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𝗥𝗼𝗯𝗼𝘁𝗶𝗰 𝗧𝗔𝗣𝗣 𝗥𝗲𝗽𝗮𝗶𝗿 𝗼𝗳 𝗥𝗲𝗰𝘂𝗿𝗿𝗲𝗻𝘁 𝗥𝗶𝗴𝗵𝘁 𝗜𝗻𝗴𝘂𝗶𝗻𝗮𝗹 𝗛𝗲𝗿𝗻𝗶𝗮 Patient Presentation: 🔵Previous open repair 🔵Mesh in preperitoneal plane 🔵Referred with painful recurrence Surgical Approach: 🔴Medial recurrence 🔴Near complete mesh excision ➡️Small disc on abdominal wall side left to avoid nerve injury 🔴Transversalis fascia approximated with V-loc ➡️Imbrication of transversalis fascia... show more

Derby Pancreaticobiliary & Robotic AWR Unit

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32,705 просмотров • 1 месяц назад •via X (Twitter)

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Robotic TAPP (rTAPP) Repair of Left Inguinal Hernia with Imbrication of Transversalis Fascia Why imbricate: 🔵Direct defect/large hernia risk factors for postoperative seroma 🔵In open hernia repair, direct defect often closed ➡️Helps create a flat posterior wall and expedite mesh placement 🔵However it is not a routine practice during MIS Robotic Imbrication of Transversalis fascia: 🔴Possible advantages include: ➡️Reduce seroma risk formation ➡️Reduce risk of recurrence (mesh migration) 🔴Avoid deep bite ➡️Cord structures can be easily caught in sutures

Robotic TAPP (rTAPP) Repair of Left Inguinal Hernia with Imbrication of Transversalis Fascia Why imbricate: 🔵Direct defect/large hernia risk factors for postoperative seroma 🔵In open hernia repair, direct defect often closed ➡️Helps create a flat posterior wall and expedite mesh placement 🔵However it is not a routine practice during MIS Robotic Imbrication of Transversalis fascia: 🔴Possible advantages include: ➡️Reduce seroma risk formation ➡️Reduce risk of recurrence (mesh migration) 🔴Avoid deep bite ➡️Cord structures can be easily caught in sutures

Derby Pancreaticobiliary & Robotic AWR Unit

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𝗘𝗺𝗲𝗿𝗴𝗲𝗻𝗰𝘆 𝗥𝗼𝗯𝗼𝘁𝗶𝗰 𝗥𝗲𝗽𝗮𝗶𝗿 𝗼𝗳 𝗟𝗲𝗳𝘁 𝗜𝗻𝗴𝘂𝗶𝗻𝗮𝗹 𝗛𝗲𝗿𝗻𝗶𝗮 𝘄𝗶𝘁𝗵 𝗜𝗖𝗚 Surgical Approach: 🔴Initial assessment of small bowel with ICG 🔴Small bowel placed in pelvis with warm wet swabs overlying 🔴TAPP approach to hernia repair ➡️Critical view of MPO ➡️ICG to help delineate key structures ➡️Progrip mesh ➡️3-0 absorbable V-lock to close peritoneum 🔴Reassessment of small bowel after hernia repair ➡️ICG present in bruised area demonstrating viability ➡️Aided decision making to not resect or oversew Robotics in EGS: 🟢Case selection key 🟢MDT approach with anaesthetic and scrub teams to coordinate 🟢Minimally invasive approaches in EGS should be encouraged #FOAMed #GITwitter #MedEd #Surgery #Hernia #EGS

𝗘𝗺𝗲𝗿𝗴𝗲𝗻𝗰𝘆 𝗥𝗼𝗯𝗼𝘁𝗶𝗰 𝗥𝗲𝗽𝗮𝗶𝗿 𝗼𝗳 𝗟𝗲𝗳𝘁 𝗜𝗻𝗴𝘂𝗶𝗻𝗮𝗹 𝗛𝗲𝗿𝗻𝗶𝗮 𝘄𝗶𝘁𝗵 𝗜𝗖𝗚 Surgical Approach: 🔴Initial assessment of small bowel with ICG 🔴Small bowel placed in pelvis with warm wet swabs overlying 🔴TAPP approach to hernia repair ➡️Critical view of MPO ➡️ICG to help delineate key structures ➡️Progrip mesh ➡️3-0 absorbable V-lock to close peritoneum 🔴Reassessment of small bowel after hernia repair ➡️ICG present in bruised area demonstrating viability ➡️Aided decision making to not resect or oversew Robotics in EGS: 🟢Case selection key 🟢MDT approach with anaesthetic and scrub teams to coordinate 🟢Minimally invasive approaches in EGS should be encouraged #FOAMed #GITwitter #MedEd #Surgery #Hernia #EGS

Derby Pancreaticobiliary & Robotic AWR Unit

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𝙇𝙖𝙥𝙖𝙧𝙤𝙨𝙘𝙤𝙥𝙞𝙘 𝙍𝙚𝙥𝙖𝙞𝙧 𝙤𝙛 𝙋𝙚𝙧𝙛𝙤𝙧𝙖𝙩𝙚𝙙 𝘿𝙪𝙤𝙙𝙚𝙣𝙖𝙡 𝙐𝙡𝙘𝙚𝙧 𝙬𝙞𝙩𝙝 𝙋𝙧𝙞𝙢𝙖𝙧𝙮 𝘾𝙡𝙤𝙨𝙪𝙧𝙚 & 𝙊𝙢𝙚𝙣𝙩𝙖𝙡 𝙋𝙖𝙩𝙘𝙝 Presentation: 🔵1 day history of sever upper abdominal pain 🔵Smoker and excess ETOH 🔵CXR ➡️Pneumoperitoneum 🔵CT ➡️Perforated duodenal ulcer 🔵Time from ED➡️theatre 3 hours Operative Approach: 🔴Thorough peritoneal lavage ➡️Lap washout allows for thorough removal of intra-abdominal contamination ➡️Modern OR table tilting can provide better view then open in select cases 🔴If fragile tissue then omental patch only ➡️This approach is a modified version of Grahams patch repair ➡️When suitable, we prefer primary closure with patch after 🔴For large perforations kocherisation of duodenum may be indicated 🔴Convert to open if: ➡️Large ulcer ➡️Associated ulcer bleed 🔴H. Pylori eradication therapy on discharge 🔴OGD in 6-8 weeks to confirm healing Key Points: 🟢Timely intervention critical 🟢Lap approach in EGS should be encouraged 🟢Compared to open, advantages of lap are: ➡️Reduced pain ➡️Reduced LOS ➡️Reduced incisional hernia rate 🟢Trainees should be exposed to lap EGS early to develop skills and confidence #FOAMed #GITwitter #MedEd #SurgEd #EGS #SoMe4Surgery

𝙇𝙖𝙥𝙖𝙧𝙤𝙨𝙘𝙤𝙥𝙞𝙘 𝙍𝙚𝙥𝙖𝙞𝙧 𝙤𝙛 𝙋𝙚𝙧𝙛𝙤𝙧𝙖𝙩𝙚𝙙 𝘿𝙪𝙤𝙙𝙚𝙣𝙖𝙡 𝙐𝙡𝙘𝙚𝙧 𝙬𝙞𝙩𝙝 𝙋𝙧𝙞𝙢𝙖𝙧𝙮 𝘾𝙡𝙤𝙨𝙪𝙧𝙚 & 𝙊𝙢𝙚𝙣𝙩𝙖𝙡 𝙋𝙖𝙩𝙘𝙝 Presentation: 🔵1 day history of sever upper abdominal pain 🔵Smoker and excess ETOH 🔵CXR ➡️Pneumoperitoneum 🔵CT ➡️Perforated duodenal ulcer 🔵Time from ED➡️theatre 3 hours Operative Approach: 🔴Thorough peritoneal lavage ➡️Lap washout allows for thorough removal of intra-abdominal contamination ➡️Modern OR table tilting can provide better view then open in select cases 🔴If fragile tissue then omental patch only ➡️This approach is a modified version of Grahams patch repair ➡️When suitable, we prefer primary closure with patch after 🔴For large perforations kocherisation of duodenum may be indicated 🔴Convert to open if: ➡️Large ulcer ➡️Associated ulcer bleed 🔴H. Pylori eradication therapy on discharge 🔴OGD in 6-8 weeks to confirm healing Key Points: 🟢Timely intervention critical 🟢Lap approach in EGS should be encouraged 🟢Compared to open, advantages of lap are: ➡️Reduced pain ➡️Reduced LOS ➡️Reduced incisional hernia rate 🟢Trainees should be exposed to lap EGS early to develop skills and confidence #FOAMed #GITwitter #MedEd #SurgEd #EGS #SoMe4Surgery

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Emergency Laparoscopic Repair of Strangulated Femoral Hernia with Small Bowel Resection & ICG 🔴Reduction of small bowel ➡️Await perfusion recovery ➡️Allows for demarcation of ischaemic segment 🔴Undertake hernia repair ➡️TAPP approach ➡️Opted for suture repair for this case ➡️Biologic mesh alternative option ➡️Synthetic mesh can be considered if no bowel resection 🔴ICG to assess bowel perfusion and delineate length of resection ➡️Given intraop at time of assessment ➡️Immediate assessment within 30 seconds key ➡️Excellent tool for teaching trainees 🔴Advanced lap skills crucial 🔴Lap EGS recommended ➡️Underutilisation in the UK

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𝗘𝘅𝘁𝗲𝗻𝘀𝗶𝗼𝗻 𝗼𝗳 𝗖𝗵𝗼𝗹𝗲𝗱𝗼𝗰𝗵𝗼𝘁𝗼𝗺𝘆 𝗳𝗼𝗿 𝗟𝗮𝗿𝗴𝗲 𝗖𝗕𝗗 𝗦𝘁𝗼𝗻𝗲 🔴CBD diameter key 🔴Extend choledochotomy with choledochotome 🔴CBD stone trapped in basket under slight tension and brought to choledochotomy 🔵Other options ➡️EHL ➡️Laser Lithotripsy 🔵Caution when extending choledochotomy ➡️Experience and training critical #FOAMed #GITwitter #MedEd #Surgery #SoMe4Surgery

𝗘𝘅𝘁𝗲𝗻𝘀𝗶𝗼𝗻 𝗼𝗳 𝗖𝗵𝗼𝗹𝗲𝗱𝗼𝗰𝗵𝗼𝘁𝗼𝗺𝘆 𝗳𝗼𝗿 𝗟𝗮𝗿𝗴𝗲 𝗖𝗕𝗗 𝗦𝘁𝗼𝗻𝗲 🔴CBD diameter key 🔴Extend choledochotomy with choledochotome 🔴CBD stone trapped in basket under slight tension and brought to choledochotomy 🔵Other options ➡️EHL ➡️Laser Lithotripsy 🔵Caution when extending choledochotomy ➡️Experience and training critical #FOAMed #GITwitter #MedEd #Surgery #SoMe4Surgery

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Laparoscopic Ileocaecal Resection with Intracorporeal Anastomosis and ICG Patient Presentation: 🔴Sudden onset severe abdominal pain 🔴Tender abdomen 🔴No previous abdominal surgery 🔴High WCC 🔴Lactate ➡️5 on arrival down to 2 in 2 hours following fluid resuscitation 🔴CT abdomen/pelvis ➡️Red arrows show no small bowel perfusion with mural thickening ➡️Green arrows show perfused small and large bowel ➡️Mesenteric vessels patent Surgical Approach: 🔴Lap EGS approach ➡️Torsion of small bowel with Meckel's adhesion to abdominal wall acting as pivot point ➡️80cm ischaemic small bowel involving ileocaecal junction 🔴Specimen retrieved via extension of LUQ 12mm port

Laparoscopic Ileocaecal Resection with Intracorporeal Anastomosis and ICG Patient Presentation: 🔴Sudden onset severe abdominal pain 🔴Tender abdomen 🔴No previous abdominal surgery 🔴High WCC 🔴Lactate ➡️5 on arrival down to 2 in 2 hours following fluid resuscitation 🔴CT abdomen/pelvis ➡️Red arrows show no small bowel perfusion with mural thickening ➡️Green arrows show perfused small and large bowel ➡️Mesenteric vessels patent Surgical Approach: 🔴Lap EGS approach ➡️Torsion of small bowel with Meckel's adhesion to abdominal wall acting as pivot point ➡️80cm ischaemic small bowel involving ileocaecal junction 🔴Specimen retrieved via extension of LUQ 12mm port

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𝗟𝗮𝗽𝗮𝗿𝗼𝘀𝗰𝗼𝗽𝗶𝗰 𝗙𝗲𝗻𝗲𝘀𝘁𝗿𝗮𝘁𝗲𝗱 𝗦𝘂𝗯𝘁𝗼𝘁𝗮𝗹 𝗖𝗵𝗼𝗹𝗲𝗰𝘆𝘀𝘁𝗲𝗰𝘁𝗼𝗺𝘆 Patient Presentation: 🔵History of severe cholecystitis 🔵CT on index admission showed: ➡️Cholecysto-colic fistula ➡️Air locules on GB ➡️Figure 1 below 🔵Follow up CT (~4 months later): ➡️Good improvement with apparent resolution of fistula as absence of air in GB ➡️Figure 2 below 🔵Symptomatic gallstones 🔵Listed for planned biliary surgery Operative Approach: 🔴Colonic adhesion to GB fundus 🔴Fused hepatocystic triangle ➡️Decision to perform subtotal cholecystectomy 🔴Dissection plane (window) identified between GB and colon 🔴Presumed area of fistula tract detached with cuff of GB wall 🔴Stone retrieved and GB opened to identify cystic duct ostium on opening GB ➡️Closed with 2/0 Vicryl 🔴Gallbladder dissected off as far as safe to do so 🔴Detached colonic attachment with GB cuff ➡️No obvious fistula tract ➡️The area was under run to achieve haemostasis 🔴Cystic artery transfixed with figure of 8 suture 🔴Drain x 1 ➡️Removed after 24 hours 🔴Uneventful postop course #FOAMed #MedTwitter #GITwitter #SoMe4Surgery #HPB

𝗟𝗮𝗽𝗮𝗿𝗼𝘀𝗰𝗼𝗽𝗶𝗰 𝗙𝗲𝗻𝗲𝘀𝘁𝗿𝗮𝘁𝗲𝗱 𝗦𝘂𝗯𝘁𝗼𝘁𝗮𝗹 𝗖𝗵𝗼𝗹𝗲𝗰𝘆𝘀𝘁𝗲𝗰𝘁𝗼𝗺𝘆 Patient Presentation: 🔵History of severe cholecystitis 🔵CT on index admission showed: ➡️Cholecysto-colic fistula ➡️Air locules on GB ➡️Figure 1 below 🔵Follow up CT (~4 months later): ➡️Good improvement with apparent resolution of fistula as absence of air in GB ➡️Figure 2 below 🔵Symptomatic gallstones 🔵Listed for planned biliary surgery Operative Approach: 🔴Colonic adhesion to GB fundus 🔴Fused hepatocystic triangle ➡️Decision to perform subtotal cholecystectomy 🔴Dissection plane (window) identified between GB and colon 🔴Presumed area of fistula tract detached with cuff of GB wall 🔴Stone retrieved and GB opened to identify cystic duct ostium on opening GB ➡️Closed with 2/0 Vicryl 🔴Gallbladder dissected off as far as safe to do so 🔴Detached colonic attachment with GB cuff ➡️No obvious fistula tract ➡️The area was under run to achieve haemostasis 🔴Cystic artery transfixed with figure of 8 suture 🔴Drain x 1 ➡️Removed after 24 hours 🔴Uneventful postop course #FOAMed #MedTwitter #GITwitter #SoMe4Surgery #HPB

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