Complex Hernia Repair Video: Recurring Right Inguinal Hernia Repair

This complex hernia surgery was performed on a patient who had two previous attempts of repairing an inguinal hernia with both open and robotic procedures. His hernia recurred within a few months. Dr. Mazen Iskandar performed a robotic hernia repair. Recurrent hernia surgery can be challenging and complicated by bladder, testicular and vascular injuries due to scarring. The patient had a smooth recovery and to date has no signs of recurrence.

Transcription of Complex Hernia Repair Video: Recurring Right Inguinal Hernia Repair

This is a video of a robotic right inguinal hernia repair after a previously failed robotic approach which was also treated with an open repair. So this was the patient’s third surgery. After lysing adhesions laparoscopically, we docked the Robot. We noticed a sliding type hernia. It appeared that the patient had a previous repair with a ProGrip mesh. We initiated the flap dissection above the previous mesh. And as you can see, we’re able to develop the pre-peritoneal plane between the mesh and the peritoneum. It’s possible that the barrier on the ProGrip has less adhesions or potentially the previous surgery was done in the pre-transversalis plane.

Started dissection in the space of Bogros laterally which appeared to be not scarred and, in these recurrent cases, I try to as much as possible dissect the easy planes first before tackling the more scarred areas.

I was not able to see the epigastric vessels but they were probably behind that folded piece of mesh. It appears that this recurrence occurred because the mesh shifted anteriorly because of clamshelling or lifted posteriorly and the peritoneum was able to pass underneath the mesh, creating this recurrent indirect hernia.

As you can see, more medially there was more scarring and fibrosis. Trying very carefully to stay in avascular planes as much as possible and reduce bleeding which can obscure the view.

The patient had a three-way Foley catheter placed to decompress the bladder and to allow for testing for bladder leak if need be/ if there was a suspicion for one.

I’m trying as much as possible to stay high and anterior above the bladder.

[00:02:39]
[silence]
[00:03:04]

Your patients deserve
renowned expertise and
unparalleled compassion.

As we can see here, the bladder is fairly adherent and stuck to Cooper’s ligament. I’m trying as much as possible to identify an avascular plane here to be able to separate the bladder, and all these adhesions appear thick.

Tried to thin all these adhesions before cutting them to avoid any bladder injury. And luckily we were able to avoid any bladder injuries.

[00:03:46]
[silence]
[00:03:58]

Finally got some avascular plane to dissect. After dissecting the space of Retzius, I had enough working space and knowledge of the anatomy and my bearings so we can tackle the indirect sac. Again, trying as much as possible to dissect sharply here because I wasn’t sure at what level in the sliding hernia the bowel stopped.

[00:04:34]
[silence]
[00:04:43]

 

Trying to reduce the hernia as much as possible before starting to dissect the cord structures away from the hernia sac.

After I did enough reduction, I switched to the needle driver so I can use the grasping function and perform blunt dissection to parietalize the cord structures.

[00:05:10]
[silence]
[00:05:23]

Then mobilizing the peritoneum posteriorly away from the psoas and the iliac vessels. There’s more adhesions between the sac and the peritoneum.

Identified the vas and continue to dissect the plane between the vas and the peritoneum. Trying to get as close to the vein as possible.

Continued a little more medial dissection until I was satisfied and encountered the previous ProGrip mesh on the left side as well.

[00:06:13]
[silence]
[00:06:30]

Then placed the mesh standard fashion.

[00:06:35]
[silence]
[00:06:53]

And closed the peritoneum. Thank you for watching.

[00:06:59]
[silence]