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Surg Endosc 10(7):729–731 Waninger I order extra super levitra 100mg mastercard erectile dysfunction medications that cause, Salm R extra super levitra 100mg erectile dysfunction at the age of 17, 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. Staples or tacks are used in laparoscopic hernia repair because the mesh is smaller than that used in open surgery (as with the giant prosthesis in the Stoppa repair), so there is a slight risk of movement immediately after surgery and for perhaps 5–7 days until the infammatory process helps to anchor the mesh.

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The bladder diary adds to this the relevant symptoms and events such as urgency buy generic extra super levitra 100mg online impotence lower back pain, pain purchase extra super levitra cheap erectile dysfunction medicine list, incontinence, episodes, and pad usage. From the recordings, the average voided volume, voiding frequency, and, if the patient’s time in bed is recorded, day/night urine production and nocturia can be determined. This information provides objective verification of the patient’s symptoms, together with key values for plausibility control of subsequent urodynamic studies, for example, in order to prevent overfilling of the patient’s bladder. Objective and quantitative information, which helps in the understanding of both storage and voiding symptoms, is provided by this simple urodynamic measurement. Adequate privacy should be provided and patients should be asked to void when they feel a “normal” desire to void. Patients should be asked if their voiding was representative of their usual voiding and their view should be documented. Automated data analysis must be verified by inspection of the flow curve, artifacts must be excluded, and verification must be documented. The results from uroflowmetry should be compared with the data from the patient’s own recording on a frequency/volume chart. Sonographic estimation of postvoid residual volume completes the noninvasive assessment of voiding function. Normal Uroflow Normal voiding occurs when the bladder outlet relaxes (is passive) and the detrusor contracts (is active). An easily distensible bladder outlet with a normal detrusor contraction results in a smooth arc-shaped flow rate curve with high amplitude. Any other shapes—such as curves that are flat, asymmetric, or have multiple peaks (fluctuating and/or intermittent)—indicate abnormal voiding, but are not specific for its cause. Typically, below the minimum urethral opening pressure, the urethral lumen is closed. With normal detrusor contractility and low intraurethral pressure, the normal flow curve is arc shaped with a high maximum flow rate (Figure F. A normal flow curve is a smooth curve without any rapid changes in amplitude because the shape of the flow curve is determined by the kinetics of the detrusor contraction that—arising from smooth muscle—does not show rapid variations. A decreased detrusor power and/or a constant increased urethral pressure will both result in a lower flow rate and a smooth flat flow curve. The same pattern may also originate from a weak detrusor in aging males and females. Fluctuations 1830 in detrusor contractility or abdominal straining, as well as variable outlet conditions (e. Rapid changes in flow rate may have physiological or physical causes that are due either to changes in outlet resistance (e. Rapid changes in flow rate may also be artifacts, when the flow rate signal is extracorporeally modified through interference between the stream and the collecting funnel (the flowmeter), movement of the stream across the surface of the funnel, or patient movements (see flow curves in Figures F. Starting with initial values for pves, pabd of 32 cmH O in the2 typical range for a standing patient with zero pdet; testing signal quality with a vigorous cough at the beginning, and regularly repeated (here less strong) coughs. Dead pves—signal during voiding, which is “live” again only at the second cough after voiding. Careful observation of signals would have made it possible to interrupt the study immediately the signal failed and to correct this problem before voiding started. Accuracy of Uroflowmeters Uroflowmetry measures the flow rate of the external urinary stream as volume per unit time in milliliters per second. There are, however, differences in the accuracy and precision of the flow rate signals that depend on the type of flowmeter, on internal signal processing, and on the proper use and calibration of the flowmeter. The desired and actual accuracy of uroflowmetry should be assessed in relation to the potential information that could be obtained from the urinary stream compared to the information actually abstracted for clinical and research purposes. Some relevant aspects of the physiological and physical information contained in the urinary stream are outlined here. The desired clinical accuracy may differ from the technical accuracy of a flowmeter. Thus, since the overall accuracy of flow rate signals will not be better than ±5%, it would not be meaningful to report a maximum flow rate of a resolution better than a full milliliter per second. Under carefully controlled research conditions, a better resolution may be possible by flowmeter calibration and instrument selection. However, such improvements in resolution may not be required for routine clinical applications. The dynamic properties of most flowmeters will be good enough for free uroflowmetry. When pressure–flow data are analyzed, however, the limitation in signal dynamics should be taken into account because pressure will be different from flow. Flow signals have a much slower response and are less accurate than pressure signals. The flow artifacts can be identified as dyssynergic events and manually 1833 corrected from Qmax. Problems in Urine Flow Rate Measurement The problems in measurement, as well as the information that can be abstracted from the flow rate signal, are rather different for free uroflowmetry compared to combined pressure–flow recordings. In free uroflowmetry, the shape of the flow curve may suggest specific types of abnormality; however, reliable, specific, and detailed information about the cause of abnormal voiding cannot be derived from a flow curve alone. Only when uroflowmetry is combined with intravesical and abdominal pressure (pabd) recordings does it become possible, from the pressure–flow relationship, to analyze separately the contributions of detrusor contractility and bladder outlet function to the overall voiding pattern (Figures F. Detrusor Contractility As the voiding function reflects the interaction between the relaxed outlet and the contracting detrusor, variation of both will affect the flow. For steady outflow conditions, all variations in flow rate are related to changes in detrusor activity alone. The detrusor contraction strength varies neurogenically and myogenically, and can cause significant variability in urine flow rate measurements (Figure F. Bladder Outflow Resistance If detrusor contractility is constant, then changes in outflow resistance will lead to changes in flow rate, for example, in patients with detrusor–sphincter dyssynergia (Figures F. Bladder Volume As the bladder volume increases and the detrusor muscle fibers become more stretched, there is an increase in the potential bladder power and work associated with a contraction. This is most pronounced in the range from empty up to 150–250 mL bladder filling volume. It appears that, at volumes higher than 400–500 mL, the detrusor may become overstretched and contractility may decrease again. This dependency will vary between individuals and with the type and degree of pathology; for example, in constrictive obstruction, Qmax is almost independent of volume, and in compressive obstruction, the dependency becomes weaker with increasingly obstructed outlet conditions and lower flow rate. Technical Considerations The flow rate signal is influenced by the technique of measurement and by signal processing. The external urinary stream should reach the flowmeter unaltered and with minimal delay. However, any funnel or collecting device, as well as the flowmeter, will inevitably introduce modifications to the flow rate recording. Physically, the external urinary stream breaks into drops not far from the meatus. This fine structure of the stream has a high frequency, which can be assessed by drop spectrometry, and contains interesting information. For standard uroflowmetry, however, such high frequencies should be eliminated by signal processing.

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