Open Onlay Hernia Repair for Recurrent Incisional Hernia

CHAPTER 1

I'm Eric Pauli. I'm a Professor of Surgery at Penn State Hershey Medical Center and I'm the Director of the Abdominal Wall Reconstruction Program. Today we're gonna do an abdominal wall surgery on a patient who I've known for several years, actually. She's an 80-year-old patient who had a complex hernia repair done three years ago. And I had met her in 2021, almost three years ago to the day that we are gonna film. When she had a series of complex hernias, she had, prior to that, had an open colectomy and developed some incisional hernias that were repaired robotically. The entire fascia was closed robotically and a piece of mesh was put in over half of the fascial closure. She developed a hernia below that repair, above that repair, and she got a port site hernia that was sort of a Spigelian type port site hernia. And to address that, we did an open TAR on her previously. She recuperated from that well, but about a year after that operation, 18 months after that operation, she presented to an outside facility with an adhesive bowel obstruction. And to manage that, the team did a laparotomy on her, divided through the mesh that I placed, managed the bowel obstruction. But unfortunately, she's developed a hernia at the lower part of that laparotomy incision now. We're gonna do an onlay hernia repair today, and the rationale behind doing an onlay repair is that we know that she's a patient who forms intra-abdominal adhesions. And so, we expect to find a fair bit of adhesions today. She's 80 and so we don't need to do anything tremendously complex to manage this. She already has mesh in the retromuscular position, so redoing a retromuscular repair would be quite challenging. And she also happens to be a Jehovah's Witness. And so kind of reentering the retromuscular plane and the inherent risk of bleeding in a patient who is not gonna be accepting of blood transfusions doesn't make a whole lot of sense. So our plan is to cut down, essentially over the hernia and free up adhesions locally, close the fascia primarily, and then do an onlay of a permanent synthetic mesh today. What I'll do so that we have an understanding of the hernia that we're gonna look at today, is we'll review the patient's most recent CT scan. We'll show you where the old repairs are and we'll show you where the hernia is today that we're going to address. This is a CT scan from our patient whose hernia we're going to repair it today with an onlay. As I mentioned, she has a previous history of an open abdominal wall reconstruction with a transversus abdominis release. And while it's challenging at times to see where the mesh is located on the scan because it's hard to see that after a TAR, there are a few hallmarks to look for. And one of the hallmarks after a well done retromuscular repair is that the rectus muscles make one big motor unit here in the middle. It's hard to find an actual linea alba, okay? So this patient has clearly had some work done. There are a few other ways you can tell that she had a retromuscular repair. Let's see if we can find one of those maybe down a little bit lower here. Here's a good spot here where you can see that the posterior abdominal wall has these kind of waves to it. Okay, this is a subtle suggestion that there's restromuscular mesh here. It's a little bit easier to see here because there is preperitoneal fat between the bladder and the abdominal wall that kind of tips you off that that's what's going on right here. Her hernia is located right here. She had a midline laparotomy to a manage a bowel obstruction. And so she has a recurrent hernia here in the midline where the mesh and the abdominal wall were cut through. The mesh was fractured and then sutured back together. But here's the gap. Our radiology team measured it at 3.6 centimeters or so. That's pretty close to accurate. They might be slightly off on the exact dimensions. It contains a loop of non-obstructive small bowel, but this area on multiple previous scans has been the source of partial bowel obstructions. And this loop here has a little bit of fecalization as well. So this is where her symptoms are coming from. It's where she has pain in a bulge and where she's had some partial obstructive symptoms. So we're gonna tackle this today. The rest of the abdominal wall is for the most part intact without any obvious problems or findings. I will briefly point out that if you come way down here, she does have a subtle suggestion right here of a fat-containing femoral hernia right here. This has been stable on multiple scans over the past five years. It hasn't changed. She's got no symptoms, and we're not planning to address that today at all. So we're gonna address this hernia. We'll free up the bowel that's stuck, we'll close the fascia back together. We'll make a little subcutaneous pocket on both sides and do an onlay of mesh in this area.

CHAPTER 2

So, I counted three centimeters below umbo, as roughly where this thing starts. Maybe like there to there-ish. We'll try and work our way in. Sam will take a knife. Pick a side, any side. That's all going with us anyway. Incision. Got a good height of the bed? That's great, yep. I'll take a two pickups. So, this patient has already had, that's good, has already had a hernia repair. She had, when I met her, had already had an open repair, a lap repair, and a robot repair. And so we did an open retromuscular hernia surgery on her. I'll take a Ray-Tec or a lap. And the repair was great. Unfortunately, she developed a bowel obstruction and on the CT scan for that bowel obstruction, there was a concern that she had an internal hernia because there was a little bit of a twist in the bowel on the images. And so, they felt that that needed to go to the operating room. They didn't think that managing it conservatively was the right answer, which is probably correct. It's hard, it'd be hard to sit on that CT scan and not do an operation. Unfortunately, they did it open, and she subsequently has developed a recurrent hernia. They did all of the correct maneuvers. They went through the mesh in the midline, which is what you'd have to do. And they ended up closing the mesh back to the mesh with Prolene. So that was all okay. Relax for a second. Let's put your finger and see what we can feel here. I think that's the hernia sac directly below you. I think it's gonna be the sac right there. You have peanuts available, good. I'll take a DeBakey. Sam will take a DeBakey as well. Unfortunately, the bottom part of this has come apart. And so, she has a recurrent hernia here. And so, we need to fix it. And given that she already has mesh in the retromuscular position, redoing a retromuscular repair, which is a thing we sometimes do, in her is a bad idea. She's older, she has minimal symptoms from this, and they're local symptoms. She doesn't have a hernia through most of it. It's really a focal area that's herniated. And she is, as we mentioned, a Jehovah's Witness. And so I think that the risk of bleeding, with a redo retromuscular repair, is obviously higher than a first time around operation. There's the sac. That's peritoneum right there. So this is the hernia sac coming up and out here. This is peritoneum herniating through the midline. You wanna maybe we can open it. Let's grab, grab there. I'm gonna re-grab here. Just pinch that, make sure we feel. It feels okay. It's a real thick sac. Do you have an Allis? We'll take an Allis. Thats on something, Sam will take another Allis. Okay, let's keep working our way down through this then. Where should we get into it? Okay. There's some bowel in there now. Got another Allis? So step one of any hernia operation is getting into the abdominal cavity safely. And we have chose - chose, chosen? Choosed? Elected. We've elected to open, relax for a second. Okay, I can feel there's the edge of the fascia there. There's the bottom edge of the fascia down there. So we gotta come down a little bit anyway, so let's... Actually, I think we're gonna be okay. I think we can probably find our way in here. We've chosen to open directly over the hernia, which is not always the best idea, but we also know that above and below, she, A) doesn't have a hernia, B) she has mesh, and we also know C) that this lady makes a lot of adhesions. And so our goal is to get in somewhere where we can kind of feel the peritoneum and kind of get through the peritoneum here and into the hernia sac. So that's what we're trying to do here safely. We're trying to get into the hernia sac here safely and open that up. But like many people, it's not always obvious. I'll take a DeBakey. Nothing comes labeled. And she didn't read the textbook to know how this should all be put back together, so... Okay, there's a little window there into the inside world. It's that in in? That's pretty close to in in. Is this bowel over here? I don't think that's bowel, Sam. I think it's just sac wall. I don't think it's a loop of bowel, do you? I don't think so. I think it's just sac. I think it's all just sac. I thought I saw a little window inside there. I think most of this is gonna be okay to go through. But it'd be nice to actually see the inside world first. Do we have any room up if we went through some of this superior stuff? The preamble stuff? Maybe, just drop those two. Let them dangle, grab this here with the DeBakey. I think this is all just pooched out anterior fascia and hernia sac here. So let's work our way as you suggested cephalad, that's sub-q stuff. I don't think we're even in the sac yet. Take it layer by layer just to make sure we're not bringing something up accidentally. Yep. Okay. Do you have a right angle? Fine. That looks like the peritoneum, the true peritoneum right there. Wowza. I'll take a DeBakey. Let's work this edge. Again, this is probably what used to be anterior fascia there. This is probably posterior stuff. You got a peanut? There's a Prolene. Okay, I think this is all okay to go through. This is all gonna be sub-q stuff, so I would extend your incision to the sub-q up to, or the skin about there. Go through all that stuff there. Yep. Yep, okay. I'll take another Allis if you got one? Let's grab that edge there. Boom, another Allis. We only have four. Yep. Peanut. Okay, there's a Prolene stitch from somebody being here before us. I guess we can work our way down now. Let's do the same maneuver inferiorly. Right angle. I think there's like a little septum here, Sam. Let's try and - I think the septum is nothing. Let's come through this stuff here. A band of some stretched out fascia there. I'll take a peanut. There's a big hernia sac that actually extends down that direction somehow. Right here is a hernia sac right here. That looks like the true peritoneum right there. I'll take a right angle. Give Sam a Metz. And come through that. Yep, and then I think we can safely extend this now inferior a bit. I would say come down through there. So on the scan, this bulge does not look this big, but she's also laying completely flat and not coughing. You can see where I marked out the bulge when she coughed, you know, on the exam. So the sac is, DeBakey, it's a pretty big sac. But the nice part is if the fascia is intact, this will allow us to kind of desacify all of this. Right angle. And then we will be able to, we'll have a little nice little pocket down below for the onlay mesh. This is probably where the sac comes off the sub-q fat right there. Let's get the - stop the bleed as they say on the trauma service. There you go, come on down through all that. That's just sub-q stuff. Fine. It'll burn there. Fine. Yep, there's the back of the sac right there. And then, this is some peritoneum. And what's left is some fascial bands right there. It's up here, right there. There we go, okay. Okay, I'll take a babcock. I think it's gonna, yeah, I think we can safely find a window now. Give Sam a babcock as well. And I'm gonna take a right angle. We'll just kind of pull those lateral. I'll take a DeBakey too. I would just put those together and let it dangle off to the side there. Let's go where you were looking. Let's go like right in there. Okay, yep. Let's lift that up. I think that's okay to Metz through carefully. Good, I think we're here, we're in here too. There you go. But you can Bovie through that. That's nonsense because, so it looks like we've actually found the real peritoneum here and we're actually going through that now. Now we're intra-abdominal, okay? So we've achieved step one of the surgery, get in safely. Congratulations.

CHAPTER 3

The last 30 minutes have been us getting in safely. Step two is to kind of open the midline and make sure that all of the midline stuff is down that needs to be down. So let's reconnoiter our stuff here, that's on the edge of the sac there. Okay, so that Prolene is actually on the abdominal wall right there. This is the bottom edge of the defect down there. So this'll need to be debrided. That's actually free. Could I have a Kocher now? I'm gonna put a Kocher on what I think is the, I mean, there's an edge of mesh in there somewhere. And this is gonna be the rectus here. So that's rectus abdominis and some of the mesh. There's some bowel stuck actually right there, Sam. And then there's some adhesions here, and then the fascia's back together right about there. Can you safely see where's the edge of the rectus? Yeah, edge of the rectus is right there. Is there room to get? You have a retractor? Is there room to get a Kocher on that safely? Let's see. I think so. Yeah, probably right there. I would get a Kocher on that right there. That's the mesh. Yeah, right there. Fine, okay, so now we've got two Kochers on safely. Let's take a look and see what's stuck here. Okay, so this is all peritoneum so that's fine. There definitely is a loop of bowel plastered right there. Very heavily stuck with some intra-loop adhesions in fact. I can see some bands and we're gonna probably want to consider taking those down. You are actually free out to about there. That's actually nice. It comes up this way. There's a band right here. So let's go to the top edge. You hold that there. I'm gonna hold this here. Can I have a... Give Sam the Bovie. This is just peritoneum, Sam. The stitch marks where the abdominal wall starts. So yeah, from there up. That's all just peritoneum. Can we have a little retractor now? And I'm gonna take a DeBakey please. Can you grab this one right here for us? That one, yep. Sam, switch hands there. Smaller retractor. Okay, can I have a DeBakey? Well, if the question is, does this patient like to form adhesions? The answer is she does. There's a whole edge of stuff right there. It goes up there, it goes up there. So we gotta get that down so we can saw to the top edge. We don't need to go much here because it's mostly free. Cut the peanut. This is some big veil of peritoneum here. Again, if I can get it down and there's no bowel up top, we're gonna be okay to then kind of come around that corner. That all comes down. That all comes down. Okay, so here's this band of peritoneum here and is there another edge here? Yeah, I can see the other side of it. That connects down to this bowel that's stuck and there's a loop of small bowel stuck right there. So it's kind of like an interloop, adhesion of some sort here. I'm gonna just work around this corner here. Peanut. Yeah, she forms adhesions. So part of why when we do our complex hernia surgeries, you saw us do that case earlier, we hid the mesh in the abdominal wall, right? We don't want mesh exposed to the abdominal cavity because when mesh touches the bowel, even when it's an anti-adhesive coated mesh, people do tend to form adhesions to it, right? And our goal is to kind of avoid that. So in this patient, we specifically went out of our way to make a big pocket behind the muscles, so that we wouldn't have as many adhesions, okay? So, I mean, there's adhesions all the way up, Sam. Part of what I told her, I would do this as well. You can actually feel, you can feel the intact midline closure right there. Put your fingers in, you can feel their Prolene, their running Prolene to there. You know, part of why I am... Part - one of the things that I do when I'm looking is to ask myself if I had to come back and do an intra-abdominal operation on her, is there a safe place to get in? You know, could we like, is the whole left side free or is the whole right side free? I mean, she's got adhesions. I mean, this retrorectus space here and all the way out appears to be free, but up top, I can't really say. Sometimes I'll actually stick a laparoscope and just do some laparoscopy will just lift up and stick the scope in and take a look around. Again, it's not gonna change what we do today. I'm gonna grab that from you, but in terms of our next step, if she recurs, it's fine. Here's the edges of the rectus here and here. Those easily overlap, so it's gonna be a pretty tension free closure. But my only concern or my big concern right now is there's a loop of bowel right here, okay? And we know that she's had obstructions in this rough of vicinity and so we gotta make sure that we are not leaving her with a source of an obstruction here, okay? So let's go here. And let's see if we can't change. I'm gonna move this one a little bit. Those are just on the sac, those can eventually come off. Let's go here and here. And that's gonna show us this loop of bowel that's stuck right there. I'll take a DeBakey please.

CHAPTER 4

And can I have a Metzenbaum scissors please. Okay, so here is some nonsense here and we're gonna look for a little plane in the nonsense. I'm gonna try and find a plane between the bowel and the posterior abdominal wall here. I think given her obstructive symptoms and the thought that this is just the hernia 'cause that's where the obstruction is, we don't need to go crazy. But I also don't think we can leave adhesions directly to the vicinity of the hernia. Not only to safely do the closure, but also because if we leave her with the same problem, she's gonna have a recurrent obstruction and that would be no fun. So relax on those a little bit because of how tight she is and how small the hernia is when you pull up, see this may actually be the problem right here, Sam. It may actually just be this adhesion that's her main issue. You know, maybe it's not the true hernia that's the problem. Maybe it's just this tight adhesion right here causing the issue. Got a peanut? Okay, so then there's this band of something here as well. What are you? You're something. And then here's another adhesion here that goes somewhere else. Yeah, that looks like it's almost a hole. Well, these are epiploicae. This is the colon, right? This is the large intestine. Here's an epiploic of the colon. There's a taenia right there. So somehow we've got like a little adhesion here, but is this between the colon and the colon? Is there a hole there? Sort of, there's a tiny little hole there. It's between the colon and the colon. And this is an epiploica, I think. Nope, that's the mesentery of the small bowel on your side. So that small bowel there that was stuck to the abdominal wall. I guess I can go back to trying to get it off the abdominal wall for starters. So this is nonsense here. That's the mesh there. This is what's stuck right now. I'll take that Metz back please. So there's the bowel there, there's the free edge there. Could I have that peanut again? I think the backside is just much less densely adherent. It's really just plastered in one spot. And it's possible that as they open, they may have exposed a little bit of mesh and even though they sewed it back up, it might be just kind of densely stuck at that. It's clearly that one spot right there. I'm going into the abdominal wall here on purpose to take down whatever this adhesion is. If I take a little bit of the peritoneum down with us, that's okay. If I leave a little bit of the bowel up, that's no bueno. That looks okay, I'm not concerned about that. We'll take that peanut again. I would just drop them down now a little bit. Yeah, there you go. Yep. Come on, bowel. So do we have enough to sew the fascia? Yes. I mean, our first goal of having enough free fascia to sew to has been achieved here. Okay, the question is, how much more this do we need or want to do? This is preper- This is abdominal wall fat right here and colonic fat. So let's take that plane right there, Sam. You get these guys here. Yeah, hold this please. Grab that there, yep. Ceci, hold this please. Yep. Grab here. Yep. Should be a little plane up there, Sam. I'll take a right angle. There's the true peritoneum right there. And then, yeah, that's okay. Fine, yep. Okay. Again, we've gotta be able to feel where's the bottom edge of the defect? Relax on that for one second. I think the bottom edge of the defect is actually a little bit farther down, Sam. I think this is... Yeah, we have to kind of get this down, I think. Yeah, I think we need a little bit more room there, yep. Take that. Get a peanut. Cut the clear stuff, Tom. That's small bowel in there. There's some bowel in there now. Yep, there's your edge. I can see through it from my side. There you go, nice. Yep. Good. Yep, let me sweep. Okay. Don't let go. Your headlight is not looking where you are, just FYI. Right angle. Stay on the upside of that. Okay, so... That's the edge of the muscle there. This is usable muscle here. So we're now down to stuff that we can sew as an actual hernia repair. Okay, I'll take another DeBakey. Peanut. Yep, let's do it. I think, yeah, we'll do it like that. I'll grab this. This is that same small bowel loop that I was working on earlier. Yep, there's your plane right there. Yep. Did I use a heavyweight mesh in her? I thought you just used the 30. I thought I used 30-by-30 soft mesh. But that looks like heavyweight mesh. This is in fact a piece of... This is not my mesh. Do you see this? You... That's the mesh we left in place. Yeah. So this mesh, it feels like a heavyweight mesh. Okay. And it actually is, if you look, it's a laparoscopic mesh, right? So all of those adhesions are to a laparoscopic piece of mesh. They're not actually even to my piece of mesh. There's the edge of that mesh right there. Yeah, there's a piece of mesh there. Yeah, that's a lap mesh. It's a Ventralex patch. That is the medial edge of the patch right there. So that's what it's stuck to. Okay, so we're down here. That's clearly in the spot of the part of the abdominal wall that's back together. So again, we just need to make sure that we have enough room down here to get our repair at the bottom edge. Let's work down at the bottom now. Let's go there on the abdominal wall there and let's take this one off here. And Ceci, I'm gonna have you go somewhere like, I think this is okay to grab here, right? Let's take a look at what that is. Make sure that's not anything bad that we're grabbing. I think it's okay. Let's grab here for now just for safety. Actually, I'm gonna move you a little bit more here. Let's go and can I grab this? Okay. Yeah, looks like... That's okay for sure. Yeah, just go there and there with that. Okay, I'll take a DeBakey. Not a DeBakey, I'll take a peanut. Sam's got the Metz. So it's like a plane right here? Yeah. Again, so there looks like there's some epiploicae of the colon in here and there's probably some, obviously some preperitoneal fat. We're down low enough that the bladder flap is gonna... Right there. Yep. There's bowel right there. There's a plane right there, yep. There you go. That's probably bladder - you know, preperitoneal fat in the space of Retzius that you're working on above. Yeah, which means that this is the proper plane here. Yep. Again, our goals here are modest, okay? We need to have a safe landing zone for our mesh. We wanna get all the bowel back into the abdominal cavity if we can. Can you see that plane there, Sam? There you go. Yep, that's all okay. Good. Let's re-sweep here. Hold on, I'm gonna... So that's actually all free down there now down to the pelvis. This is stuff that was clearly herniating up and out when she was herniating stuff through. I'll take a right angle. The bowel edge is right there. So this is what needs to go. Yep, go ahead, take that there. This loop is stuck though all the way up and under. Okay, so let's make sure we free it up completely from where we think it stuck to the abdominal wall. Now we're cooking. Okay, so there's gonna be a plane here between something and something. I would start at that edge right there. Let's see if we can't free it up here. I'm not sure if that's preperitoneal fat or epiploic fat, Sam, but pretend like it's something important. As we come through it. Yep. Good. Okay. And then here's this loop now, able to be freed up a bit more. Yep. We're gonna start running into just more and more adhesions. Okay, and so if we think that that loop is down and off the abdominal wall, which it is safely, the question is how much more do we need to get down? Because she's got a ton of adhesions, right? And so, lysing all these adhesions is not necessarily gonna help us. That's that part of bowel that I left in there. This loop is definitely way down back into the corner there. I'm not sure that taking much more of this down, Sam, is gonna be truly helpful for anybody. I'm willing to work on... I'll take the scissors. I'm willing to work on this corner here just very briefly to see if I can get the last of this loop off of the laparoscopic mesh, okay? Okay, that is now down and off that mesh. Again, there's still more adhesions up top, but that edge is now completely free. So anything there that was concerning to us should now be not concerning. But she's, I mean, listen, no matter what we do, this lady's gonna have a risk for forming another adhesive-based bowel obstruction and there's really not a whole lot we can do about that at this point, okay? Would you entertain Seprafilm? Yeah, I don't think it's gonna help, but I mean, sure. I mean, part of the issue is these adhesions are spots where there's normal peritoneum, you know, and they did a complete enterolysis last time and here she is. So, you know, I'm gonna say no, but we could certainly entertain it. It's an okay discussion point. Just making sure this mesh is not flipped or rotated. Nope, that mesh is pretty flat. Okay, fine. Got a lap pad wet in a square. Thank you. It's gonna be too big. Want a Ray-Tec? Yeah, Ray-Tec going in. Okay, fine.

CHAPTER 5

Now we need to debride the abdominal wall here and define what's usable tissue and what's not. All right, so let's do that now. Get your Bovie there, Sam. Let's come through. This is clearly a big old hernia sac right here. So let's... Can I get a Bonneys please. I would just buzz through all that. Just get down to the edge of a fascia somewhere. So all of the hernia sac, we're gonna try and remove. Number one, it's just gonna form some seroma. It's a bunch of dead space that we don't want. Number two, we have to... We need to find actual usable abdominal wall where there's fascia and muscle and mesh. So it's gonna be somewhere like there. Got a peanut for me? Actually, I'll take a right angle instead. Yeah, I would do that, Sam, that's an okay maneuver. Fine, that's all sac now. And let's try to peel the sac then. I got that. Thank you. I can change the tension and direction a little bit more easily if I'm holding it. That's the rectus right there. So let's go here. Okay, fine. So that, a lot of that stuff we were seeing was just blown out anterior fascia, it looks like. Is this anterior fascia? Is that what this is? Like did she lift the anterior fascia up and off? You know what I'm saying? Let's just debride some of this stuff and get out of the way for now, guys. You'll get a specimen here called abdominal wall debridement for gross evaluation only. Yeah, fine. Do it. Do you care about that? Probably. Okay. Let's go over here. I think I see... I thought I saw... You see some fascia there? Anterior here maybe. Yeah, so grab it. This is the stuff. Okay, if there's anterior fascia, then take that your way. And see, there's still this stuff here though. Let's go to the other side. There's just less sac there. And let's see what we can define in here. So this is clearly the mesh, right? This is mesh here and that mesh is retromuscular, okay? So there's gotta be another layer of stuff here that needs to come with us. So I think that all of that needs to stay on our side of the dissection. Give me a little buzzy buzz buzz right in there. You just take it there. We'll figure out the skin in a minute. Fine, okay, so this is anterior stuff. This is anterior fascia right there. You can actually see the anterior fascia. DeBakey, please. Buzz. Tell them we'll be over in about 30 minutes. Okay. All right, so that's a usable - this is good fascia here. This is the sub-q pocket we're gonna raise up. Let's go this direction now. So again, here's anterior fascia here. I'm gonna grab here and I'm gonna re-grab here. So that's mesh and fascia now. So there's the whole anterior edge we're gonna work on. Okay? Let's go - yep, let's take this here to here. Go for it. Okay. Hold this right here. This used to be fascia here, Sam. That's the anterior fascia. Looks like they closed the mesh and maybe not the anterior fascia layer. Fine. So this is anterior fascia here. That's peritonealized mesh. So this is actually anterior fascia here. Let's take that off. This is just nonsense right here. Pick up of some sort. Okay, there's more stuff right there. Okay, so that's a defined edge there. That's intact abdominal wall there. We're gonna go up there for our onlay. There's a big onlay space there. Pocket going that way. Let's continue around the corner pocket here. We need a little retractor now. So let's go around this corner. That's retracting in the sub-q. Yep. So let's find what we think is anterior fascia. So this is the mesh is here. That's some nonsense. That's anterior fascia back to there so we get a lift. I'll take a babcock please and I'll take a right angle. So I think we're gonna be all right here. Yeah, probably. I think you're looking at the right stuff. Good. Okay, that's all sub-q space now. This is just old hernia sac and scar from somebody being here before. So that's fine. We know where that is now. Okay, that'll all go when we're done. Let's come around the corner for now. Let's keep coming this way. So I start taking that to that direction. And again, let's grab this. This, I think, is that's posterior stuff. This is probably a little bit of muscle and this is probably the anterior stuff here. I'm gonna put all three of those back together. So there's your layer right there. I'll take a right angle please. Yep. Just get through that stuff there to there. There's some sub-q fat, that's what we want to see. Fine. There's the true anterior fascia right back there. Okay, the good healthy stuff. Now in this area where we're working, there are going to be some blood vessels. Sam, and this all lifts up. I don't think any of that is useful. Cutting currents, okay, just come through. There are gonna be some blood vessels coming through the rectus muscle and going up to the anterior abdominal wall. Okay, and those are perforating blood vessels that come from the deep epigastric. And work their way around through the rectus muscle to the skin. This is well above the repair, right? Because we stopped over there. We're stopped. We don't need any of this. We just gotta find how to connect these. Let's just do that for now. And they're called periumbilical perforator vessels and they supply the skin with blood in the mid-abdomen. Our Ray-Tec is no longer doing what Ray-Tecs are supposed to do, which is keep the bowel out of the way. Okay, let's keep going this way, so there's the fascia. There's the fascia.

CHAPTER 6

Okay, so we now have some good edges. I say we spend the next few minutes here to make our pockets. Okay, so we want, how much overlap do we want? I'll take a right angle. It's four or five centimeters. I would go for five, okay? And so we're gonna wind up sacrificing some of the periumbilical perforators. Like that thing's gonna have to go. If they're really big, and they can be big in some people. Can you hold this guy right here for me? Just kind of pull right there. If they're really big in some people, you either wanna clip them or, you know, use an advanced energy device. Again, this is a lady who we don't want to bleed afterwards. Obviously, we don't want anybody to bleed. But she would be a little bit higher risk of problems if she has some bleeding. The other problem with doing this is that we are raising skin flaps and so we're taking the blood supply from the central abdomen. So where is her skin here gonna get its blood supply from if we are taking it? Do you know, Ceci? Are there... I mean, you could easily just say somewhere else. Somewhere else. Somewhere else! Somewhere else. The answer is yes, somewhere else. The blood supply comes from... The iliacs? Well, a little bit. Most of it comes from lateral, from vessels, they are essentially lumbar vessels. They're actually up in the upper abdomen, they're intercostal vessels. Oh, and they have some like blood supply that drips down here. Well, those vessels all wrap around the back and come around to the front. And so that's where the blood supply comes from at that level. Okay, so, Sam, this is the anterior fascia right there. We just gotta kind of get from here to here through... You know, we didn't go the way down through the last of the scar, so this is just gonna be some sub-q scarring here. There to there. Yep, go for it. Fine. All right, let's go here now. Let's get this, we get this fat up and off. Don't, let's go with a bigger retractor. And you don't need to pull too hard. We just wanna go right there. Yeah, just right there. We just wanna kind of, we gotta get the fat. I'll take a DeBakey, we gotta get the fat up and off. We want the fat up and off the fascia 'cause we want the mesh to sit against the fascia, right? We're trying to reinforce the fascial closure. We're not trying to reinforce the fat. And so, we also want good tissue ingrowth between the mesh and the fascia. And to do that requires the mesh to be against the fascia. So those are kind of the hallmarks and the plan for what we're about to do. Just making sure there's fascia down below. I don't want to cut anything that could be... I think there's fascia down there. Give me a little bit of a window here, Sam. Just go there to there for a minute. Fine, and there's usable fascia behind us there, okay. That's all native anterior abdominal wall fascia there. Yep, there's fascia back there. So this is just some stretched out blood vessels and a bit of scarring, I think, so go there to there. Yep, there's fascia there. So this is all nonsense. It's gonna have to go up. And again, the goal is to get five centimeters in all directions. Top, bottom, left, right, with where we're working. Fine, take this in your other hand so Sam can get a DeBakey. Lift that fat up there. Yep. Yep, and if you see vessels, you can pinch burn them as we go, okay? Give that a little pinch burn. Good, okay. Yep, this is the spot we already, yeah, it's nice, yep. This is the spot we already started to see the flap edge forming, so that's great. Good. Okay, so again, you got a little ruler there for us. We'll take the ruler. Let's just look at the bottom 50%. So we have five centimeters overlap there, yep. Five for sure. Let's go down in this corner pocket here. Where's the edge of the fascia? Actually about there. Okay, this is just a little more scarred down here because of the midline. So let's get a few more centimeters of the sub-q stuff up. It's just gonna be more scarred because of the old laparotomy incision. Make sure we're not taking any anterior fascia with us. I think we're okay. That's just all scar. She formed scar in all the wrong places. You got a ruler? That should be okay. Keep coming around that corner, Sam. Take this your way. I'll take this my way. Yep. Yeah, let's get those guys, yep. You wanna get it right down here at the edge of the fascia. I'll take this guy from you. Yep. Yeah, that's all good. We're all the way out to there. So give Sam the ruler again. Just make sure. Check this little corner pocket there to there. Right there is where we are. That's up just about four. Let's get those bands right there. I'll take a right angle. So we're just making a pocket under the sub-q tissue between the sub-q tissue and the abdominal wall fat. And it's a little more scarred here in the lower abdomen where she's previously had a midline laparotomy incision. Sometimes you get down into an area that may have been lifted up with a C-section and you just don't, you know, you're not, it's not as easy to necessarily see that scar. Yep. Okay, fine. That looks okay. I just gotta think about how it's gonna come back together when you're pulling on things. So this probably has to go too, I would pinch burn that, Sam. DeBakey. DeBakey to Sam. Yep, do it. Okay, fine. All right, that all looks okay. Let's see the retractor. Happy with that. Yep. Yep, so we just gotta go this direction now. This patient wondered if there are Oscars for medical videos. I told her about the World Cup of Surgery at DDW. The World Cup of Endoscopy videos. She was excited to potentially be a... This is all nonsense. It's nothing. I can see the anterior fascia intact down below us. And so we're gonna have to do is we're gonna have to debride that off of the abdominal wall once we get it kind of freed up from there. And then we're probably, you know, her umbo on the scan was within three centimeters of where we need to be, so we're gonna have to lift the umbo off the wall. That's just scaring. We're in the midline, it's just nonsense scarring. Okay, fine. So go there. Hold that right there, Sam. My bad. That's up, that'll come with us. You know, that doesn't look too terrible. On the fascia. Yeah, we're up under the umbo, I think. That may have been the umbo stalk we took down then. If we are, that's fine. I got this here. Yep. Fine. Okay. So let's connect this corner then that way, I'm just gonna switch hands here. I'll take a peanut. There's the fascia. There's the fascia. So we gotta come through that stuff right there. Let's go right there. I'm not sure how to best do this because there's a little septum. See this little septum right here? It's the septum probably from us being here before. Let's take two retractors, two small retractors please. Let's do one here. You can take that off, I think that's okay. Let's go there and let's go here. So, CC, you're gonna take that one right there. Yep, I'll take a right angle. That's the last corner we gotta get. Okay, so we need, this is the anterior fascia back there. We need this plane to come down. And again, a lot of this is just midline scarring from the previous midline laparotomy and closure. Okay, now the trick is obviously to make sure that there's not a hernia up here 'cause if there is a hernia, A) we gotta go up higher, B) it's possible if there's something important in the hernia, we don't want to injure anything that might be poking its way through. So part of why having that scan is helpful is to say, yeah, there's just one hernia that's at the bottom of all of this. Okay, so there's the midline fascia right there. Let me take my finger here. That's all intact midline. Okay, can I have the ruler? We've got plenty of coverage here now. Much overlap in the upper midline, and we can tuck that mesh way up there safely. Okay, let's come around the corner. Definitely got more than five there. Five, five, five, so I think we're good. Okay. All right, so let's take our Ray-Tec out and let's close the fascia. What do you wanna use to close it? Wanna use mesh suture? Yeah, we may, we may. Let's do it. We'll take the number one mesh suture in the red box if you have one. Ray-Tec coming out. The Mesh suture is kept in the mesh cart? No, the mesh suture, I thought they had it? We asked for it earlier. The mesh suture is kept in room 17. Okay. It's in a red box. Number 1 mesh suture. I'll go and grab it. Sorry, I must have missed that when you asked for it. Do we have a ruler? Would you write some numbers down there for us? Write, "4-by-4 M..." It's gotta be three and four, right? I mean, it's within three, well, I guess I measured three outside the umbo. So let's call it M4 - 4x4, M4. Right angle. How about that? We found it. I'll take a DeBakey. Do you wanna tie that? Yeah, see what happens when you're done with it. You got a clip? Medium or large? Do you have a large? We'll take a large clip. No, there was one this morning. I confirmed. I don't know, this is all I have. Okay. Are you okay with this? Yeah, we'll take it, yeah. Okay. Yep. That's okay. All right, so we're gonna use this stuff called mesh suture, which is halfway between mesh and suture. It's appropriately named, albeit not very creatively named. Run from the bottom up. Yeah. Sure. Okay. I'll take another Kocher. We'll take a snap on the end of that as well. When you hand it up. Abdominal wall debridement for gross evaluation only. Okay, give Sam the mesh suture. We'll take a medium-sized Richardson there.

CHAPTER 7

Hang on that guy right there. Yep. For evaluation? Gross evaluation only. Gross, okay. Sounds good. Thank you. Hold on, Sam. Can I have a DeBakey? You think we're not getting it? I don't know, I just don't like that stuff being in it. I think it's just preperitoneal fat. Hold this right here for one second. Can I have a DeBakey? There's colon there. Yeah, we just want the anterior fascia stuff. I think that's okay, Sam. Let's come through the other side and let's tie it up. I just wanna look at this one more time. I just wanna make sure that that's not bowel. I don't think so, but something about it just makes me uncomfortable. Okay. Let's take it down. Yep. Let's see. Let's move this Kocher down. Put this Kocher right here. Get this out? No, leave it there for now. Hold this guy right here. I'll take a DeBakey now please. Like we thought it was just the pre, I'll take a DeBakey as well. So this looks like... Yeah, that's okay. That's the peritoneum there, I think. Yep. Yep, go for it. That's colon right there. Can you hold this guy right here? I'll take another DeBakey or right angle if you got one. You can - just don't cut the mesh suture. Yep. Pause for one second. Is this an appendix? What are you? It's all just preperitoneal fat, Sam. That's the median umbilical ligament right there. Do you see it? Yeah. Right there. Okay, I would just buzz that down. We'll make sure that little thing isn't bleeding. Yep. Go ahead. And then your bite is fine. We're okay to use it. And then when the fat's also out of the bite so we're not grabbing any fat. Okay. Make sure that whole thing isn't bleeding. Yep, do it. Okay. Okay, fine. Go to your home. All right, carrying onward. I'll take a Bonneys back. I'll take a DeBakey. We can avoid this. There's still a bit of fat stuck here. Sam, just kind of go inside. Just go inside right there and come out. You don't need to go too far. You're inside the fat now. Yep, there you go, good. Come on through. Okay, great. Yep, okay, tie it up. Let's go around here. Yep, you're good. So, we use this mesh suture stuff when we're concerned that tissue might pull through. And this lady's had multiple repairs here and already has mesh here. So we're using a permanent stuff and it's gonna take some bites of the fascia. There's probably a little bit of muscle in here. We don't normally sew to muscle, but when we do, we don't want stuff that's gonna rip right through and there's probably gonna be some bites into the mesh. And so we want permanent suture material here to kind of help hold this layer together. Okay, so that's fine, good. Now we're good to go. I'm gonna move this one up. You're gonna follow, you're gonna grab Sam's tail right there and kind of lift it up. Now you're gonna follow along. Okay. I'm gonna move these almost up to the apex, Sam. Okay, go for it. This needle does not facilitate small bites unfortunately. We would normally use a smaller needle to do this, but our small needle versions of this are out of stock evidently. Let it go, let it go, let it go. Yep, and Sam will pull it up and he'll pull it up and he'll set the tension for you. Okay. Good. DeBakey. Get a little bit of this stuff, which I think is some of the anterior fascia. Do it as two bites, yep, roll through. Yep, there you go, and then go through the rest because that's gonna be - that's gonna be muscle and the mesh there, yep. That's a muscle mesh bite and then everything's together on that side, so that's all fine. Yep, good. Man, that needle is gigantic, huh? Yeah, I mean, I guess some people sew fascia with this size or larger. I cannot imagine. So when we sew fascia closed, we normally don't want gigantic bites of stuff. Okay? Big needles facilitate big bites of tissue and it just makes it easier to get stuff in the bite that you don't want. And that may be abdominal wall bites that you don't want, it might be bowel on the downside that you don't want. It just makes it easier to do things that are not necessarily the way you would want to do them. So, these bites, we're intentionally getting kind of all three layers of the abdominal wall. We want some of the mesh, which is essentially the posterior layer is now mesh, and the anterior stuff is... Yeah, got room there. I would leave it loose, yep. Happy with that? I think so. Looks pretty good, tie up there. Okay, and take this off. Needle off. I'll need the ruler next. And then get ready with some mesh. Probably the 15-by-15. Because our defect was four-by-four and if you add 10 to that, it's 14-by-14. And so the 15-by-15 should do. You can leave it relatively short. A little shorter right there's fine. Good. We'll have it out by then, we'll take the 15-by-15. You can give it a little dunk there, sure.

CHAPTER 8

Staples are probably gonna be fine. Tisseel? Yeah, we're gonna need to trim this. Don't forget that when we close the midline. Give that a dunk again. You can open the Tisseel as well. Give us 10 of Tisseel. When you open up, when you close the midline, your pocket is generally now zero, 'cause your midline is now zero. It's only gonna be 12. So let's take off three centimeters from the side of this here. Let's see. That's fine, yep. Go for it. Good, and now we'll take a centimeter off the top. Okay, let's try that again. This way, the mesh goes in. Thank you. Okay, fine. So, you got a skin stapler there for me? Have we done an onlay yet this year? Yeah. You're gonna feel real dirty, dude. Get ready. Put a staple right there. Yep. Boom. Okay. Good, okay. I'll take a retractor, skin retractor. Yep. Yep, get into the fascia. We got a pocket there. Get into the corner, right there. Yep, good, good. Yeah, right there in the midline. Yep. Go to the corner. You were with me yesterday, right? Yes. Do I seem happier doing this or sewing on the robot? Different. Can I have a DeBakey? Just make sure your mesh is flat. Make sure you're happy that it's flat. Good. This does seem to be your happy place. Way happier doing this. Did you mention this is one of the procedures that drew you to MIS? Right there. Onlays. Not so much. Okay, so we'll need to trim. We'll need to trim the little corner pocket there probably 'cause the corners are more than five away. So get your scissors then. Okay, scissors and a DeBakey please. Yeah, just kind of eyeball where it needs to go and just trim the corners off. Yep, and once you're sure it's gonna sit flat, you can put a tack in it. Yep. Okay, that's pretty flat there. Yep, one right there. Again, the goal now is just to kind of increase the points of fixation for the mesh with some tack. I'll take the tacker to me. I don't think anyone does a huge volume of onlays. Guy Voeller does a lot of onlays. That's true. But I think for a lot of folks, it has fallen out of some favor except for, you know, more specific circumstances. Yeah, I mean, this is not a repair that we do regularly. Or commonly. Sam's been here a whole year and we haven't done one yet. Okay? But it has clear advantages. You know, we are finishing up. It took an hour and a half or so, okay? We didn't have to deal with every scrap of adhesions that she had in her abdominal cavity. We've got wide mesh overlap. The fascia is completely closed, and we're gonna reinforce. We'll take the glue next. How many 2-0 Vicryl do you want? We don't need any 2-0 Vicryls - well, we need one 2-0 Vicryl for the skin. So now we need 2-0, 3-0, 4-0. And do you want a drain? Yeah, and a drain. Yep. For nylon. 2-0 nylon. Knife to Sam. How we doing? We have about 20 minutes left. We just gotta glue our mesh in place. Put a drain and close the skin. Tonsil, please. Drain please. Drain. Get your scissors, Ceci. May I have a scissor? Thank you very much. I'll take a drain stitch please. Yep. Yeah, some people have like a specific like, cool sort of self-locking knot that they do. So long as it stays in place, nobody cares. There it is. Now let's double around. But I think the key is that you're perpendicular and not off angle. Cut the drain right about there. And do it on a little bit of an angle like that. Yep, there we go, good. I'll take the glue. You can take the white tip off, we don't need that. Leave a tail. I'll take some retractors. I'll take a stapler again. All right, go for it. So we are again trying to increase the amount of fixation between the mesh and the abdominal wall. Okay. And this is just some fiber and sealant, AKA glue, which is gonna help to do that. So you're not using a Tisseel here just as like a hemostatic substance. You're using it as an adhesive. Correct, but it has the added advantage of being hemostatic. Okay. And now that mesh is completely fixated to the anterior abdominal wall with the glue and we put some hemostatic agent in there as well. So we feel good about that stuff. We got a drain in place right there. Let's close, we'll take a 2-0 Vicryl, please.

CHAPTER 9

Try to find a deep layer there, Sam. We're gonna run a deep layer here in something that resembles Scarpa's fascia. Okay. Can I have the scissor please, thank you. Short tail or long? Longer tail then? A little longer, yeah. Sure. Yeah, this is gonna be well buried, so, yeah. Okay, so you leave room to like leave the... Yeah. Okay. So the clear disadvantages of this repair, number one, we had to raise a skin flap up and so the skin could theoretically not have the best blood supply, okay? Number two is we had to raise a skin flap up. So there's some dead space there now, right? There's a pocket that needs a drain. And so that can form a seroma. And, you know, number three, the mesh is kind of sitting right here. Yeah? And so, if she were to develop a skin infection, we had to open, what are we looking at next? The mesh. But you can either salvage the mesh by putting a vacuum dressing on it or say, "Okay, your mesh is infected. We're just gonna take it out and leave you with just the fascial closure." So, you know, the consequences of an onlay mesh being infected are very, very different than an intraperitoneal mesh being infected or a retromuscular mesh being infected. So this is not our go-to way to fix a hernia. You know, we definitely prefer a retromuscular repair, but she already had that and then unfortunately, it had to be undone for her other surgery. It happens. And so here we are. Now, if she gets a hernia back again, what should we do? If the onlay space has been used, which it has, and the retromuscular space has been used, which it has, where do we go next? Well, is there an... It depends. It depends? Okay. Okay. There are some spaces that haven't been used yet, right? Like the intraabdominal space. I guess that's sort of been used 'cause there is mesh nearby, but that would be the next maneuver is to put a mesh inside the abdominal cavity underneath all of this. Even though there's already a mesh there? Since it's not an... Well... It's just kind of there. Yeah, I mean, that's not ideal, but it's what she's got. Okay. -So, I'd guess your last one, Sam, I would just, yep. Tie that up. There you go. And once a mesh fails, you can't like primarily repair mesh. Well, it's sort of what they did, right? When they cut through it to do her laparotomy needle down, that is a mesh failure. They cut, they broke the mesh in half and they did what you would normally do, which is they used a Prolene suture to sew it back together. What I typically do is actually close in two layers, right? Normally, when we close the fascia in the midline, we close anterior fascia only, 'cause the posterior fascia has no tensile strength. Right. Well, in her case, it does. 3-0 Vicryl now. In her case, it does because she has mesh. I'll take that. I'll take one as well. She's got mesh in the posterior space, so I would've closed the posterior layer with the Vicryl - I'm sorry, with the Prolene. And I would've closed the anterior fascia as a separate layer. So a two-layer midline closure. Guys, I might step out and let you just record with those ones and head over to that other room where they've been waiting for us for a few minutes, if that's okay. Are you running or...? Yeah, I'd run a four. Oh, this one, no. I'm gonna do a couple of interrupteds here and we'll run a Monocryl. I'd just make her OPER, Sam. Okay. She got a block. We did minimal bowel work. Sounds like a plan. She should be all right. So the reason to choose the overlay versus doing what you described before and going back into the abdominal space for her, is it just because it's a shorter procedure with less blood loss or...? Just less work on the bowel. You know, this lady has a very focal problem that is fixable with a lesser repair. Okay? Like the best hernia repair is the one that is the right for the patient at the time. Okay? And while this is not the repair I would do on everybody all of the time, this is the repair you do on some people some of the time. Right, okay. I'm gonna give you the suture back. We'll need a 4-0. Let me swing this down here, Sam. You can cut that drain right about here. Angled or...? That's fine, straight. I'll take the bulb. And then she'll call for 30 a day times two days. 30? Or 10? 10, sorry, 10. I used to do a bunch of other stuff. I used to leave folks on minocycline and I used to put a biopatch around the drain. Those are all things that Guy does. Okay, and again, like he does the most of these, of anybody in the US. Yeah. You know, just the concern was when you're leaving a drain in long term, does it track down to the mesh? I don't know, I think leaving the biopatch, I mean, it's all belt and suspenders, but I think the antibiotics for sure like increase your risk of other problems. Right, so, I don't know, I feel comfortable as a clean case. You know, she's otherwise healthy. So I think it's okay. All right, I'm gonna step out and go to the other room, okay?

CHAPTER 10

No major surprises with the case today. We did pretty much all the steps that we wanted to. Her adhesions were about as dense as we expected them to be and there were some adhesions in the local area. So her obstructive type bowel symptoms that she had been having may have been related to the adhesions as much as they were to the hernia. One of the things that I did during the case, and we talked about it, was to take a look around because if she gets a hernia back, it would be nice to have an idea of where it may or may not be easy to access the abdominal cavity for a future operation. Some people, you know, an entire side is free. Unfortunately, in this particular case, it looks like she's got a lot of abdominal adhesions that may preclude a laparoscopic operation if she were to reoccur. We elected to use mesh suture to close the fascia today, and I don't think that that's mandatory, but we feel that mesh suture, especially in people who've got recurrent hernias, probably reduces the risk of that primary fascial closure coming apart. And so the onlay reinforced a mesh suture closure. We certainly could have used Prolene or some other permanent monofilament mesh to do that. The drain that she has in is gonna stay until there's roughly 10 mL a day for two days or so in a row. For an onlay repair, we really want that space to be dry and make sure that the pocket is kind of collapsed down on top of the mesh. She'll spend overnight here in the hospital. We'll reassess in the morning time. But given that she got preoperative TAP blocks by our anesthesia team, we really did about an hour and a half worth of surgery. I think she'll be able to go home tomorrow.