Laparoscopic ipom plus

Dr Pravin John & Dr John Thanakumar, Anurag Hospital, Coimbatore present on ventral hernia laparoscopy

1. LAPAROSCOPIC IPOM PLUS DR.PRAVIN HECTOR JOHN, MS, FIAGES, FALS, FIBC DR.JOHN AC THANAKUMAR MS, MNAMS, FRCS, FRCS, FICS, Dip MIS (FR), FALS

2. IPOM-INTRA PERITONEAL ONLAY MESH IPOM Plus = Defect closure with suture + IPOM

3. INDICATIONS: Ventral hernia Incisional hernia Recurrent hernia Defects up to 5cm

4. CONTRAINDICATIONS: To laparoscopy in general Shock Cardiorespiratory compromise Pregnancy Specific to IPOM plus Fecal peritonitis Gangrene bowel Intra-abdominal sepsis Large defects with LOD Pediatric age group Cirrhosis with caput medusae

5. POSITION & OPERATION THEATRE SETUP Ergonomics Supine Arms tucked Empty bladder

6. ERGONOMICS: Straight line (Surgeon, operating organ and monitor to be in straight line) Azimuth angle Manipulation angle Elevation angle

7. OT SETUP

8. Mesh Coated (Dual) mesh 10*15cm, 15*15cm or larger Visceral side: repels adhesions and ingrowth Parietal side: integrates into abdominal wall 7-14 days for neo-peritoneum formation No polypropylene mesh!!

9. INSTRUMENTS: Laparoscopic set and open surgery set Laparoscopic camera unit with 30 degree scope Dual mesh of adequate sizes Trocar, Verres needle Suture passer Thick non absorbable suture (1-prolene, loop Ethilon) Suture for fixing mesh (non absorbable) Trackers (absorbable/non-absorbable) Bowel grasper Medium grasper Curved Maryland Needle holder Energy source

10. PORTS: 3 or 4 ports: Camera 10-12mm Working 5mm ports Triangulation for ergonomics

11. PROCEDURE: PART 1 Verres needle or Hassan open entry or direct view trocar entry Diagnostic laparoscopy Adhesiolysis and reduction of contents Measure defect with low IAP Choose dual mesh size Suture defect-non absorbable suture Sac bite to prevent seroma Defect closure at low pneumoperitoneum Re-insufflate

12. Mesh deployment and fixation Centering stitch 3 to 5cm overlap of mesh with normal tissue all around defect 4 corner transfascial sutures Sutures to fix mesh-intracorporeal suturing Tacks: Double crowing-1 to 2 cm apart Omentum between mesh and bowel Correction of divarication when large Skin closure with steristrip/subcuticular PROCEDURE: PART 2

13. FOR / AGAINST IPOM PLUS FOR : RESTORES FUNCTIONALITY OF ABDOMINAL WALL AGAINST : REPAIR UNDER TENSION LARGE DEFECTS SUTURE CUT THROUGH CENTERING STITCH ON MESH FOR : HELPS ADEQUATE POSITIONING AGAINST : CAN GET INFECTED AS IT IS SUBCUTANEOUS TACKERS FOR : NON ABSORBABLE – LESS PAIN, ADHESIONS AGAINST : ONLY 2 MM PENETRATION GLUE FOR : PAINLESS AGAINST : EXPENSIVE

14. POST OP CARE: Oral fluids 4 hours---normal diet Ambulate Chest physiotherapy Adequate analgesia Antibiotics for 24 hours Discharge 48 to 72 hours Pressure dressing over hernia site or abdominal support if necessary

15. COMPLICATIONS: Trocar injury (vascular, hollow viscus) Seroma Recurrence Wound infection Intestinal obstruction Port site hernia

16. To minimize complications ENTRY OPEN HASSON DIRECT VIEW CARE IN SCARRED ABDOMEN CHECK FOR INJURY DIAGNOSTIC LAPAROSCOPY RULE OUT OTHER DISEASE INSPECT BOWEL INJURY CHECK AHDESIOLYSIS PATIENCE SCISSORS NO CAUTERY HEMOSTASIS - BIPOLAR PREVENT BOWEL TRAUMA GENTLE MANIPULATION HOLD MESENTERY ATRAUMATIC GRASPER AVOID ENERGY NEAR BOWEL VISUALLY INSPECT BOWEL RE-LAPAROSCOPE IF DOUBTFUL

17. To minimize complications ENTEROTOMY – WHAT NEXT? DEFER REPAIR? GROSS SPILLAGE OUTSIDE LUMEN? SURGEON’S WISDOM PAIN GLUE LIBERAL LOCAL ANALGESIA ADEQUATE IV ANALGESIA SEROMA COMPRESSION DRESSING CLOSE DEFECT BITE ON SAC DURING CLOSURE CAUTERY – INCREASED INFECTION! MESH INFECTION PROPHYLACTIC & PERIOPERATIVE ANBIOTICS STERILITY OF INSTRUMENTS CHANGE GLOVES MINIMUM HANDLING OF MESH POST AS FIRST CASE NEW FIXATION DEVICE LARGER PORE MESH

18. To minimize complications INTESTINAL OBSTRUCTION TISSUE SEPARATING MESH LARGER MESH MORE SUTURES TACKERS AT PERIPHERY OF MESH INTERPOSE OMENTUM BETWEEN MESH AND BOWEL PREVENT RECURRENCE PRE-OP OPTIMISATION APPROPRIATE TECHNIQUE 5CM OVERLAP OF MESH COVER INCISION SITE IF NECESSARY LARGE MESH TRANSFASCIAL SUTURES ANCHOR MESH EDGES WITHOUT GAP CENTRE MESH WELL

19. LVHR

20. ANURAG HOSPITAL NO.8, KRISHNA NAGAR, SOWRIPALAYAM MAIN ROAD, COIMBATORE -641028 PH: 8015087871 ; 0422-4341486 EMAIL: [email protected] Web: www.anuraghospital.com