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Laparoscopic Ventral Hernia Repair
Published in Jeff Garner, Dominic Slade, Manual of Complex Abdominal Wall Reconstruction, 2020
The falciform ligament should be taken down to provide a smooth, firm fascial base for optimal mesh fixation taking care to avoid the vessels running along its free edge. One technique to do this is to begin above the umbilicus, using the diathermy hook to incise through the base of the ligament immediately adjacent to the abdominal wall, right through from one side to the other, and then continue the dissection caudally in the same avascular extraperitoneal plane towards and around the umbilicus. In this way the entire hernial sac can be delivered intact and the dissection can continue inferiorly to bring down the median and lateral umbilical folds as well if required, all without having to divide the vessels of the falciform ligament at any stage: they simply hang down centrally, still attached at the upper and lower ends.
Abdominal wall, hernia and umbilicus
Published in Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie, Bailey & Love's Short Practice of Surgery, 2018
Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie
Incisional hernias are increasingly being repaired by laparoscopic mesh techniques. Laparoscopy and division of adhesions is initially performed. Hernia contents are reduced and the fibrous margins of the hernia defect(s) are exposed. Often the falciform ligament and median umbilical fold need to be taken down. Some surgeons prefer to suture close the muscle defects first and then reinforce with mesh. Others simply fix the mesh under the defect with adequate overlap. The use of a tissue-separating mesh is essential. Various techniques have been described to size and then position the mesh accurately. The mesh is fixed to the abdominal wall by staples or transfascial sutures which pass through all muscle layers to hold the mesh.
Simplified anatomy of the vesicourethral functional unit
Published in Jacques Corcos, David Ginsberg, Gilles Karsenty, Textbook of the Neurogenic Bladder, 2015
Saad Aldousari, Jacques Corcos
The bladder (Figure 1.1), located in the pelvis behind the pubic bone, can be divided into two portions. The dome, the upper part of the bladder, is spherical, extensible, and mobile. The median umbilical ligament (urachus) ascends from its apex behind the anterior abdominal wall to the umbilicus, and the peritoneum behind it creates the median umbilical fold. In males, the superior surface of the dome is completely covered by the peritoneum extending slightly to the base. It is in close contact with the sigmoid colon and the terminal coils of the ileum. In females, the difference arises from the posterior reflection of the peritoneum on the anterior face of the uterus, forming the vesico–uterine pouch. In both sexes, the inferolateral part of the bladder is not covered by the peritoneum. In adults, the bladder is completely retropubic and can be palpated only if it is in overdistension. In contrast, at birth, it is relatively high and is an abdominal organ. It descends progressively, reaching its adult position at puberty.
A minimally invasive treatment of an asymptomatic case of mesh erosion into the caecum after total extraperitoneal inguinal hernia repair
Published in Acta Chirurgica Belgica, 2019
Gert Mulleners, Frederick Olivier, Mohamed Abasbassi
An exploratory laparoscopy was performed using a 12 mm supra-umbilical port, that revealed adhesion of the caecum anteriorly to the right groin (Figure 2(b)). The clips that were previously used for peritoneal closure were no longer visible. Three additional 5 mm ports were inserted under direct vision in the left lower quadrant, the suprapubic region and the left upper quadrant. The ileum was flipped over from the pelvis to the right upper quadrant to expose the ileocolic pedicle. A retromesenteric plane was entered posterior to the ileocolic pedicle. The retromesenteric plane was further developed by blunt dissection laterally and in a cephalad direction along the duodenum. Subsequently, the hepatic flexure was mobilised by incising the hepatocolic ligament from medial to lateral to establish a connection to the previously freed retroperitoneal plane. The right colon was released from its lateral peritoneal attachments by dividing the white line of Toldt. This allowed for the complete mobilisation of the right colon and a straightforward attachment of the caecum to the mesh (Figure 2(c)). The mesh was then cut by sharp dissection, leaving a defect of 2.5 by 2 cm. A 3 cm midline incision was made by extending the supra-umbilical port cephalad. The mobilised right colon was exteriorised after insertion of an Alexis® wound protector (Figure 2(d)). Only the resection of the base of the caecum and appendix was required as the ileocecal valve was not affected by the inflammatory process. A stapled resection was performed after opening the caecum and ensuring complete removal of the mesh. After returning the colon and re-insufflating the abdomen, the lateral umbilical fold was sutured over the peritoneal defect to cover the remainder of the mesh.
The Septum Inguinalis: A Clue to Hernia Genesis?
Published in Journal of Investigative Surgery, 2020
Giuseppe Amato,, Piergiorgio Calò,, Vito Rodolico,, Roberto Puleio,, Antonino Agrusa,, Leonardo Gulotta,, Luca Gordini,, Giorgio Romano,
Recognition of the septum inguinalis, and the fact that it may degenerate into oblivion from the compressive effect of advanced pantaloon hernia in the form of a combined hernia, allows a revision of the traditional anatomic concepts in relation to the inguinal canal. Classically the inguinal floor is described in 2 parts: Hesselbach’s triangle medial to the epigastric vessels and the deep inguinal ring laterally [15–19]. However, functionally this may not be correct. On the basis of the cases reported here and many others we have encountered in our clinical practice [3] we characterize the functional anatomy of the inguinal floor as follows:A medial aspect consisting of the fossa supravesicalis—fossa inguinalis media complex. These 2 zones, longitudinally divided by the medial umbilical fold and covered in the posterior aspect by the transversalis fascia, are tightly connected and often involved together in direct hernia protrusion.An intermediate aspect: the septum inguinalis that divides the medial from the lateral part of the inguinal floor. This comprises, anteriorly, the muscle bundles of the internal oblique and transverse, covered by the transversalis fascia and forming the medial border of the deep inguinal ring. Posteriorly is composed by the epigastric vessels and sheath. The latter may act as a protective shield as it is the last recognizable structure to disappear when a combined hernia converges into a single protrusion. Comprising more than just the inferior epigastric vessels, the septum inguinalis structure includes the lateral part of the fossa inguinalis media and the medial part of the internal ring.A lateral aspect that comprises the transversalis fascia and deep inguinal ring, its medial aspect being functionally connected with the septum inguinalis.