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General and digestive surgery

Find all the surgical interventions, lectures, experts opinions, debates, webinars and operative techniques per specialty.
Left iliac fossa incisional hernia: live laparoscopic repair
Dr. Salvador Morales-Conde presents the clinical case of a 59-year old female patient managed for an incisional hernia with a 6-7cm sac in the left lower quadrant. The patient’s history included a left iliac fossa laparotomy to control bleeding caused by an epigastric artery injury following a laparoscopic appendectomy. The patient was placed in a Trendelenburg position. An optical port and two 5mm operating ports were inserted on the right lateral side of the abdomen. Peritoneal dissection was performed to expose anatomical landmarks including pubic bone, iliac crest, and iliac vessels for proper mesh fixation. The defect of the abdominal wall was closed using a continuous suture. A trimmed mesh (Parietex™ Composite Mesh) was inserted and fixed with tackers to Cooper’s ligament, to the iliac crest, and to the abdominal wall to sufficiently cover the sutured defect. Finally, the preperitoneal flap was fixed on the mesh to prevent intestines from getting into the mesh gap.
S Morales-Conde, T Urade, D Mutter, J Marescaux
Surgical intervention
1 month ago
2151 views
12 likes
3 comments
42:53
Left iliac fossa incisional hernia: live laparoscopic repair
Dr. Salvador Morales-Conde presents the clinical case of a 59-year old female patient managed for an incisional hernia with a 6-7cm sac in the left lower quadrant. The patient’s history included a left iliac fossa laparotomy to control bleeding caused by an epigastric artery injury following a laparoscopic appendectomy. The patient was placed in a Trendelenburg position. An optical port and two 5mm operating ports were inserted on the right lateral side of the abdomen. Peritoneal dissection was performed to expose anatomical landmarks including pubic bone, iliac crest, and iliac vessels for proper mesh fixation. The defect of the abdominal wall was closed using a continuous suture. A trimmed mesh (Parietex™ Composite Mesh) was inserted and fixed with tackers to Cooper’s ligament, to the iliac crest, and to the abdominal wall to sufficiently cover the sutured defect. Finally, the preperitoneal flap was fixed on the mesh to prevent intestines from getting into the mesh gap.
Laparoscopic TAPP approach to bilateral reducible inguinal hernia: live interactive procedure
We present the clinical case of a 57-year old male patient managed for a bilateral reducible inguinal hernia. The patient’s history included a right inguinal hernia repair in his childhood. A first port was inserted 1cm above the umbilicus and two 5mm ports were placed 7cm away from the umbilicus on the right and left side. Peritoneal dissection starts with a horizontal incision and parietalization is performed carefully to avoid injury to the vessels and deferent duct. After the myopectineal orifice has been sufficiently exposed, polypropylene meshes (Parietene™) trimmed to a 13 by 12cm size are inserted into the preperitoneal cavity and fixed using absorbable tacks. Finally, the meshes are fully covered using peritoneal flaps.
D Mutter, T Urade, J Marescaux
Surgical intervention
1 month ago
2240 views
19 likes
4 comments
46:18
Laparoscopic TAPP approach to bilateral reducible inguinal hernia: live interactive procedure
We present the clinical case of a 57-year old male patient managed for a bilateral reducible inguinal hernia. The patient’s history included a right inguinal hernia repair in his childhood. A first port was inserted 1cm above the umbilicus and two 5mm ports were placed 7cm away from the umbilicus on the right and left side. Peritoneal dissection starts with a horizontal incision and parietalization is performed carefully to avoid injury to the vessels and deferent duct. After the myopectineal orifice has been sufficiently exposed, polypropylene meshes (Parietene™) trimmed to a 13 by 12cm size are inserted into the preperitoneal cavity and fixed using absorbable tacks. Finally, the meshes are fully covered using peritoneal flaps.
Laparoscopic TEP unilateral inguinal hernia repair: a live interactive procedure
We present the clinical case of a 45-year old male patient managed for a right direct inguinal hernia. The patient’s history included a former approach for right inguinal hernia in his childhood and a laparoscopic left inguinal hernia repair. A first port was inserted below the umbilicus and access to the pubic bone was gained on the midline without using balloon. In this case, dissection of adhesions related to the previous operation was required. Attempts were made to identify anatomical landmarks after insertion of 5mm ports. The direct hernia content was dissected and reduced with blunt dissection. Once anatomical landmarks including pubic symphysis, Cooper’s ligament, epigastric vessels, spermatic cord, and psoas muscle were identified, a trimmed polypropylene mesh was inserted and the myopectineal orifice was sufficiently covered without fixation. Finally, the preperitoneal cavity was desufflated to complete the procedure.
B Dallemagne, T Urade, D Mutter, J Marescaux
Surgical intervention
1 month ago
570 views
8 likes
0 comments
39:46
Laparoscopic TEP unilateral inguinal hernia repair: a live interactive procedure
We present the clinical case of a 45-year old male patient managed for a right direct inguinal hernia. The patient’s history included a former approach for right inguinal hernia in his childhood and a laparoscopic left inguinal hernia repair. A first port was inserted below the umbilicus and access to the pubic bone was gained on the midline without using balloon. In this case, dissection of adhesions related to the previous operation was required. Attempts were made to identify anatomical landmarks after insertion of 5mm ports. The direct hernia content was dissected and reduced with blunt dissection. Once anatomical landmarks including pubic symphysis, Cooper’s ligament, epigastric vessels, spermatic cord, and psoas muscle were identified, a trimmed polypropylene mesh was inserted and the myopectineal orifice was sufficiently covered without fixation. Finally, the preperitoneal cavity was desufflated to complete the procedure.
Laparoscopic Spigelian hernia repair
Spigelian hernia is a rare condition and it is difficult to diagnose it clinically. It has been estimated to account for 0.12% of abdominal wall hernias. The hernia ring is a well-defined defect in the transversus abdominis aponeurosis. The hernia sac, surrounded with extraperitoneal adipose tissue, often lies interparietally passing through the transversus abdominis and the internal oblique muscle aponeuroses and then spreading out beneath the intact aponeurosis of the external oblique muscle. The laparoscopic repair is well-established. Most authors use a transperitoneal approach either by placing the mesh in an intraperitoneal position or by raising the peritoneal flap and placing the mesh in the extraperitoneal space. In this video, we demonstrate the laparoscopic repair of a Spigelian hernia through the transabdominal preperitoneal (TAPP) placement of a composite mesh.
A D'Urso, D Mutter, J Marescaux
Surgical intervention
1 month ago
732 views
5 likes
0 comments
08:23
Laparoscopic Spigelian hernia repair
Spigelian hernia is a rare condition and it is difficult to diagnose it clinically. It has been estimated to account for 0.12% of abdominal wall hernias. The hernia ring is a well-defined defect in the transversus abdominis aponeurosis. The hernia sac, surrounded with extraperitoneal adipose tissue, often lies interparietally passing through the transversus abdominis and the internal oblique muscle aponeuroses and then spreading out beneath the intact aponeurosis of the external oblique muscle. The laparoscopic repair is well-established. Most authors use a transperitoneal approach either by placing the mesh in an intraperitoneal position or by raising the peritoneal flap and placing the mesh in the extraperitoneal space. In this video, we demonstrate the laparoscopic repair of a Spigelian hernia through the transabdominal preperitoneal (TAPP) placement of a composite mesh.
LIVE INTERACTIVE SURGERY: left direct inguinal hernia: laparoscopic TAPP approach
We present the clinical case of a 50-year-old patient managed for a left direct symptomatic reducible inguinal hernia, with a palpable impulse on examination. The patient’s history included a left indirect inguinal hernia repair in his childhood.

The procedure begins conventionally with an open laparoscopy with the introduction of a supra-umbilical port. The exploration confirms the presence of a left hernia and rules out the diagnosis of right hernia. Dissection starts with a horizontal peritoneal incision, which allows to progressively parietalize all elements of the cord, making sure to stay in contact with the peritoneum. Dissection of the previously operated hernia dating back to the patient’s childhood is slightly more painstaking and constraining due to the presence of adhesion-related scars. However, the parietalization of the peritoneum is carried on without any particular problem, and considering that it is a direct hernia, the deferent duct is very easily identified and parietalized. Reduction of the direct hernia is performed easily with the reintroduction of the transversalis fascia. Given the small size of the hernia, the fascia will not be exteriorized.

After complete lowering, a 15 X 15cm polypropylene mesh (Parietene™) is recut to a 13 X 12cm size with external trimming. The mesh is positioned in order to cover all direct and internal hernial orifices. It is only fixed to Cooper’s ligament, to the anterior superior iliac spine, and to the anterior abdominal wall so as to prevent any early mobilization postoperatively. Reperitonization is then performed with peritoneal fixation using absorbable staples (of the AbsorbaTack™ type). Exsufflation is achieved under visual guidance.

The entire procedure is performed as an outpatient surgery. The patient was admitted to our unit just before the intervention. He is discharged a few hours later.
D Mutter, J Marescaux
Surgical intervention
1 year ago
16806 views
1392 likes
2 comments
25:14
LIVE INTERACTIVE SURGERY: left direct inguinal hernia: laparoscopic TAPP approach
We present the clinical case of a 50-year-old patient managed for a left direct symptomatic reducible inguinal hernia, with a palpable impulse on examination. The patient’s history included a left indirect inguinal hernia repair in his childhood.

The procedure begins conventionally with an open laparoscopy with the introduction of a supra-umbilical port. The exploration confirms the presence of a left hernia and rules out the diagnosis of right hernia. Dissection starts with a horizontal peritoneal incision, which allows to progressively parietalize all elements of the cord, making sure to stay in contact with the peritoneum. Dissection of the previously operated hernia dating back to the patient’s childhood is slightly more painstaking and constraining due to the presence of adhesion-related scars. However, the parietalization of the peritoneum is carried on without any particular problem, and considering that it is a direct hernia, the deferent duct is very easily identified and parietalized. Reduction of the direct hernia is performed easily with the reintroduction of the transversalis fascia. Given the small size of the hernia, the fascia will not be exteriorized.

After complete lowering, a 15 X 15cm polypropylene mesh (Parietene™) is recut to a 13 X 12cm size with external trimming. The mesh is positioned in order to cover all direct and internal hernial orifices. It is only fixed to Cooper’s ligament, to the anterior superior iliac spine, and to the anterior abdominal wall so as to prevent any early mobilization postoperatively. Reperitonization is then performed with peritoneal fixation using absorbable staples (of the AbsorbaTack™ type). Exsufflation is achieved under visual guidance.

The entire procedure is performed as an outpatient surgery. The patient was admitted to our unit just before the intervention. He is discharged a few hours later.
Transumbilical single-access laparoscopic subxiphoidal incisional hernia repair
Background: In this video, the authors report the case of a 65-year-old man who consulted for a subxiphoidal incisional hernia after open cardiac surgery. A transumbilical single access laparoscopic repair was proposed.

Video: The umbilical scar was incised and, after having placed a fascial umbilical purse-string suture, an 11mm reusable trocar was introduced. DAPRI curved reusable instruments (Karl Storz Endoskope, Tuttlingen, Germany) were introduced. The subxiphoidal hernia was put in evidence. The fatty tissue covering the defect was freed and the hernia defect was measured to be 8cm cranio-caudally and 6cm latero-laterally. A dual face mesh of 15 and 14cm (Surgimesh XB, Aspide Medical, Saint-Etienne, France) was chosen and introduced into the cavity through the 11mm trocar. The mesh was fixed against the abdominal wall using absorbable tacks (Sorbafix, Bard Davol Inc., Warwick, RI, US), and against the pericardial sheet using a polypropylene suture, in order to prevent any potential cardiac tamponade.

Results: The final umbilical scar was 15mm. Operative time was 65 minutes, and operative bleeding was insignificant. The patient was discharged on postoperative day 1. At visit consultations, no recurrence was evidenced.

Conclusion: Subxiphoidal incisional hernia after open cardiac surgery can be treated successfully using a transumbilical single access laparoscopy.
G Dapri, A Cadenas Febres, L Cardinali, SH Sondji, I Surdeanu, GB Cadière
Surgical intervention
2 years ago
1414 views
132 likes
0 comments
06:30
Transumbilical single-access laparoscopic subxiphoidal incisional hernia repair
Background: In this video, the authors report the case of a 65-year-old man who consulted for a subxiphoidal incisional hernia after open cardiac surgery. A transumbilical single access laparoscopic repair was proposed.

Video: The umbilical scar was incised and, after having placed a fascial umbilical purse-string suture, an 11mm reusable trocar was introduced. DAPRI curved reusable instruments (Karl Storz Endoskope, Tuttlingen, Germany) were introduced. The subxiphoidal hernia was put in evidence. The fatty tissue covering the defect was freed and the hernia defect was measured to be 8cm cranio-caudally and 6cm latero-laterally. A dual face mesh of 15 and 14cm (Surgimesh XB, Aspide Medical, Saint-Etienne, France) was chosen and introduced into the cavity through the 11mm trocar. The mesh was fixed against the abdominal wall using absorbable tacks (Sorbafix, Bard Davol Inc., Warwick, RI, US), and against the pericardial sheet using a polypropylene suture, in order to prevent any potential cardiac tamponade.

Results: The final umbilical scar was 15mm. Operative time was 65 minutes, and operative bleeding was insignificant. The patient was discharged on postoperative day 1. At visit consultations, no recurrence was evidenced.

Conclusion: Subxiphoidal incisional hernia after open cardiac surgery can be treated successfully using a transumbilical single access laparoscopy.
Single incision laparoscopic peritoneal hole repair during right TEP procedure
Background: Laparoscopic inguinal hernia repair offers various advantages both to the patient and the surgeon. Transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) repairs represent the two laparoscopic options. A personal technique of single incision laparoscopic TEP has already been published on WebSurg (Link: http://www.websurg.com/MEDIA/?noheader=1&doi=vd01en4054).
Video: This video demonstrates the single incision laparoscopic treatment of a peritoneal hole, which occurred accidentally during a right TEP procedure.
Results: The TEP procedure lasted 41 minutes and the peritoneal repair 8 minutes. The final umbilical scar length was 10mm and the patient was discharged within 24 hours.
Conclusions: Peroperative complications can occur during single incision laparoscopy, as well as during conventional laparoscopy and open surgery. The procedure can be performed without conversion or additional trocars, depending on the complications which occurred.
G Dapri
Surgical intervention
2 years ago
2175 views
148 likes
0 comments
04:03
Single incision laparoscopic peritoneal hole repair during right TEP procedure
Background: Laparoscopic inguinal hernia repair offers various advantages both to the patient and the surgeon. Transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) repairs represent the two laparoscopic options. A personal technique of single incision laparoscopic TEP has already been published on WebSurg (Link: http://www.websurg.com/MEDIA/?noheader=1&doi=vd01en4054).
Video: This video demonstrates the single incision laparoscopic treatment of a peritoneal hole, which occurred accidentally during a right TEP procedure.
Results: The TEP procedure lasted 41 minutes and the peritoneal repair 8 minutes. The final umbilical scar length was 10mm and the patient was discharged within 24 hours.
Conclusions: Peroperative complications can occur during single incision laparoscopy, as well as during conventional laparoscopy and open surgery. The procedure can be performed without conversion or additional trocars, depending on the complications which occurred.
Laparoscopic intraperitoneal mesh repair of a parastomal hernia
A 73-year-old male patient, previously submitted to a radical cystoprostatectomy with ileal conduit as urinary diversion for urothelial cancer, was admitted to the emergency department because of stomal tumefaction and malfunction. There was no evidence of oncologic relapse.
CT-scan revealed an abscess in the parastomal area as well as a parastomal hernia. The abscess was treated with percutaneous drainage and antibiotics. In a second time, he was submitted to a laparoscopic correction of the parastomal defect.
The procedure was performed with no-flexible cameras and straight laparoscopic instruments. For defect correction, a laparoscopic intraperitoneal mesh repair (IPOM) technique was used.
No complications were observed and the patient was discharged on postoperative day 6.
P Mota, P Leão, E Lima, H Rios, E Dias, A Goulart
Surgical intervention
3 years ago
2402 views
77 likes
0 comments
08:27
Laparoscopic intraperitoneal mesh repair of a parastomal hernia
A 73-year-old male patient, previously submitted to a radical cystoprostatectomy with ileal conduit as urinary diversion for urothelial cancer, was admitted to the emergency department because of stomal tumefaction and malfunction. There was no evidence of oncologic relapse.
CT-scan revealed an abscess in the parastomal area as well as a parastomal hernia. The abscess was treated with percutaneous drainage and antibiotics. In a second time, he was submitted to a laparoscopic correction of the parastomal defect.
The procedure was performed with no-flexible cameras and straight laparoscopic instruments. For defect correction, a laparoscopic intraperitoneal mesh repair (IPOM) technique was used.
No complications were observed and the patient was discharged on postoperative day 6.
Laparoscopic treatment of parastomal hernia and concomitant midline incisional hernia
An individual approach to the treatment of patients with incisional hernia is essential. The objective of this video is to demonstrate the advantages of a laparoscopic parastomal hernia repair in a selected patient.
This video demonstrates the case of a 61-year-old female patient (BMI of 28.4 kg/m2) with a huge parastomal hernia compromising the stoma care, and with a suspected midline incisional hernia. After a complete adhesiolysis, we were able to detect and measure both abdominal wall defects. After narrowing the parastomal defect, a local hernioplasty was performed by applying the Sugarbaker technique with a Parietex™ Parastomal Mesh (PCOPM15). For a midline incisional hernia, we used a Parietex™ composite mesh (PPC1510). Both prostheses were fixed to the abdominal wall with transfascial sutures and tacks (ProTack™). Both operative and postoperative periods were uneventful.
The laparoscopic treatment of a parastomal hernia should be considered as a first option because it endeavors to join the advantages of a minimally invasive approach with a low incidence of infection and recurrence rate, and offers the opportunity of repairing a concomitant incisional hernia, if present.
M Panovski, I Roso Sazdovska
Surgical intervention
3 years ago
2309 views
72 likes
0 comments
10:13
Laparoscopic treatment of parastomal hernia and concomitant midline incisional hernia
An individual approach to the treatment of patients with incisional hernia is essential. The objective of this video is to demonstrate the advantages of a laparoscopic parastomal hernia repair in a selected patient.
This video demonstrates the case of a 61-year-old female patient (BMI of 28.4 kg/m2) with a huge parastomal hernia compromising the stoma care, and with a suspected midline incisional hernia. After a complete adhesiolysis, we were able to detect and measure both abdominal wall defects. After narrowing the parastomal defect, a local hernioplasty was performed by applying the Sugarbaker technique with a Parietex™ Parastomal Mesh (PCOPM15). For a midline incisional hernia, we used a Parietex™ composite mesh (PPC1510). Both prostheses were fixed to the abdominal wall with transfascial sutures and tacks (ProTack™). Both operative and postoperative periods were uneventful.
The laparoscopic treatment of a parastomal hernia should be considered as a first option because it endeavors to join the advantages of a minimally invasive approach with a low incidence of infection and recurrence rate, and offers the opportunity of repairing a concomitant incisional hernia, if present.
Stomal prolapse and parastomal incisional hernia treatment using laparoscopic Sugarbaker modified technique with intraperitoneal onlay mesh repair
Introduction: Prolapse stands for one of the most common complications of colostomy (>10%). Parastomal incisional hernia also represents 10 to 50% of complications. When both are present, the Sugarbaker technique represents a good indication due to mesh repair and pseudo-subperitonization, which can manage both prolapse and hernia. The laparoscopic modified Sugarbaker technique can be performed laparoscopically even in case of multiple previous laparotomies.
Clinical case: We report the case of a 71-year-old male patient presenting with parastomal incisional hernia and stomal prolapse after multiple abdominal procedures for ulcerative colitis, including rectosigmoidectomy, Hartmann procedure for anastomotic leak, left extended colectomy and stomal transposition for ischemic necrosis. An intra-abdominal proctectomy was attempted to manage the recurrence of colitis on the rectal stump. However, this attempt proved unsuccessful, and a local abdominoperineal resection was performed. Due to symptomatic hernia and prolapse, the laparoscopic Sugarbaker modified surgical technique with intraperitoneal onlay mesh (IPOM) repair is performed to manage prolapse by pseudo-subperitonization and to manage hernia using an IPOM repair. As shown in this video, this technique is safe, reproducible, and effective.
J Leroy, HA Mercoli, S Tzedakis, A D'Urso, D Mutter, J Marescaux
Surgical intervention
3 years ago
2215 views
98 likes
0 comments
10:54
Stomal prolapse and parastomal incisional hernia treatment using laparoscopic Sugarbaker modified technique with intraperitoneal onlay mesh repair
Introduction: Prolapse stands for one of the most common complications of colostomy (>10%). Parastomal incisional hernia also represents 10 to 50% of complications. When both are present, the Sugarbaker technique represents a good indication due to mesh repair and pseudo-subperitonization, which can manage both prolapse and hernia. The laparoscopic modified Sugarbaker technique can be performed laparoscopically even in case of multiple previous laparotomies.
Clinical case: We report the case of a 71-year-old male patient presenting with parastomal incisional hernia and stomal prolapse after multiple abdominal procedures for ulcerative colitis, including rectosigmoidectomy, Hartmann procedure for anastomotic leak, left extended colectomy and stomal transposition for ischemic necrosis. An intra-abdominal proctectomy was attempted to manage the recurrence of colitis on the rectal stump. However, this attempt proved unsuccessful, and a local abdominoperineal resection was performed. Due to symptomatic hernia and prolapse, the laparoscopic Sugarbaker modified surgical technique with intraperitoneal onlay mesh (IPOM) repair is performed to manage prolapse by pseudo-subperitonization and to manage hernia using an IPOM repair. As shown in this video, this technique is safe, reproducible, and effective.
Colonic stomal prolapse and parastomal incisional hernia: laparoscopic Sugarbaker repair procedure
The objective of this film is to demonstrate stoma prolapse and parastomal incisional hernia repair according to the technique described by Sugarbaker in open surgery, reproduced here with a laparoscopic approach.
Mesh placement into the abdominal cavity presents a risk that seems minimized by the development of dual-sided composite meshes, with one collagen coating that will be in contact with the digestive tract, hence limiting the risk of adhesions.
The principle of the Sugarbaker technique is to create a colonic zigzag route and to fix it on the non-absorbable side of the mesh, thereby preventing colonic prolapse. The mesh is also used as an obstacle to the passage of small bowel loops into the parastomal defect.
Here, the difficulty lies in the combined presence of an incisional hernia and prolapse on a diverting transverse colostomy. The risk of vascular injury is all the more important. Here, authors highlight pitfalls as well as tips and tricks to overcome them.
J Leroy, J Marescaux
Surgical intervention
5 years ago
4078 views
108 likes
0 comments
11:09
Colonic stomal prolapse and parastomal incisional hernia: laparoscopic Sugarbaker repair procedure
The objective of this film is to demonstrate stoma prolapse and parastomal incisional hernia repair according to the technique described by Sugarbaker in open surgery, reproduced here with a laparoscopic approach.
Mesh placement into the abdominal cavity presents a risk that seems minimized by the development of dual-sided composite meshes, with one collagen coating that will be in contact with the digestive tract, hence limiting the risk of adhesions.
The principle of the Sugarbaker technique is to create a colonic zigzag route and to fix it on the non-absorbable side of the mesh, thereby preventing colonic prolapse. The mesh is also used as an obstacle to the passage of small bowel loops into the parastomal defect.
Here, the difficulty lies in the combined presence of an incisional hernia and prolapse on a diverting transverse colostomy. The risk of vascular injury is all the more important. Here, authors highlight pitfalls as well as tips and tricks to overcome them.
Incisional hernia: laparoscopic hybrid repair
About 10% of laparotomies are complicated by the development of incisional hernia (1). The prosthetic repair is the rule in the treatment of incisional hernia and is reported to have a lower recurrence rate than primary suture repair (2). The laparoscopic approach proposed since the early nineties with intraperitoneal onlay mesh (IPOM) repair has gained popularity over years. The IPOM technique is easy in case of midline incisional hernia but is more complex in case of lateral suprailiac hernia. The laparoscopic repair is associated with fewer infections as compared to the open technique (3). There are only very few reports on laparoscopic-endoscopic sublay mesh repair of abdominal wall hernias (4, 5).
We present the case of a 66-year-old patient admitted for an incisional hernia subsequent to an open liver resection for gallbladder carcinoma in 2011. The patient developed a symptomatic lateral incisional hernia in the right side of his subcostal incision. The oncologic preoperative work-up was negative. The patient was scheduled for a laparoscopic approach with a hybrid onlay and sublay mesh repair.
Here, authors aim to propose an original technique with a combined onlay and sublay approach to this complicated lateral abdominal incisional hernia.
Bibliographic references:
1. Mudge M, Hughes LE. Incisional hernia: a 10-year prospective study of incidence and attitudes. Br J Surg 1985;72:70-1.
2. Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 2004;240:578-83.
3. Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M. Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. Cochrane Database Syst Rev 2011;3:CD007781.
4. Schroeder AD, Debus ES, Schroeder M, Reinpold WM. Laparoscopic transperitoneal sublay mesh repair: a new technique for the cure of ventral and incisional hernias. Surg Endosc. 2013;27:648-54.
5. Miserez M, Penninckx F. Endoscopic totally preperitoneal ventral hernia repair. Surg Endosc 2002;16:1207-13.
A D'Urso, J Leroy, T Piardi, P Pessaux, J Marescaux
Surgical intervention
5 years ago
3683 views
54 likes
0 comments
07:27
Incisional hernia: laparoscopic hybrid repair
About 10% of laparotomies are complicated by the development of incisional hernia (1). The prosthetic repair is the rule in the treatment of incisional hernia and is reported to have a lower recurrence rate than primary suture repair (2). The laparoscopic approach proposed since the early nineties with intraperitoneal onlay mesh (IPOM) repair has gained popularity over years. The IPOM technique is easy in case of midline incisional hernia but is more complex in case of lateral suprailiac hernia. The laparoscopic repair is associated with fewer infections as compared to the open technique (3). There are only very few reports on laparoscopic-endoscopic sublay mesh repair of abdominal wall hernias (4, 5).
We present the case of a 66-year-old patient admitted for an incisional hernia subsequent to an open liver resection for gallbladder carcinoma in 2011. The patient developed a symptomatic lateral incisional hernia in the right side of his subcostal incision. The oncologic preoperative work-up was negative. The patient was scheduled for a laparoscopic approach with a hybrid onlay and sublay mesh repair.
Here, authors aim to propose an original technique with a combined onlay and sublay approach to this complicated lateral abdominal incisional hernia.
Bibliographic references:
1. Mudge M, Hughes LE. Incisional hernia: a 10-year prospective study of incidence and attitudes. Br J Surg 1985;72:70-1.
2. Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 2004;240:578-83.
3. Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M. Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. Cochrane Database Syst Rev 2011;3:CD007781.
4. Schroeder AD, Debus ES, Schroeder M, Reinpold WM. Laparoscopic transperitoneal sublay mesh repair: a new technique for the cure of ventral and incisional hernias. Surg Endosc. 2013;27:648-54.
5. Miserez M, Penninckx F. Endoscopic totally preperitoneal ventral hernia repair. Surg Endosc 2002;16:1207-13.
TAPP laparoscopic repair of right inguinal hernia after artificial sphincter placement for post-prostatectomy urinary incontinence
Incapacitating post-prostatectomy urinary incontinence may be managed by the placement of an artificial sphincter. This sphincter is composed of an inflatable circular tape (the sphincter itself), a remote control located in the scrotum, and of a reservoir connected to the sphincter by a catheter. This reservoir is positioned within the preperitoneal space using an anterior inguinal approach through a mini-incision in the transversalis fascia which weakens the posterior wall of the inguinal canal, hence increasing the risk of inguinal hernia.
This film demonstrates a typical case management of such hernia. The anterior approach is delicate as repair of the inguinal canal may well induce trauma to the catheter connected to the retromuscular balloon. The posterior approach is therefore valuable as it allows to see the balloon prior to dissecting the preperitoneal space. The film highlights the specific issues to be dealt with as well as the tips and tricks related to this approach.
J Leroy, C Saussine, J Marescaux
Surgical intervention
5 years ago
5188 views
108 likes
1 comment
08:18
TAPP laparoscopic repair of right inguinal hernia after artificial sphincter placement for post-prostatectomy urinary incontinence
Incapacitating post-prostatectomy urinary incontinence may be managed by the placement of an artificial sphincter. This sphincter is composed of an inflatable circular tape (the sphincter itself), a remote control located in the scrotum, and of a reservoir connected to the sphincter by a catheter. This reservoir is positioned within the preperitoneal space using an anterior inguinal approach through a mini-incision in the transversalis fascia which weakens the posterior wall of the inguinal canal, hence increasing the risk of inguinal hernia.
This film demonstrates a typical case management of such hernia. The anterior approach is delicate as repair of the inguinal canal may well induce trauma to the catheter connected to the retromuscular balloon. The posterior approach is therefore valuable as it allows to see the balloon prior to dissecting the preperitoneal space. The film highlights the specific issues to be dealt with as well as the tips and tricks related to this approach.
Single incision transumbilical laparoscopic bilateral inguinal hernia repair (TEP)
Background: Laparoscopic repair of inguinal hernia by preperitoneal mesh placement (TEP) has been popularized. Recently, with the advent of single incision transumbilical laparoscopy, this procedure has to be considered because it allows to place a big mesh with a very small final scar, which is also cosmetically acceptable.

Video: A 48-year-old male was admitted to hospital for right direct and indirect and left direct inguinal hernia. A single-incision transumbilical bilateral TEP was proposed. The patient was placed in a supine position with his legs straight. The surgeon stood first on the patient’s left and on the patient’s right later on in the procedure. The natural umbilical scar was incised and the rectus fascia on the left side was opened. A purse-string suture using Vicryl 1 was placed starting at a 9 o’clock position. An 11mm reusable metallic trocar was introduced behind the left rectus muscle into the preperitoneal space. A 0-degree, normal length and rigid scope was advanced into the 11mm trocar and the preperitoneal space was insufflated. This space was dissected using the optical system, first on the right side, and then on the left side. At the time of hernia sac retraction, a monocurved reusable grasping forceps IV according to DAPRI (Karl Storz Endoskope, Tüttlingen, Germany) was introduced inside the purse-string suture, at a 9 o’clock position, parallel to the 11mm trocar. The bilateral hernia sac was reduced, the peritoneal sheet was retracted, and the spermatic elements skeletonized. Two 15cm (latero-lateral) by 10cm (medial cranio-caudal) by 8cm (lateral cranio-caudal) polypropylene meshes (Bard Davol Inc., Warwick RI, US) were introduced through the 11mm trocar. Both meshes were adequately positioned using the monocurved grasping forceps, placing the lateral corner anteriorly to the peritoneal sheet and the medial corner underneath the pubic bone. Meshes were not fixed and the space was desufflated under view.

Results: Operative time was 67 minutes and the final incision length was 12mm. Postoperative pain was controlled by paracetamol (4 g/day) and the patient was discharged after 24 hours.

Conclusions: Single incision transumbilical bilateral TEP makes sense because it allows to place two big meshes using a very small final scar. This treatment allows to increase abdominal trauma reduction, already obtained through conventional multitrocar laparoscopic TEP.
G Dapri, L Gerard, V Zulian, M Bortes, J Bruyns, GB Cadière
Surgical intervention
5 years ago
4118 views
75 likes
2 comments
07:50
Single incision transumbilical laparoscopic bilateral inguinal hernia repair (TEP)
Background: Laparoscopic repair of inguinal hernia by preperitoneal mesh placement (TEP) has been popularized. Recently, with the advent of single incision transumbilical laparoscopy, this procedure has to be considered because it allows to place a big mesh with a very small final scar, which is also cosmetically acceptable.

Video: A 48-year-old male was admitted to hospital for right direct and indirect and left direct inguinal hernia. A single-incision transumbilical bilateral TEP was proposed. The patient was placed in a supine position with his legs straight. The surgeon stood first on the patient’s left and on the patient’s right later on in the procedure. The natural umbilical scar was incised and the rectus fascia on the left side was opened. A purse-string suture using Vicryl 1 was placed starting at a 9 o’clock position. An 11mm reusable metallic trocar was introduced behind the left rectus muscle into the preperitoneal space. A 0-degree, normal length and rigid scope was advanced into the 11mm trocar and the preperitoneal space was insufflated. This space was dissected using the optical system, first on the right side, and then on the left side. At the time of hernia sac retraction, a monocurved reusable grasping forceps IV according to DAPRI (Karl Storz Endoskope, Tüttlingen, Germany) was introduced inside the purse-string suture, at a 9 o’clock position, parallel to the 11mm trocar. The bilateral hernia sac was reduced, the peritoneal sheet was retracted, and the spermatic elements skeletonized. Two 15cm (latero-lateral) by 10cm (medial cranio-caudal) by 8cm (lateral cranio-caudal) polypropylene meshes (Bard Davol Inc., Warwick RI, US) were introduced through the 11mm trocar. Both meshes were adequately positioned using the monocurved grasping forceps, placing the lateral corner anteriorly to the peritoneal sheet and the medial corner underneath the pubic bone. Meshes were not fixed and the space was desufflated under view.

Results: Operative time was 67 minutes and the final incision length was 12mm. Postoperative pain was controlled by paracetamol (4 g/day) and the patient was discharged after 24 hours.

Conclusions: Single incision transumbilical bilateral TEP makes sense because it allows to place two big meshes using a very small final scar. This treatment allows to increase abdominal trauma reduction, already obtained through conventional multitrocar laparoscopic TEP.
TEP repair of a recurrent right inguinal hernia following failed TAPP repair: world’s first report
A 10mm paraumbilical balloon-tipped port was inserted into the preperitoneal space under direct vision and CO2 was insufflated.
Blunt dissection of the preperitoneal space to the pubis inferiorly and towards the left hernial orifices was performed using the 10mm laparoscope.
A further 10mm port was introduced into the pre-peritoneal space midway between the pubic symphysis and umbilicus. An atraumatic grasper was used to aid with further pre-peritoneal dissection. An indirect sac was identified on the left, freed from the adherent cord and then reduced. After excluding a direct hernia on the ipsilateral side and ensuring adequate clearance for mesh placement, a third 5mm port was introduced. This was inserted 1cm above and medial to the left anterior superior iliac spine
Dissection of the right pre-peritoneal space was performed using a combination of atraumatic graspers, scissors and diathermy. The mesh from the previous repair was identified and noted to be very adherent to the anterior abdominal wall. Careful and patient mobilisation revealed that this mesh had curled up and formed part of the contents of a direct inguinal hernia on the right. After meticulous dissection, the mesh was entirely freed from the anterior abdominal wall and direct space and reduced inferiorly remaining adherent to the underlying peritoneum. The inferior epigastric vessels were then identified. Preperitoneal dissection had resulted in distortion of their position such that they had been pulled down away from the anterior abdominal wall. Care was required not to injure these vessels as they were mobilised and lifted up to their normal anatomical position. The cord on this side was examined and after confirming the absence of an indirect sac, further preperitoneal dissection was performed to ensure adequate space for mesh placement.
Bilateral Bard™ 3D meshes were inserted ensuring adequate cover of all hernial orifices with overlapping of meshes in the midline. The left indirect sac and right direct hernia contents, consisting mainly of old mesh, were well clear of the new meshes. No tackers were used. CO2 insufflation was stopped and the preperitoneal space was allowed to close under vision ensuring no mesh displacement. Ports were closed via a standard technique.
MH Mobasheri, A Wan, G Vasilikostas , KM Reddy
Surgical intervention
8 years ago
5422 views
42 likes
0 comments
10:26
TEP repair of a recurrent right inguinal hernia following failed TAPP repair: world’s first report
A 10mm paraumbilical balloon-tipped port was inserted into the preperitoneal space under direct vision and CO2 was insufflated.
Blunt dissection of the preperitoneal space to the pubis inferiorly and towards the left hernial orifices was performed using the 10mm laparoscope.
A further 10mm port was introduced into the pre-peritoneal space midway between the pubic symphysis and umbilicus. An atraumatic grasper was used to aid with further pre-peritoneal dissection. An indirect sac was identified on the left, freed from the adherent cord and then reduced. After excluding a direct hernia on the ipsilateral side and ensuring adequate clearance for mesh placement, a third 5mm port was introduced. This was inserted 1cm above and medial to the left anterior superior iliac spine
Dissection of the right pre-peritoneal space was performed using a combination of atraumatic graspers, scissors and diathermy. The mesh from the previous repair was identified and noted to be very adherent to the anterior abdominal wall. Careful and patient mobilisation revealed that this mesh had curled up and formed part of the contents of a direct inguinal hernia on the right. After meticulous dissection, the mesh was entirely freed from the anterior abdominal wall and direct space and reduced inferiorly remaining adherent to the underlying peritoneum. The inferior epigastric vessels were then identified. Preperitoneal dissection had resulted in distortion of their position such that they had been pulled down away from the anterior abdominal wall. Care was required not to injure these vessels as they were mobilised and lifted up to their normal anatomical position. The cord on this side was examined and after confirming the absence of an indirect sac, further preperitoneal dissection was performed to ensure adequate space for mesh placement.
Bilateral Bard™ 3D meshes were inserted ensuring adequate cover of all hernial orifices with overlapping of meshes in the midline. The left indirect sac and right direct hernia contents, consisting mainly of old mesh, were well clear of the new meshes. No tackers were used. CO2 insufflation was stopped and the preperitoneal space was allowed to close under vision ensuring no mesh displacement. Ports were closed via a standard technique.
Laparoscopic TAPP for bilateral inguinal hernia
This video, recorded live during a surgical course, demonstrates the TAPP approach to bilateral hernia repair. Dr. Joel Leroy performs the repair using two separate meshes, one side at a time. This procedure is recommended to a general surgical audience.
The author uses a 3-trocar approach with a 0-degree 10mm optical scope. Exploration reveals some vivid landmarks, including abdominal wall adhesions from a previous appendectomy. The midline of the urinary bladder, umbilical ligament, vas deferens duct crossing behind the umbilical artery from behind —a key landmark the author will use during dissection of the peritoneum — and spermatic vessels all come into view. The direct hernia is visible between the epigastric vessels, retracted medially, and the umbilical ligament, retracted into the sac. When the author tries to reduce the sac, pressure pushes it back.
J Leroy
Surgical intervention
11 years ago
5396 views
130 likes
0 comments
12:37
Laparoscopic TAPP for bilateral inguinal hernia
This video, recorded live during a surgical course, demonstrates the TAPP approach to bilateral hernia repair. Dr. Joel Leroy performs the repair using two separate meshes, one side at a time. This procedure is recommended to a general surgical audience.
The author uses a 3-trocar approach with a 0-degree 10mm optical scope. Exploration reveals some vivid landmarks, including abdominal wall adhesions from a previous appendectomy. The midline of the urinary bladder, umbilical ligament, vas deferens duct crossing behind the umbilical artery from behind —a key landmark the author will use during dissection of the peritoneum — and spermatic vessels all come into view. The direct hernia is visible between the epigastric vessels, retracted medially, and the umbilical ligament, retracted into the sac. When the author tries to reduce the sac, pressure pushes it back.
Anatomical landmarks and TAPP approach for right inguinal hernia
This video, recorded live during a surgical course, demonstrates the TAPP approach to unilateral hernia repair. A detailed discussion of the technique is presented by Dr. Joel Leroy. This procedure is recommended to a general surgical audience.
The author carries out this transabdominal preperitoneal approach using 3 trocars: a 12mm (for mesh and camera), and two 5mm trocars. After exploration to assess the anatomy, the author proceeds to determine the landmarks. With the left trocar, he takes down adhesions from a previous appendectomy. Using low-energy coagulation, he carries out the vertical incision. The procedure continues as he carries out the dissection laterally and then places the mesh.
J Leroy
Surgical intervention
11 years ago
6729 views
204 likes
3 comments
12:55
Anatomical landmarks and TAPP approach for right inguinal hernia
This video, recorded live during a surgical course, demonstrates the TAPP approach to unilateral hernia repair. A detailed discussion of the technique is presented by Dr. Joel Leroy. This procedure is recommended to a general surgical audience.
The author carries out this transabdominal preperitoneal approach using 3 trocars: a 12mm (for mesh and camera), and two 5mm trocars. After exploration to assess the anatomy, the author proceeds to determine the landmarks. With the left trocar, he takes down adhesions from a previous appendectomy. Using low-energy coagulation, he carries out the vertical incision. The procedure continues as he carries out the dissection laterally and then places the mesh.
Removal of mesh plug and TEP repair of a recurrent left inguinal hernia in a 72-year-old man
This video demonstrates in great detail the laparoscopic TEP approach to recurrent hernia. The previously placed mesh plug is carefully dissected and removed. The preperitoneal space is thus created in order to place a mesh in the correct position. This video is suitable for experienced laparoscopic hernia surgeons.
The author begins the dissection lateral to the inferior epigastric vessels, then uses sharp dissection to take down the adhesions. This step requires caution because of the proximity of major vessels. The author then continues with sharp and blunt dissection to further develop the lateral peritoneal space. A few clean sweeps of the scissors or blunt forceps downward make adequate space lateral to the inferior epigastric vessels for mesh placement.
P Arora
Surgical intervention
11 years ago
867 views
35 likes
0 comments
11:28
Removal of mesh plug and TEP repair of a recurrent left inguinal hernia in a 72-year-old man
This video demonstrates in great detail the laparoscopic TEP approach to recurrent hernia. The previously placed mesh plug is carefully dissected and removed. The preperitoneal space is thus created in order to place a mesh in the correct position. This video is suitable for experienced laparoscopic hernia surgeons.
The author begins the dissection lateral to the inferior epigastric vessels, then uses sharp dissection to take down the adhesions. This step requires caution because of the proximity of major vessels. The author then continues with sharp and blunt dissection to further develop the lateral peritoneal space. A few clean sweeps of the scissors or blunt forceps downward make adequate space lateral to the inferior epigastric vessels for mesh placement.
Right inguinal hernia and intrafascial psoas hernia: TEP repair
This is a video demonstrating the laparoscopic preperitoneal approach to repair a right inguinal hernia. The Veress needle is used directly at the beginning of the procedure to create the preperitoneal space. Interestingly, a psoas herniation is also discovered during the dissection. This video is suitable for general surgeons with an interesting laparoscopic hernia surgery.
The authors gain view of the pubic bone, following it to the Cooper’s ligament. Their goal is to create space with blunt dissection and gentle traction only. They proceed with caution to avoid the epigastric vessels. The hernia comes into view, but the authors remain close to the hernia sac to avoid the epigastric vessels until they discern the exact anatomy. This guides the operators to the hernia, and they then continue to develop additional lateral space.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
11 years ago
1840 views
53 likes
0 comments
13:39
Right inguinal hernia and intrafascial psoas hernia: TEP repair
This is a video demonstrating the laparoscopic preperitoneal approach to repair a right inguinal hernia. The Veress needle is used directly at the beginning of the procedure to create the preperitoneal space. Interestingly, a psoas herniation is also discovered during the dissection. This video is suitable for general surgeons with an interesting laparoscopic hernia surgery.
The authors gain view of the pubic bone, following it to the Cooper’s ligament. Their goal is to create space with blunt dissection and gentle traction only. They proceed with caution to avoid the epigastric vessels. The hernia comes into view, but the authors remain close to the hernia sac to avoid the epigastric vessels until they discern the exact anatomy. This guides the operators to the hernia, and they then continue to develop additional lateral space.