Laparoscopic hernia repair, IPOM following lower laparotomy - general and visceral surgery
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Determining the mesh size
Establishing pneumoperitoneum and inspecting the abdominal cavity
Perform careful adhesiolysis only with scissors (no RF-electrosurgery, no ultrasonic scalpel!) in cephalocaudal direction. This is the only way to avoid thermal injury with secondary intestinal perforation. Only in sharp dissection will the carbon dioxide enter the adhesions and increase the distance between the abdominal wall and its adherent structures.
Tip: Outside pressure of the non-dominant hand on the abdominal wall can help facilitate the preparation.
Dissecting the prevesical space
In order to ensure a wide overlap with the prevesical space, first transect the parietal peritoneum and the medial umbilical folds. Free the bladder wall off the anterior abdominal wall and clear the symphysis and the pubic rami.
Note: In epigastric access transection of the ligamentum teres hepatis and the falciform ligament ensures mesh placement cephalad of the costal arch with sufficient superior overlap.
Parietalizing the peritoneum
Catching the stay sutures