The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed. All questions answered. The patient was transported to the operating room and placed on the table in supine position, boney areas padded, sequential compression devices applied to the bilateral lower extremities and secured with straps. General anesthesia was induced, and patient was intubated without issue. Preoperative Ancef and 5,000u subcutaneous heparin were given. A foley was placed and the scrotum was wrapped with Kirlex. Timeout was done and all were in agreement.
I accessed the peritoneal cavity with a 5mm optical trocar entry in the left upper quadrant and insufflated the cavity to 8 mmHg. I looked down at the pelvis and noted bilateral inguinal hernias containing fat. Two additional 8 mm robotic ports were placed under direct vision without injury to triangulate the pelvis as well as a 12 mm assistant trocar at the left costal border. The original 5 mm port was exchanged for an 8mm robotic port. There was no visceral injury on port placement. The robot was docked, and we took our place on the console.
On the left side I created a preperitoneal flap exposing the myopectineal orifice, exposing the pubis medially, the lateral abdominal wall laterally. I reduced the direct hernia which contained fat. There was no indirect hernia. The cord structures and vas deferens were parietalized without injury. The internal iliac vein was located and there was no hernia in the femoral space. The dissection was carried down to the obturator space were there was noted to be a small fat containing hernia that was reduced. I made sure to free the inferior peritoneum enough to allow for flat mesh placement.
The right side was done in a similar fashion. There was a direct fat containing hernia that was reduced. There was no indirect, femoral or obturator hernia.
The left side 3D max 12 x 17 cm mesh was placed into position covering the entire myopectineal orifice including the femoral, indirect, direct and obturator spaces. It was secured to Cooper's ligament and the anterior-lateral abdominal wall with simple 3-0 Vicryl suture. The inferior edge layed flat and did not bunch with the peritoneum.
The right side mesh was placed in the same fashion.
The peritoneal flap was closed with size 2-0 V-lock suture in a running fashion. The abdomen was desulfated, the robot undocked and the incisions closed with 4-0 Monocryl and dressed with dermabond.
The final count was correct. The patient was liberated from anesthesia. The foley and scrotal wrap were removed and the testicles were palpated in the scrotum.
Dr. [attending] was present or available for the entire case.
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Author: Garrett Skinner