02 March 2011

MIS: the last surgery

Ok, so it was technically the second to last surgery, but the true last one wasn't nearly as unique.

The picture is not my patient, but the operation was the same: repair of a rather large primary umbilical hernia. He literally had a basketball-sized hernia filled with bowel and omentum hanging off of a 8cm x 8cm fascial defect. We managed to reduce the hernia completely, placed some synthetic mesh to bridge the defect, covered it with some muscle flaps, then closed fascia, deep dermis and skin. For those of you up on your hernia repairs, he did not require separation of parts to achieve repair nor did he necessitate a full laparotomy. We only extended our incision 2 inches above the hernia sack (the defect in the picture must be larger since his sack extends to the xiphoid). We did remove quite a bit of skin, as you can imagine.

The operation was complicated by a difficult foley placement. I thought it was just my technical error... but I was vindicated when my chief couldn't pass the catheter either and we had to call urology. They managed a foley with the assistance of a flexible scope, which revealed a significant stricture in the urethra.

In slightly less medical terms: a hernia is a weakness or hole in one of the connective tissue layers separating two compartments in your body. In this case, the hole was in the abdominal wall where your belly button is. It was about 8cm in diameter. The man's intestines had crept out of the hole and were right below his skin in the big ball hanging off of his belly. We cut open the skin, pushed his intestines back into his belly and put some mesh over the hole to prevent his intestines from getting out again. We then pulled his abdominal muscles over the mesh to strengthen the repair. Sometimes when we pull the muscles, they don't close properly because they can't reach each other. If that's the case, we cut them free from other muscles on your sides (separation of parts) so that they can move more centrally and cover the hole. Since the hernia stretched the skin, we cut off some of the extra skin and stapled the incision closed.

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