Poland 2012; TEP How I Do It 2
-
Upload
blackhorse-science-business-media -
Category
Documents
-
view
214 -
download
0
Transcript of Poland 2012; TEP How I Do It 2
![Page 1: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/1.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 1/42
![Page 2: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/2.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 2/42
NEW ZEALAND:population 4.6M
Auckland:population 1.5M
Size: NZ = UK
![Page 3: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/3.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 3/42
NEW ZEALAND
POLAND
![Page 4: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/4.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 4/42
![Page 5: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/5.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 5/42
![Page 6: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/6.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 6/42
![Page 7: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/7.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 7/42
LAPAROSCOPIC HERNIA REPAIR IN NZ
Public sector no data
Private sector• New Zealand 50% laparoscopic• Auckland 80% laparoscopic
![Page 8: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/8.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 8/42
LAPAROSCOPY AUCKLAND•
Purpose built laparoscopic surgical unitopened 2001• Annually: 1300+ surgical procedures
![Page 9: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/9.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 9/42
LAPAROSCOPIC EXPERIENCE (AB)
• Laparoscopic hernia repairs 6280
•
Laparoscopic cholecystectomy 2365Single port 30
• Laparoscopic fundoplication 550
![Page 10: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/10.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 10/42
LAPAROSCOPIC INGUINAL HERNIA REPAIR
First repair 1991
Personal series 6280• TAPP 270• TEP 6010
Recurrences (TEP) 0.2% (12)
![Page 11: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/11.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 11/42
TEP: HOW I DO IT
• Patient preparation• Theatre setup•
Equipment• Operative technique• Economic considerations• Postoperative management• Results• Pain post hernia repair
![Page 12: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/12.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 12/42
PREOP
Consent• open vs. laparoscopic
Day surgery
Preparation•
Limited shave• No catheter• Antibiotic at induction
![Page 13: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/13.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 13/42
Infra-umbilical accessBalloon dissectionIpsilateral rectus sheath
![Page 14: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/14.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 14/42
Purse string around 10mm port (avoid muscle)0 ° laparoscope + 8-10mm Hg pressure
5mm ports in midline (avoid muscle)
![Page 15: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/15.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 15/42
Nurse/assistant same sideInstrument table rotatedLaparoscopic stack shiftedErgodynamically comfortable
![Page 16: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/16.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 16/42
• Identify landmarks: Superior pubic ramusInferior epigastric vessels
• Dissect widely, especially laterally
•
15x10cm mesh lightweight, large pore
• Fix to sup pubic ramus + linea alba (avoidmuscle/fascia)
• Local anaesthetic around umbilicus + inextraperitoneal plane
![Page 17: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/17.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 17/42
Mesh introduction
![Page 18: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/18.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 18/42
L DIRECT INGUINAL HERNIA: COMMENCEMENT
![Page 19: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/19.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 19/42
R INDIRECT INGUINAL HERNIA: TECHNIQU
![Page 20: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/20.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 20/42
R INDIRECT INGUINAL HERNIA: TECHNIQU
![Page 21: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/21.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 21/42
LARGE LIIH: REDUCTION OF SAC
Dissect completely
![Page 22: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/22.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 22/42
REC LDIH: AVOIDANCE OF SEROMA
![Page 23: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/23.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 23/42
ECONOMIC CONSIDERATIONS
Costs: Laparoscopic repair > open repair• Laparoscopic equipment• Disposables
Operating portsInstrumentsBalloon dissectionMeshTacker / glue
• Operation time:most surgeons laparoscopic > open
![Page 24: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/24.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 24/42
COST SAVINGS (AB)
• Reusable instruments• “Home made” balloon dissector •
Flat mesh• Short tacker
• Operating time laparoscopic << open
![Page 25: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/25.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 25/42
• Hasson cannula• Finger large glove• 3-way tap + 60ml syringe
“Home made” balloon dissector
![Page 26: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/26.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 26/42
![Page 27: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/27.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 27/42
Cost: short tacker = 2/3 long tacker
![Page 28: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/28.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 28/42
COST SAVINGS
• Reusable ports and instruments• Avoid “package deals” ( balloon+tacker+mesh)• “Home -made” balloon dissector?
• Avoid light weight large pore meshes?• Avoid barrier meshes
• Avoid fixation?• Glue = more expensive• Short tacker?
POSTOP
![Page 29: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/29.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 29/42
POSTOP
• Discharge same day
• Analgesics only if needed
• Encourage activity (no restrictions)
• Review 7-10 days
• Phone review at 3 months
•
Phone review at 12 months
![Page 30: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/30.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 30/42
POSTOP INFORMATION SHEETImportant•
Wound care• Advice on activity• Follow up instructions
More important• Abdominal distension• Constipation likely
Most important….. • Warn of bruising +/- pain in testes• Typically 3-4 days after operation• = Cause of great concern to males• Stops anxious phone calls after work hours!
![Page 31: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/31.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 31/42
Records: Touch rugby day 0Ballroom dancing day 0Bedroom dancing day 0Mowing lawns day 1Basketball day 1Indoor cricket day 1Volleyball day 1Cycling (50km) day 1Rowing (single scull) day 1Round of golf day 1Pig hunting day 2Fishing (117kg marlin) day 2
Skiing day 3Running (10k) day 3Surfing day 5Snowboarding day 6
Pall bearing day 2
NO RESTRICTIONS POSTOP!!
![Page 32: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/32.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 32/42
PAIN POST HERNIA REPAIR
TAPP/TEPN=989
Open MeshN=994
Long term neuralgia or other pain
9.8% 14.3%
TEPN=240
Open Mesh
Chronic pain or discomfort 22.5% 38.3%
Neumayer et al NEJM 2004;350:1819-27
Macintyre et al BJS 2002;89:1476-79
![Page 33: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/33.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 33/42
PAIN POST TEP HERNIA REPAIR AT 3 MONTHS(male, unilateral; groin strain excluded)
Nil Mild Mod Severe
Restriction(N=951)
99.9%(950)
0.1% (1) Nil Nil
Pain or
discomfort(N=951)
91.1%(866)
8.5%(81)
0.4% (4) Nil
Andrew Bowker personal series
![Page 34: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/34.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 34/42
PAIN: NEUROGENIC
• Nerve interference
Care with tacker fixation…
…Should not experience nerve pain
![Page 35: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/35.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 35/42
PAIN: MUSCULOSKELETAL/MYOGENIC
• Muscular interferenceSuture at umbilical access point
Port placementDissection into muscleFixation to muscle
• Mesh contraction against points of fixation= Major cause of chronic (myogenic) pain?
![Page 36: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/36.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 36/42
Dir
F
Ind
CONTRACTION with drag through tissue
+ PAIN
MECHANISM FOR PAIN WITH SOFT TISSUE FIXATIO
Contraction
ContractionContraction
Contraction
![Page 37: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/37.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 37/42
D
F
I
OPTION: NO FIXATION (OR GLUE FIXATION)
No drag…..
but risk of medial recurrence
ContractionContraction
ContractionContraction
![Page 38: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/38.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 38/42
D
F
I
ALTERNATIVE OPTION: MEDIAL BONE FIXATION O
Contraction
No drag
No risk of medial recurrence
Contraction
![Page 39: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/39.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 39/42
Fixation is safe (and important)
• Fixation to muscle/tendon• Fixation medially and laterally
= potential for pain
Mesh contraction unimportant if no soft tissuefixation
![Page 40: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/40.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 40/42
TEP OPERATION: KEY POINTS
• Ports in midline• Dissect side of hernia only• Identify landmarks + maintain orientation (0°
laparoscope better?)
• Wide dissection especially laterally
• Mesh 15x10cm (lightweight wide pore?)• Penetrative fixation: medially only
![Page 41: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/41.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 41/42
END
![Page 42: Poland 2012; TEP How I Do It 2](https://reader030.fdocuments.in/reader030/viewer/2022021223/577ce5201a28abf1038fde75/html5/thumbnails/42.jpg)
7/31/2019 Poland 2012; TEP How I Do It 2
http://slidepdf.com/reader/full/poland-2012-tep-how-i-do-it-2 42/42