CARLUCCI BILATERAL INGUINAL HERNIA

Good morning. Today we are approaching a patient with bilateral inguinal hernia.

He is 48 years old and the largest hernia is on the right side.

We approach laparoscopically with a TAP technique,

transperitoneal technique, as we use in bilateral hernia.

The operation will be done by Dr. Carlucci and Dr. Rocchetti, and we're going to start, okay?

It's a three trocha technique with the first trocha placed by the belly and the two trochas laterally by the mid-clavular line, okay?

So we're going to start.

Okay, we start now.

Hello?

Bisturi?

Un vasetto.

Mhm.

C'è già dentro.

Ok.

Ok.

Sì.

Scusa.

Siamo in Dellenburg.

Va troppo?

Troppo?

Troppo?

Basta?

Ok.

Mettiamo in trocca.

Ti conviene venire di qua.

Ok.

Pulire la telecamera.

Abbassa un po' il letto, per favore.

Basta?

Mi devi far vedere, per favore.

Gira la telecamera.

Ok.

wave you can start the intervention is the description of the case

clinical thanks but describe the case rome rome you hear me

forbice pinza allo roma attenzione sono amica re da roma il vostro collegamento è in onda

potete iniziare l'intervento è la descrizione del caso clinico grazie allora luca tu inizia

attenzione good morning il vostro collegamento è in onda potete iniziare l'intervento è la

description of the clinical case thank you let me see straight please

now we we start with the operation in this site there is the iliac spine and we proceed with to

To cut the peritoneal.

Good morning to everybody.

The patient we are approaching is a 48-year-old male with a bilateral inguinal hernia.

As you can see, the largest defect is on the left side.

The patient has a BMI of almost 25.

He has previous abdominal surgery.

as you can see the paratomic appendectomy now we are approaching the peritoneal scar of the

previous surgery at this point we start with this section of the peritoneum from the iliac spine

to the umbilical artery as you can see with a deep dissection and okay

Here we can see the epigastric vessels and now we are searching for the Cooper ligament

that is a marker point for our dissection and for the reconstruction.

Now we can see the deferent, this one, this white, these are all our marker points for

prepare it to allow the positioning of the mesh. Here it is, you can see it over there.

Buongiorno. Hello. Hello. Buongiorno, good morning. Good morning. Buongiorno. My name

My name is Umberto Grandi. I will be with you during your procedure.

Sorry, I don't understand.

I'm so sorry. I don't know if it's a problem of audio.

I'm Umberto Grandi from Ravenna on behalf of Professor Palazzini.

I just wanted to thank you for joining us in these two surgical days.

Can you hear me? Can you hear me clearly?

Okay, great. I will be with you during your procedure.

So I see you are going to perform a transabdominal preperitoneal hernia repair.

Yeah.

Great.

We have been so fond of hernia repair during the last decades.

I'm from Ravenna and I have been able to stay with Professor Stancanelli so many times during these procedures.

So it's something we do like most.

usually the deferent duct goes on your left

and it performs a triangle with the vessels

that you can see they are going on the right

I'm sorry I joined you late

and probably there are some things you already told to the audience

so this looks like to be a right hernia

and it looks like a right hernia and I don't know if you already told told us

something about the trochan positioning we did it before but we can repeat if

you need well I really I really don't need but I'm so sorry we joined you on

when you already started your procedure yeah

So we use the 3-4 technique with the optical trochars placed by the belly and the other

two trochars laterally to the metronome and we start with the right ear as you can see

we open the peritoneum from this iliac spine to the umbilical artery immediately.

And as we stressed before, it's really important to make a deep dissection

until the cupral ligament in order to correctly place the mesh at the end of the dissection.

It's really important to identify the spermatic vessel

And you can see the iliac vessels, the vein and artery is quite slim, so you can see them quite clearly.

I would say before the patient has been operated a lot of years ago, has performed a appendectomy,

so we have to face some address at the beginning of the operation due to previous surgery.

Surgery. Preparing all the walls. Here we are approaching the pain triangle on the right side.

You can see the internal ring. This is the internal ring that you can see here.

It was a direct hernia so it was on our left, on the left of the epigastric vessels.

Both hernias are quite small, as you can see, but very disturbing for the patient,

that is an active part of the life, so we have to correct both the effects.

Okay, Titranger, give me the bipolar, let me see it.

He is lean so we can really see very clearly the structures we have to recognize and preserve.

I think we are ready to put the mesh on.

The Cooper ligament over there, the vessels as we've seen before,

and the funicular structures here on the right the vessels and on the left the diaphragm.

Mesh.

Is it possible to find the mesh?

I have a 10x15.

This is 15x15.

This is not right.

No, this is 15x15.

We usually cut the mesh, performing even the plates for the vessels.

Can you tell to the audience what kind of mesh you are going to use while you are shaping

it right now?

yeah yeah can we show the shape of the measure yes we use a 10 15 mesh and we

usually shape it to understand which to give the place for the vessels and we

We place the bigger part on the Cooper ligament

Okay, okay, this is the ultra pro-advanced

Resorbable mesh

macroporous and

We usually

utilize this kind of mesh

mesh surrounding the Cooper ligament to cover all the possibility of the

This is why we use a very big mesh to cover all the defects of the possible defect.

What is important is the largest is the section, especially medially, the better will be the mesh.

All the defects have been covered and repaired.

Direct hernia like in this case, also indirect, also femoral or internal.

We don't know if we already know what we are saying and what we are doing,

and so maybe we are quite simple in our...

I think that the images are perfectly clear

and there is no question from the audience right now. I just wanted to ask you

can you show us, I mean superiorly, where the

defect was, and having

the peritoneum somehow detached from the... yes, great.

Thank you. Okay. That's what I was

was asking for. Thank you to you. No problem.

above the cupar ligament as you can see on on the left of the molecular structures

how many centimeters of overlap do you rely on normally normal we perform like five centimeters

meters at each side to be sure to have the less number possible of recurrence.

Well, how are you going to, well, again, I beg your pardon.

Yes, okay, can you take, that's the move I wanted you to do.

Thank you so much.

Just to get the prosthetic patch somehow higher.

Great, great, great, great, thank you.

I really think it's a surgical procedure,

very satisfying from the anatomical point of view.

This is the T.A.P.P. procedure, I mean.

Yes.

Okay.

Call the glue.

Use the...

Fibrin glue.

Fibrin glue to put the mesh in place.

Two centimeters for each mesh.

And we put the glue on the tupper ligament and on the mesh,

on the upper side and on the downer side of the mesh.

Okay.

We think that this mesh is the best one to perform this kind of operation and this kind

of, this kind of way of fixing the mesh is the best one to avoid pain and damage, yes.

Yes, you are right, you can glue wherever you want, so there is no problem that you

have with endohernia or whatever, definitely, I agree.

hernia I mean bilateral or recurrence yes usually the usual indications so bilateral hernia or sport

hernia some usually in young young patients and recurrence hernia monolateral or bilateral the

the recurrence one. We never perform for primary singular hernia. This case was a young patient

who was a runner or something like that, who was quite disturbed by these little hernias

so he asked us to repair them both and to perform it in the mini-invasive way to start

peritoneal defects in order to avoid bowel migration or nation between the peritoneal

sheets and the mesh you are right i can recall a couple of patients having an

intestinal obstruction due to a shutter-like effect of the two flap peritoneal flaps

It's really difficult to clinically understand because you usually don't feel the hernia

because the bowel has migrated between the two sheets.

So it's literally an intra-abdominal cavity but has been herniated.

And I just wanted to tell you that we, of course, we performed the same approach.

I mean, by laparoscopy it was quite easy to take out the intestinal loop that was stuck inside

side and then close in a better way the two peritoneal flaps and it was easy and

well it occurred I well the two patients that I recall it occurred some days

after the operation some days we had a case like yours and we did it by

laparoscopy as you did and it was one week after the operation so it

went at home the same day of operation and good conditions and well canalized

and then it came back to emergency seven days later with this problem and we

approached laparoscopy and as you did we we could repair the defect

laparoscopy and one thing we learned by experience it was not to cut this

these adhesions when you find some color peritoneal adhesion we never cut this

because you you perform a hole in the in the peritoneal layer and it's difficult

to repair it so we usually leave these kind of adhesions in place so we can see

on the other side this is the hernia the fact that is yes direct medial to the

big acid vessels so we can understand that this is a direct hernia and we have to change our side.

Clean the camera.

We can see the bulging on the peritoneal surface here.

Do you see it?

It's quite medial this hernia so we have to be careful.

We can see in transparency all the structure we need because it's quite slim and we can see it.

The dissection in direct hernia, as well as in the ones that we call obliquo interne,

as well, it's so satisfying and so easy.

yeah not not the same we can say when we when we have to dissect the the position

you are dissecting now the indirect area can can be somehow tricky

The position on him will be not hurt very bad, because it's a completely different view.

Yeah.

Thanks to the doctor's view, it's quite easy to make the right accession, as always happens in laparoscopy surgery.

In few seconds we will reach the patch, the prosthetic patch on the opposite side.

Yes, we did.

You have to stop the camera, otherwise I can't see you.

Come here. Perfect.

The mesh on the other side.

So we are sure we are in the right position and we did the correct resection.

and the sector there and I'll go here

you can see the other size that we are preparing

Thank you

There you can see the whole

the colonotis over there

Ok, bipolar that works

Polare doesn't work.

Monopolare.

Complete this section.

Farbice.

You can see them here, as before, this triangle made by the deferent duct on the right this

time and the vessels on the left.

I hope to complete the preparation of the layer where we have to put the mesh.

Lateral.

Lateral.

as big as we can

Usually after this kind of surgery

the patient will be discharged on the same day

We don't say anything about this patient in order to avoid the Italian surgery.

We never talk about discharge during the operation.

But in selected patients, we think it is quite safe to discharge the same days of surgery.

You can see the iliac vessels between the funicular structures.

Then we perform the same cut as before.

Let's turn on the camera.

Pinsa.

You can have a view.

Give me some space, please.

After surgery, the patient starts our brain killer as soon as possible, usually paracetamol.

So, it can continue after discharge.

This patient can't take FANS because of previous reaction to FANS, but we have a very good

anesthesiologist today.

We have Franco Demi, who is also responsible in SARA for pain control.

So we are quite sure that the patient won't have any pain after the operation.

It's really important to be in control of the ulceration because it's well-established

that it's a risk factor for chronic pain after this kind of surgery.

This is okay for me.

And for you?

Yes, definitely.

Again, can you show us the superior part of the defect?

When I see this view, I recall when we used to put a single mesh in bilateral hernia.

And passing through a pre-vehicle tunnel, we started putting, I'm speaking about years and years ago,

we started positioning two patches, but when we realized that we were, they were overlapping in the middle line,

so we we tried we used the several times a single mesh yeah that was almost 30

centimeters per 12 or 15 yes but this is perfectly position when it's a so flat

it's a so satisfying I mean in the middle of the mesh so there are five

This type of mesh is very easy to use.

Yes, because it's soft.

I consider this the best at the moment.

A little bit less than the previous one.

This is the advanced, so it's useful and it's easier to put in place.

Okay. Stratafix?

The same speech that we had before, so self-stripping.

and my best compliment because of the skill you showed us during this procedure

that was perfectly clear and anatomically was so satisfying.

that I really think that everyone was able to appreciate it so are you thank

you no problem it's not a compliment it's it's it's not a lie I mean and it

was a really satisfying are you going to have some extra operations today yeah I

mean some other kind of operations not in the Congress but okay no no I was

I was not curious, I was wondering if you should have been with us again during the morning.

No, I don't think so.

Will we perform an adrenalectomy for a caching adenoma?

Right or left?

Left.

Okay.

Well, I don't know if you are able to be with us again, I mean, technically.

I just ask Giorgio Palatini what's going on with us, and then I will be with you again.

just in case yeah thank you very much no problem it's my pleasure thank you

I'm between the legs of the patient after.

it's not necessary

to raise a little

let's put two

he made a knot more or less

more or less

now I tell you some little things

the microphone is off

That's a good one.