In this video we present the case of a 98 year old chinese gentleman who presented to the emergency department for 2 days of painful right groin lump. He has a history of bilateral inguinal hernia for many years, but declined surgery. Otherwise, his past medical history includes degenerative disc disease, osteoporosis and hearing impairment. On presentation, he was able to tolerate oral feeding with no nausea or vomiting and still able to pass stools. On examination, there was a large and tender right irreducible inguinal hernia with overlying erythema and warmth. There was also a small left inguinal hernia that was reducible. CT Abdomen-Pelvis was done and showed an incarcerated right inguinal hernia containing a loop of sigmoid colon with poor enhancement of the bowel wall. The colon proximal to the incarcerated segment was also mildly dilated.
Patient underwent urgent repair of the strangulated right inguinal hernia via laparoscopic, transabdominal preperitoneal (TAPP) approach. Intra-operatively, a loop of sigmoid colon was incarcerated within a direct right inguinal hernia. A small colotomy had to be made to decompress the incarcerated loop in view of difficulty in reducing the sigmoid colon. After reduction, the incarcerated segment was gangrenous and non-viable requiring sigmoid colectomy with primary anastomosis. Pantaloon inguinal hernias with femoral hernias were seen over bilateral groins. An Ultrapro 10x15cm composite mesh was inserted over bilateral groins with adequate medial overlap ensured.
The operation took three hours and fifty minutes with minimal blood loss. Drain was removed and feeding was escalated to diet on post-operative day four. Patient was able to pass stools and then discharged on post-operative day six. His case was complicated with a small 2cm seroma at the right groin.
In this video we present the case of a 98 year old chinese gentleman who presented to the emergency department for 2 days of painful right groin lump. He has a history of bilateral inguinal hernia for many years, but declined surgery. Otherwise, his past medical history includes degenerative disc disease, osteoporosis and hearing impairment. On presentation, he was able to tolerate oral feeding with no nausea or vomiting and still able to pass stools. A large and tender right irreducible inguinal hernia with overlying erythema and warmth was noted. There was also a small left inguinal hernia that was reducible. CT Abdomen-Pelvis done showed an incarcerated right inguinal hernia containing a loop of sigmoid colon with poor enhancement of the bowel wall. The colon proximal to the incarcerated segment was also mildly dilated.
- Bilateral groin hernias
- Complex groin hernias: sliding inguinal hernia, strangulated hernia, incompletely reduced groin hernia, groin hernia with adhesions around the orifice
- Female patients with groin hernia
- Recurrent hernia after previous open anterior repair
- Pelvic floor hernia
- Conversion from TEP repair when difficulty arises during TEP repair of hernia
- Patients who are not suitable for general anesthesia
- Patients who are not suitable for pneumoperitoneum
- Relative contraindication: previous pelvic irradiation (can result in induced fibrosis and adhesion in pelvis resulting in dense adhesions around the iliac vessels and myopectineal orifices in the pre-peritoneal space)
Operation is done under general anesthesia, with the patient placed in supine position with both hands tucked in. The laparoscopic camera screen is placed at the patient's foot. The main surgeon stands on the contralateral side of the hernia, while the camera assistant holding the laparoscope stands behind the main surgeon facing the camera screen. The first assistant stands on the opposite site (side of hernia).
An infra-umbilical incision was first made for open insertion of Hasson's port. Pneumoperitoneum is created with carbon dioxide generally at 12–15 mmHg pressure. 5mm ports were then inserted over the right and left flank under direct vision. In this video, an additional 5mm assistant port was inserted over the right flank after diagnostic laparoscopy for retraction. The 5mm left flank port was also converted to a 12mm Excel port to allow the passage of the laparoscopic surgical staplers for bowel resection. At the end of the operation, the midline incision was extended for specimen extraction through a wound protector
Pre-operative blood investigations - full blood count, renal panel, coagulation studies, electrocardiogram and chest x-ray to ensure that patient is fit for operation
1. Diagnostic laparoscopy
2. Reduction of hernia
3. Bowel resection and anastomosis - sigmoid colectomy done in this case as incarcerated segment was gangrenous and non-viable
4. Identification of hernia defect
5. Creation of pre-peritoneal flap
6. Mesh placement
7. Closure of peritoneum
Advantages: lower incidence of post-operative chronic pain, lower risk of wound infection, shorter duration of stay in hospital
Possible complications:
1. Bleeding
2. Wound infection
3. Mesh infection
4. Hernia recurrence
5. Post-operative pain/numbness
6. Seroma formation
7. Any perforation or intra-abdominal soilage would contraindicate the use of mesh for hernia repair - would require primary hernia repair rather than mesh repair
This is case, patient developed a small 2cm seroma at the right groin. This was managed conservatively and resolved spontaneously thereafter.
N.A.
N.A.
N.A.
Review Laparoscopic TAPP mesh repair of a strangulated right inguinal hernia. Cancel reply
Related Videos
Temporal Artery Biopsy – gold standard for the diagnosis of temporal (giant cell) arteritis
As technique and technology have evolved in the modern age, surgical emphasis has shifted steadily towards minimally invasive alternatives. In colon surgery, laparoscopy has been shown to improve multiple outcome metrics, including reductions in post-operative morbidity, pain, and hospital length of stay, while maintaining surgical success rates. Unfortunately, despite the minimally invasive approach, elective laparoscopic sigmoidectomy typically requires an abdominal wall extraction site, leaving a large incision in addition to the laparoscopic port sites. It also utilizes three different types of intestinal staplers, leading to an anastomosis that may have multiple intersecting staple lines, thereby potentially influencing the anastomotic integrity, as well as increasing procedural costs substantially.
We present a case of a totally robotic sigmoidectomy utilizing a single stapler technique and natural orifice specimen extraction in a patient with multiple, severe, recurrent episodes of sigmoid diverticulitis over a 2-year period.
Disclosure/ Conflict of interest: The authors whose names are listed above certify that they have NO affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers ’bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
Review Laparoscopic TAPP mesh repair of a strangulated right inguinal hernia.