Robotic General Surgery

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SECTION 2 • Discipline-Based Practice - General Surgery

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FIGURE 6.3 Developing an appropriate preperitoneal pocket for mesh. A, Lateral dissection. B, Parietalization of cord structures. C, Mesh placement. D, Mesh fixation to ipsilateral Cooper ligament.

hernia repair that allows for a reproducible approach. The following describes the critical steps to establish ing an adequate dissection of the myopectineal orifice. Figure 6.4 summarizes essential aspects of obtaining the critical view. 1. Identification of Cooper ligament and the pubic tubercle across the midline: Beyond identification of the ipsilateral Cooper ligament, we recommend aiming to identify the contralateral Cooper liga ment, in particular for cases with medial defects (eg, femoral, obturator, direct, suprapubic). 2. Evaluate for direct hernia: It is important to recog nize that many direct hernias will not have a peri toneal invagination in the transabdominal view. However, upon performing a preperitoneal dissec tion, a number of direct defects may be identified. Care should be taken to completely reduce unusual appearing fat in the space and clearly identify the ipsilateral Cooper ligament. 3. Perform an adequate retropubic dissection: To ensure that the mesh prosthesis is not dislodged with bladder distension, it is advisable to develop at least 2 centimeters of retropubic dissection between Cooper ligament and the bladder. 4. Evaluate for femoral hernia: Dissection is then car ried along Cooper ligament, medial to the femoral vein, assessing for and reducing femoral hernias.

There will likely be adipose and lymph tissue in this space, and care should be taken to avoid exces sive dissection. 5. Evaluate for indirect hernia: Next, the indirect space is evaluated. Peritoneum that is invaginating into this space should be reduced, taking care to avoid injury to the vas deferens and gonadal vessels. The cord elements should be parietalized sufficiently to ensure that the mesh prosthesis will sit flat in the space. For the vas deferens, the surgeon should care fully assess and ensure that the vas is not tented up because of attachments to the distal elements of the medial umbilical ligament. Visual cues that the dis section is complete can be performed by manipulat ing the peritoneal flap and observing if there is any movement of the cord components. With adequate parietalization, the cord contents will be indepen dent of the peritoneal flap such that manipulation of the peritoneum will not induce any movement. 6. Evaluate for a lipoma of the cord: The deep ring should be explored after reduction of a hernia sac to determine if a lipoma is present. These often appear small and inconsequential but may be the lead point for a retroperitoneal recurrence. If a cord lipoma is reduced, it is not necessary to resect the tissue but care should be taken to ensure the lipoma is positioned posterior to the mesh, ensuring it cannot track back through the

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