: transverse infraunbilical incision. S retractors to find rectus sheath. Transverse incision of anterior sheath 12mm on side of hernia. Avoid midline (sometimes linea alba wide). Mayo clamp to push rectus muscle laterally. develop space, identify posterior sheath. Insert structured-balloon port. Inflate balloon 2-3 full pumps. Cinch sponge to anchor trocar. Remove obturator, inflate to 15mmHg. Use camera to bluntly dissect laterally in preperitoneal space until lateral port sites can be placed under direct vision. Place working ports using finder needle with local anesthesia. Identify iliopubic tract, vas, vessels, lateral space, and hernia. If indirect, dissect sac off vessels \ and cord structures and reduce completely. Sometimes sac must be opened to reduce contents. If so, use endoloop to recluse sac after reduction Once reduced, prepare mesh: DIRECT: use Bard 3D large mesh. Pointed side goes laterally. INDIRECT: use 4.5 x 6 in flat sheet polyester or polypropylene, round the corners Pointed side of mesh goes laterally. Mark medial side with pen If indirect hernia present, slit mesh MEDIALLY. Inferior tail of mesh passes under cord structures (need to dissect a window) insert mesh via umbo port, grabbing lateral side, and push through port without rolling. Protacks: 2 in Cooper’s ligament just above bone (not pubic bone periosteum). 1 laterally above iliopubic tract pushing against your hand to get good purchase. Stay high to avoid lateral femoral cutaneous nerve. Deflate under direct vision to ensure mesh stays in right place Close rectus sheath with 0 maxon HGU46 Close skin 4-0 biosyn + Indermil

Postoperative Care: Home on vicodin / colace No restriction in activity Work in about 2 weeks 5% rate of postop urinary retention – patient must void before discharge.