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One trick is to move the camera to one of the left lower ports in order to get a direct view of the left fascia of Toldt 25mg indocin free shipping. Again discount indocin 50 mg mastercard, traction on the mesocolon of the transverse colon and traction on the adhesions of the splenic fexure will lead to safe division of the splenic fexure buy online indocin. The spleen should not be seen and one should stay as close as possible to the colon (Fig order indocin with a visa. When the whole colon has been mobilized, it is possible to go down into the pelvis and decide on the site for the anastomosis. Metallic clips are avoided as they may interfere with proper fring of the stapler. Sometimes, with a large rectum it is necessary to fre two shots to complete the transection. Before fring the stapler it is essential to make sure that no rectal tubes are in the rectum. The fully mobilized left colon is exteriorized through a muscle splitting incision using one of the left lower quadrant ports or a Pfannenstiel, and the specimen is resected. An anvil is then placed in the proximal end after trimming the area appropriately, and a purse string suture applied. A circular stapler is then introduced into the rectum, with care being taken to perforate anterior to the staple line. Using a specifc instrument that allows appropriate handling of the anvil, it is connected to the shaft of the stapler and fred (Fig. At its completion, the anastomosis is checked for leaks using intrarectal methylene blue, or by introducing air into the rectum through a rigid rectosigmoidoscope. If there is a small leak, it can be located by using methylene blue and eliminated by inserting a stitch that is tied intracorporeally. As in open surgery, it is always imperative to check the Left Hemicolectomy 137 Fig. A surgeon’s left hand; B surgeon’s right hand, also used for the introduction of the stapler; C camera; D, E graspers of the assistant. A surgeon’s left hand; B surgeon’s right hand, also used for the introduction of the stapler; C camera; D, E graspers of the assis- tant. An incomplete doughnut should prompt a laparoscopic suture repair of the anastomosis. If the area of the rupture is not recognized, the entire anastomosis should be revised and interrupted sutures placed around the circumference. In the medial to lateral approach, the sigmoid colon is grasped with the left hand and retracted until the superior hemorrhoidal arteries are under tension. After the vessels are transected, the rest of the procedure is per- formed as described. If a hand port is used, again it can be placed through a midline of a Pfannenstiel incision. Then the colostomy site is Procedure used for a Hasson port, and insuffation begins. Dense adhesions can block the view, and must be carefully dissected; this is especially true in the midline, as the adhesions obscure the view for the insertion of additional ports. The port sites must therefore be suitably chosen to permit lysis of adhesions (Fig. Once the rectal stump has been pierced with the shaft of the circular stapler, an anastomosis is performed. One possible problem in this operation is inadvertent stapling of the bladder, espe- cially in male patients. It is therefore essential to check the bladder and to make sure that it is not involved in the suture line, as this will increase the risk of creating a colovesical fstula. Firstly, the bladder is infated with saline through a Foley catheter to visualize the limits of the bladder; secondly, a metallic dilator is introduced into the rectum to help identify the rectal stump. Dis Colon Rectum 39(10 suppl):S1–S6 Clinical Outcomes of Surgical Therapy Study Group (2004) A comparison of laparoscop- ically assisted and open colectomy for colon cancer. N Engl J Med 350(20):2050–2059 Dalibon N, Moutafs M, Fischler M (2004) Laparoscopically assisted versus open colec- tomy for colon cancer. Surg Endosc 8(6):669–671 Huscher C, Silecchia O, Croce E et al (1996) Laparoscopic colorectal resection. Dis Colon Rectum 39(2):155–159 Mouiel J, Katkhouda N, Gugenheim J, Bloch J, Le Goff D, Benizri E, Darois J (1989) Near total colectomy followed by caeco-rectal anastomosis using stapling technique. Surgery 142(4):546–553 Laurent C, Leblanc F, Wütrich P, Scheffer M, Rullier E (2009) Laparoscopic versus open surgery for rectal cancer: long-term oncologic results. Surg Endosc 8:12–17 Small Bowel 9 Obstruction A patient presenting with small bowel obstruction in the presence of an abdominal scar, suggesting that an adhesive band may be present, is an ideal case for a laparoscopic approach. The laparoscope is inserted on the side opposite to the site of maximal intestinal distension. It is possible in these cases to perform an open Hasson technique and insert a blunt trocar providing direct viewing of the intra-abdominal contents. Making a small skin incision and opening the layers of the fascia under direct vision provides access to the abdomen. A purse string is placed on the fascia using 2–0 suture, and a 10-mm port together with a video laparoscope is inserted while the surgeon’s left hand retracts the abdomen before insuffation. This allows the surgeon to visualize the intra-abdominal contents prior to insuffation, and ensures that the port and laparoscope are properly placed in the abdo- men. The purse string is secured and insuffation is then begun, which generally puts the adhesive band under tension (Fig. If the intra-abdominal pressure has reached a peak (15 mmHg) with the volume insuffated equal or less than 2 L, and provided the patient is well paralyzed, there is probably not enough working space due to the ileus. It is possible to position the patient in Trendelenburg or reverse Trendelenburg and with either side up in order to create the appropriate space. Mobilization with the laparoscope itself by breaking some of the loose bands can make room for the insertion of the second port, which is usually the port for the surgeon’s right hand when the surgeon is standing opposite the area of maximum abdominal distension. Insertion of a second port permits introduction of scissors, which is the best instru- ment for laparoscopic enterolysis. When one is performing enterolysis, it is safer not to use electrocautery, and although the harmonic shear can facilitate dissection, a sharp dissection is the best. In the case of bowel stuck to the abdominal wall, it is possible to remove a piece of fascia with the small bowel (Fig. This is certainly safer than trying to free the small bowel from the abdominal wall and exposing it to serosal tears or unrec- ognized injuries. If severe, dense adhesions are encountered, it is impossible to complete a dissection without violating the bowel, and it is best to convert to an open procedure. Once the frst two ports are inserted, it is possible to sharply dissect the adhesive band from the abdominal wall. It is best to stay close to the abdominal wall and at a respectable distance from the intra-abdominal contents to avoid injury. It is also recom- mended to limit the use of cautery; the harmonic shears are probably safer in this setting once enough working space is available. The third and fnal port is inserted in a triangulated manner to the video laparo- scope (Fig. This is used to insert a grasper, allowing the left hand to put the adhesive band under tension while the right hand removes the attachment. If the site of obstruction is not easily identifed, locate the terminal ileum and run the bowel in a retrograde fashion to fnd the transition point. Occasionally if bowel is run anterograde, there is a chance that the band causing the obstruction is taken down, thereby decompressing the bowel without defnitive localization of the band. When han- dling the bowel, great care is taken to avoid grasping the distended and paper-thin bowel wall with traumatic graspers. Once the adhesive band has been removed, the small bowel should be inspected carefully to assess vascularity, motility, and the state of the serosa. If there is any doubt about the viability of the small bowel, an open inspection is mandatory. A small incision can be made, or one of the port incisions can be enlarged and the small bowel is examined outside the abdomen. If a resection is indicated, it can be performed extracorporeally, after which the bowel is carefully returned to the abdomen and the small incision closed. Am Surg 75(3):227–231 Nagle A, Ujiki M, Denham W, Murayama K (2004) Laparoscopic adhesiolysis for small bowel obstruction. Am J Surg 187(4):464–470 Posta C (1996) Surgical decisions in the laparoscopic management of small bowel obstruction: report on two cases.

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For this order indocin online from canada, the patient is put in the Trendelenburg discount indocin 75 mg, right side up position order discount indocin, putting the cecum under tension and facilitating the dissection order indocin 75 mg line. Once again, this puts the appropriate tension on the hepatic fexure to assist the dissection. The mesocolon should now be clearly identifable, and if the patient is not too obese, it is possible to perform intra-abdominal division of the vessels with vascular staplers. Otherwise, if mobilization of the colon is suffcient, it is possible to deliver the whole right colon and the terminal ileum through a right upper quadrant muscle splitting incision, followed by an anasto- mosis outside the abdomen. If a hand assisted port is used, a midline incision is used for the hand port, which can be used to deliver the colon and construct the anastomosis at the end of the case. A umbilical scope; B surgeon’s left hand; C surgeon’s right hand; D, E graspers of the frst assistant. Note that the trocar Left positions are moved down when a low anterior resection is performed. Hemicolectomy As described previously, a medial to lateral or lateral to medial approach can be cho- sen. In the lateral to medial approach, the frst step is to mobilize the sigmoid colon by applying traction and counter-traction during the dissection. At this point it is important to identify the rectosigmoid junction and the ureters. If a ureter is not clearly visible because of intense infammation, it is possible to locate it by inserting a ureteral stent or even an ultraviolet stent. J Laparoendosc Surg 6(2):117–120 Slutzki S, Halpern Z, Negri M, Kais H, Halevy A (1996) The laparoscopic second look for ischemic bowel disease. Surg Endosc 10(7):729–731 Waninger I, Salm R, Imdahl A et al (1996) Comparison of laparoscopic handsewn suture techniques for experimental small-bowel anastomoses. Am J Surg 194(6):882–887 Inguinal Hernia Repair 10 General The understanding and recognition of the anatomy of the preperitoneal space is Considerations essential to the performance of a safe and effective laparoscopic hernia repair (Fig. Medial umbilical ligament and the inferior epigastric vessels as they come off the external iliac vessels. Along with the iliopubic tract, these landmarks defne the three spaces associated with groin hernias (Fig. Direct inguinal hernia: medial to the inferior epigastric vessels and lateral to the border of the rectus abdominus muscle within the triangle of Hesselbach. Femoral hernia: under the iliopubic tract, medial to the iliac vein, and lateral to Cooper’s ligament. They are no different from the hernia spaces seen in the traditional open anterior approach (Fig. The “triangle of doom” is located between the vas deferens medially and the gonadal vessels N. There is another dangerous space at the superior aspect of the internal ring where the genital branch of the genitofemoral nerve enters the spermatic cord (Fig. It is hazardous to apply electrocautery in this area because of the risk of injury to the nerve. Electrocautery is usually applied when raising the peritoneal fap at the beginning of the transabdominal preperitoneal operation, and the dissection should start 1 cm above the internal ring. There is another dangerous zone inferior to the iliopubic tract and lateral to the gonadal vessels, the “triangle of pain,” where one can fnd the genitofemoral and lateral femoral cutaneous nerves. Both arms are tucked to allow the surgeon to stand behind the shoulder opposite to the hernia, and the camera assistant to stand on the other side of the patient. Steep Trendelenburg is required in order to remove the small bowel from the pelvic area. Three ports are necessary for this operation: a 10-mm umbilical port for the laparoscope and two 5-mm ports which can be placed at the junc- tion of a line between umbilicus and the anterior superior iliac spine along the lateral border of the rectus muscle on either side. Alternatively, the two 5-mm ports can be placed at midline between the umbilicus and the pubic bone (Fig. Indeed, the oblique orientation of the inguinal canal makes it diffcult for a right-handed surgeon to visualize small indirect hernias and the canal itself without the 30° angle. The most diffcult hernia to operate upon is a large left indirect inguinal hernia, because the huge sac and the oblique angle of the canal do not allow for an easy dissec- tion. Following induction of the pneumoperitoneum, which is maintained at 15 mmHg, the ports are inserted as described above. If the trocars are inserted too low it can be very diffcult to raise the fap and maneuver the stapler device or the fbrin glue sprayer easily. Therefore, before inserting trocars, one should ensure that the distance is adequate by indenting the abdominal wall from the outside with a fnger. Dissection of the Preperitoneal Space The hernia sac is reduced and the peritoneal fap is incised from lateral to medial (Fig. The incision begins over the psoas muscle laterally, extends medially 1 cm above the deep inguinal ring to avoid the genital branch of the genital femoral nerve, and ends at the medial umbilical ligament. The peritoneal fap is dissected towards the iliac vessels inferi- orly and then superiorly towards the anterior abdominal wall muscles. This is the technique for direct hernias, but with very large indirect inguino-scrotal hernias, the distal part of the sac is divided and left within the scrotum. A blunt technique with the closed scis- sors is used to sweep tissue in each direction. Cooper’s ligament can now be visualized: it is a white, shiny, bony structure with small veins running on its surface. One should be very careful during the dissection around these veins of the corona mortis (“crown of death”), as bleeding from them is very hard to stop. When dissection is complete, the arch of the transversus abdominous muscle, the conjoint tendon, and the iliopubic tract can be seen. The femoral nerve is present under the iliopubic tract at the lateral aspect of the dissec- tion running deeply but this nerve is commonly not seen. In very thin patients, the lateral femoral cutaneous nerve and the genital femoral nerve may also be identifed. A umbilical telescope; B and C 5 mm trocars for the right and left hands of surgeon. This will allow the spermatic cord and the vas to be completely free from the hernia sac and the peritoneum in order to lay the mesh over the hernia defect without having to cut a slit in the mesh. This dissection consists of separating the elements of the spermatic cord from the peritoneum and the peritoneal sac. It is important to continue the dissection until the peritoneum has reached the iliac vessels inferiorly. If this is not done, the mesh will need to be cut and a keyhole slot created in order to cover the hernia defects. However, on the basis of experience from the open preperitoneal hernia repair, this may predispose the repair to recurrence. Placement of the Mesh and Fixation When the hernia sac has been completely reduced and dissection of the preperitoneal space is completed, the mesh is introduced and fxed in place using fbrin glue (Tisseel). The mesh should be cut to an appropriate size; usually an 8 × 14-cm piece will suffce for one side, but measurements can be made using either an umbilical tape or the open jaw of the instru- ments themselves. The corners of the mesh should be rounded to avoid any wrinkles that might lead to a foreign body reaction, or even recurrences as described by Stoppa. Once it is within the peritoneal cavity, it is unrolled into place and should cover all the hernia spaces - the aforementioned indirect, direct, and femoral spaces (Figs. The mesh can be marked with a sterile marker at its midline, as it is sometimes diffcult to orientate it inside the small preperitoneal space. Although some surgeons are still using tacks to fx the mesh in place, 156 Chapter 10  Inguinal Hernia Repair a b Fig. The fbrin glue is sprayed over the mesh in a thin layer, especially onto Cooper’s ligament and the lateral aspect of the mesh. However, if one chooses to use tacks, the mesh fxation can begin with stapling its middle part, “three fngers” above the superior limit of the inter- nal ring to avoid any branches of the genitofemoral nerve (Fig. Then it is possible to staple both laterally and medially; laterally, it is essential to stay above the iliopubic tract, but medially staples are inserted into the rectus muscle and on Cooper’s ligament. Finally, one staple laterally completes fxation of the mesh above the iliopubic tract (Fig. Hence, a stapler with 20 staples should be suffcient for fxation of the mesh and closure of the peritoneum.

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It can be helpful to educate them that sustained improvement depends upon their continued exercise buy indocin with visa. Among the barriers to daily exercise are difficulty remembering to do the exercises and difficulty finding time [29 buy cheap indocin line,30] buy generic indocin. To assist patients to remember their exercises discount indocin express, a variety of cues can be considered, including alarms or notes in prominent places in the home or car. Another approach is to teach them to integrate their pelvic floor muscle contractions into their daily lives or associate them with several daily activities. Once they are proficient, they no longer need to set time aside to concentrate on their exercises. Rather, they can do a few exercises during certain daily activities, such as taking a shower or sitting at a traffic light. Not only does this not add time to their busy schedules, but the activities eventually become cues, reminding them to exercise. This can improve adherence during active treatment and supports continued exercise during the maintenance phase when motivation tends to wane. Using Muscles to Prevent Stress Incontinence Although exercise alone has been known to improve urethral pressure and structural support and reduce incontinence [31], the best results seem to be achieved when patients contract their muscles consciously before and during coughing, sneezing, or any other activities that precipitate urine loss [16,26]. Initially, this new skill requires a conscious effort, but with consistent practice, patients can develop the habit of automatically contracting their muscles to occlude the urethra in situations of physical exertion. This skill has been referred to varyingly as the “stress strategy” [19], “counterbracing,” “the knack” [32], perineal cocontraction, and “the perineal blockage before stress technique” [33]. Even when their muscles are weak, some women will benefit from simply learning how to control their pelvic floor muscles and use them to prevent urine loss. In one trial, women were taught to voluntarily contract pelvic floor muscles before or during a cough and demonstrated reduction in leakage after only 1 week of training [32]. Pelvic floor muscle precontraction has been recommended, not only during coughing but also during any daily activity that results in increased intra-abdominal pressure [34]. The strength that is needed to occlude the urethra and prevent urine leakage is not known, and some women will still need a more comprehensive program of pelvic floor muscle rehabilitation to increase strength in addition to learning this skill. The literature on pelvic floor muscle training and exercise has demonstrated that it is effective for reducing stress, urge, and mixed urinary incontinence in most outpatients who cooperate with training. It is now established as a central component in the treatment of urge incontinence and overactive bladder as well. Initially, it was observed that detrusor contraction could be inhibited by pelvic floor muscle contraction that was induced by electrical stimulation [38–40]. Then, in the 1980s, 644 Burgio and colleagues demonstrated that voluntary pelvic floor muscle contraction can be used not only to occlude the urethra but also to inhibit detrusor contraction [8,20] (see Figure 42. Pelvic floor muscle control and exercise is taught in the same way as it is for stress incontinence. What differs is how women with urge incontinence are taught to use their muscles to manage urgency and prevent urine loss. Using Muscles to Prevent Urge Incontinence: Urge Suppression Strategies Most patients with urge incontinence feel compelled to rush to the toilet to void. This behavior can make incontinence more likely, because it increases intra-abdominal pressure on the bladder and increases the feeling of fullness, and when the patient reaches the vicinity of the toilet, she is exposed to visual cues that can trigger incontinence. Behavioral training teaches patients a new way to respond to the sensation of urge. Although it may seem counterintuitive at first, the urge suppression strategy encourages patients to pause, sit down if possible, relax the entire body, and contract pelvic floor muscles repeatedly to diminish urgency, inhibit the detrusor contraction, and prevent urine loss. After the urge sensation subsides, they are to proceed to the toilet at a normal pace [41]. Detrusor inhibition using pelvic floor muscle contraction can be taught and documented in the clinic. A handout for teaching patients about the urge suppression strategy appears in Figure 42. Patients are then encouraged to practice this urge suppression technique to manage urge and prevent incontinence episodes in their daily lives. The home program for urge incontinence follows the same daily exercise regimen as for stress incontinence. In addition, it is often helpful for women with urge incontinence to practice interrupting or slowing the urinary stream during voiding once per day. Not only does this provide practice in occluding the urethra and interrupting detrusor contraction, it does so in the context of the urge sensation, when patients with urge incontinence need it most. Some clinicians express concern that repeated interruption of the urinary stream may lead to incomplete bladder emptying in certain groups of patients. Therefore, caution is recommended when using this technique with patients who may be susceptible to voiding dysfunction. Behavioral training for urge incontinence has been tested in several clinical series utilizing pre–post designs. In randomized controlled trials using intention-to-treat models, mean reductions of incontinence range from 60% to 80% [20,21]. This urge suppression strategy can be combined with bladder training or delayed voiding as one of several coping techniques that can help patients postpone voiding. Bladder training is a behavioral intervention that was developed to break the cycle of urgency and frequency using consistent, incremental voiding schedules. Bladder drill was an intensive intervention, often conducted in an inpatient setting, in which 645 women were placed on a strict expanded voiding schedule for 7–10 days to establish a normal voiding interval [43,44]. Bladder training is a sequel to this procedure that increases the voiding interval more gradually, over a longer period of time, and is conducted in the outpatient setting [45–55]. This is believed to increase bladder capacity and decrease overactivity, resulting in improved bladder control. To follow this regimen, patients must resist the sensation of urgency and postpone urination. Several behavioral techniques have been used to help patients control the urge to urinate while they wait for their next scheduled void. The traditional approach has been to suggest various techniques for relaxation or distraction to another activity [52]. Patients are encouraged to distract themselves from the bladder by engaging in a task that requires mental but not physical effort, such as reading, calling a friend, or making a to-do list. Self-statements such as “I am in control of my bladder” and “I can wait” are also helpful. Bladder training programs have differed widely in terms of the instructional approach, intensity of clinical supervision, scheduling parameters, strategies for controlling urgency, frequency of schedule adjustments, criteria for increasing the voiding interval, length of treatment, and use of adjunctive treatments. At present, there is no evidence for determining which parameters are most effective. The classic study of outpatient bladder training is a randomized clinical trial that demonstrated a mean 57% reduction in frequency of incontinence in older women [52]. In this trial, bladder training reduced not only incontinence associated with detrusor overactivity but also incontinence associated with sphincter insufficiency, possibly because patients acquired a greater awareness of bladder function or that the exercise of postponing urination increased the use of pelvic floor muscles. A subsequent trial compared bladder training to oxybutynin; 73% of women in bladder training were reported to be “clinically cured” [53]. Identify with the patient the longest voiding interval that is comfortable for her. Patient Instructions: Empty your bladder… First thing in the morning Every time your voiding interval passes during the day Just before bed Teach coping strategies for occurrence of urge. Self-statements (affirmations) Distraction to another task Relaxation Urge suppression strategy (using pelvic floor muscle contraction) Gradually increase interval When patient is comfortable for at least 3 days By 30-minute intervals or clinical judgment based on patient confidence Delayed Voiding Another approach to helping patients to increase control and expand the interval between voids is delayed voiding. Unlike bladder training, delayed voiding does not involve putting patients on a predetermined voiding schedule. Instead, patients are taught urge suppression strategies and instructed to use them when they have an urge to void. When the urge subsides, instead of going to the bathroom immediately, they are encouraged to wait 5 minutes before voiding. Even a mild urge to void can prompt a trip to bathroom in a woman with urge incontinence, due to the fear of urine loss.

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