Chapters Transcript Video Clinical experience, data and review of complex repairs with two innovative biomaterials - John P. Fischer, M.D. All right, we're gonna finish up here with Dr Fisher. Thank you again to to Gore appreciate it. Um, so some cases, um, it's a tough one, right here. Interesting case. Um, so in case one of my first informed cases, actually. And so, you know, this guy had multiple multiple defects? Um, really challenging case. I think the idea of using something that goes away within a few months and someone like this patient, I think makes a lot of sense. Um, got his fashion clothes, reinforces the anterior abdominal wall with a piece, then form, I think a really nice outcome for him. He had a couple complications. We got him through it. But but But I think a nice outcome for him. Um, another case, Um, this guy's got a really big defect, I think. Actually, Kelly Slater actually watching me in this case, this is a tough, tough case. Um, here's his preoperative cat scan. If it plays, let's see, Big defect. And we got him to lose some weight before we operated on him. Um, he has got multiple defects. Um, his initial starting weight was, I think 3 20 something. We got to lose um, £30, 40. You guys get the idea with this cat scan? Kind of a Swiss cheese type scenario here. Pretty high risk guy. Um, kind of losing weight. Got a B m I. Below 40. Which I think is important. Um, This is repair interop. We did a transverse incision big piece of an in form. So I guess a 30 by 40 with some trans fashion has got the anterior fascia closed. A great example of, I think, just leveraging negative pressure wound therapy, wide surgical drainage. And then here he is back in the office, which I think is great. with this pre op and post operative quality of life. Huge improvement. Nice result. No recurrence. He came back for something else. I think that the e r and got scanned no recurrence. Well, it's nice, as you can see, that you can see that everything is incorporated. I think you know really, really nicely. Not a pet scan. Have been cool if the mesh lit up like like old buddies, patient. But this guy is doing well. Um, yeah, I think a nice result for for a big big guy in a big, complex hernia so it's kind of kind of cool. Um, So we talked about this. I'll skip this. Uh, this is not totally I think I have more than 25 cases, but, um, some examples. I've used a lot as an online. Um, some pretty big case is a fair number of wound complications in these high risk patients. Haven't seen any recurrences yet. And I haven't removed any mesh. Here's just a quick example of a patient, big, big defect. Um, you know, difficulty sitting up anti r component separation. Re suspended the external oblique only repair. Close this close the skin up over it. Um, this lady really interesting case. Um, uh, chronic infected, draining mesh. Previous history of breast reconstruction. Just awful scenario. So all these open draining wounds had been going on for years, so she got kind of like I would call it radical extirpated surgery of anything permanent inside of her anterior abdominal wall, and then a pretty complex soft tissue closure. I I picked this up from Dr Hannaford is a delayed primary closure when there is active infection. So they go back, you know, 3 to 5 days post op for delayed closure, um, typically, I build like 13160, which is complex, delayed, closure open wound and it gives me a second look at the tissue. It's been awesome. Um, so I have to explain it to the patients ahead of time so they don't like kind of misinterpret that it's it's a planned re operation. It's a It's an awesome idea to change my practice. Another great case. This is a lady who had bariatric surgery has a mesh mesh fish villa. Um, kind of crazy. I decided to inject some methylene blue into the Sinus track, followed this down all the colorectal surgeon I was working. I found it down to about the bowel and track right to the mesh and and clearly there was a mash fish villa. Risk did a bowel resection and then did an open tar. And that's the inter operative view of the tar. Laid a piece of informant draped beautifully. Close the anterior fascia, and this is this is the approach delayed primary closure and then took her back. Did a neo umbilical plasticky and the pumpkin teeth need umbilical plasticky and then negative pressure wound therapy on top of it. And there she is. Post up. So So what happened with her? So that infected matter, prosthesis and fistula, uh, did a staged delayed primary closure and the umbilical plasticky and then negative pressure wound back in, and she was good. Um, I think kind of a nice kind of holistic approach to a pretty complex patient. So some of these folks that I've taken back as kind of a scheduled, delayed closure gotten a second look at the mesh looks really, really interesting. You know, rapid Inc. I think, as Dr Fiona has already kind of shared with, That's really, really great inoculation of the mesh. I think it looks really good at this to these time points. These two cases that are shown here, these were both highly heavily contaminated cases, like both infected meshed official scenarios or active open wounds. So that's kind of been my experience with This was only like, four days incredible, right? Is that incredible? I know. I was I was I was thrilled. Um, you know, I think I think this this one to the right is actually the guy with all the open ones and multiple honey. That's a picture of him when I took him back to do his delayed closure. Really cool. So I'm gonna quickly to share my experience with sin, a core which has also been positive. Here's a case that I used in this this young kid had, I think, an osteosarcoma of his chest wall and one of my partner just did a latte flap, I think with a threat. Sick guy and so tricky case. We took a page out of Dr Hanford's book here and did a really big prepared meal dissection. Um, one of the one of the kind of the tenets of plastic surgeries. Um, you can always kind of, you know, you know, you know, don't know waste anything. So we say the lotus in this class, we took the skin and the muscle and flip to the side and save that we did a big prepared meal dissection, put in some cynic or reinforced this flank defect, and I took the skin off the muscle and just kind of flapped it back on top to cover the bridging portion of the map because it was just too big, too close, and so a really nice early postoperative result for this this young man who they came and his mom had moved out of town. But they've done well and just, I think, a tricky case because it's just a nasty, nasty hernia. And so we published, Um, the data for this cohort. It's almost It seems too good to be true. We didn't have any recurrence. I'm almost blushing up here that I would report something with no recurrences. Lots of complications, but no recurrence in these patients. It was 35 patients. All clean case is a little over two years of follow up. Um, here is kind of just a snapshot of the types of patients that we were treating. Um, pretty co morbid. Um, you know, b m. I kind of in that low 30 range kind of what you might expect. And here's kind of a little bit more. The data about them, fair amount of components, separation, you know, the median length of stay about three days, average length of surgery about three hours or so Defects about 200 square centimeters. No recurrence, no infected mesh. A fair number of complications, though, Like like, you know, anywhere between, you know, 20 to 40 So if you looked at, like non healing incision, there was not insignificant. A lot of these folks had particular Inktomi's any complication was close to 45%. So I think really good to see that. You know, even though there's complications were not seeing mesh infections, only two year outcome. But I think I think pretty good. And then, as I mentioned before, um, going back to the quality of life as being so so important in this cohort, we saw major improvements across really all domains of quality of life for these folks. A small cohort. I think everything would reach statistical significance if the cohort were a little bit bigger. But we're seeing a really good signal here, right? Like overall quality of life, improved pain, improved sleep didn't hit significance routine, improved attractiveness, symmetry, etcetera. So I think really, really exciting early data for me on cynic or and and form. So that is it. Yeah. If you want Easter, sir. Little man in front of the back. Yeah, four days. Yeah, that's a great question. I haven't yet, but I kinda I like that idea. I feel like getting the fashion clothes and putting the meshing is kind of like one of those critical steps that I want to do at the index operation. Um, but it's a It's a good good. True. True. That's a good point. I wonder that. Does that make sense, right? Because we've got to leave him with, like, like, an app Vera or something, or, um, you know, I don't know. Is that good or I don't know. Yeah, sure. Yeah. Todd, what do you think about? Like, if you have infected match, do you do the single stage repair at once? You put the mesh in and then delayed. Primary closure of the skin. I just copy what he does. One more, I suppose mostly. Yeah. Yes, as a doctor. Well, yeah. Okay. It's thanks. Yes. Yeah. Choice in what? Sure When he was trying bacteria down within the skins, that's all. Mhm, Brian. Well, I remember the hospital switching back. Oh, you never antibiotic surgery, But of course, it's well, once here appeared to be on right his car. Prepare to withdraw. Yes, Just Oh, Moved by Never. Oh, no, no. Yeah, Me neither. Yeah, so right. The other is correct. This is giddy up. Yeah, No, Never is. Never. Yeah, so far. Like the one the one case I should where she had the mesh fish to let me did a big tar. So I mean, you're extra peritoneal. So we just We laid the informant, closed the entire fashion, then delayed the skin closure, which I thought was nice, because then I got to make a new belly button for her and, you know, it just it seems very controlled, but yeah, I don't know. I kind of want to I want to front load some of this work because, I mean, you know, if you do the repair and put the mesh in the second, it becomes a big second operation, you know? Pass. Gracias. Totally. Totally. Yeah. Yeah. Playing. Yeah. They had official like hell, no. Yeah. Delivered by hurting it. Heard of the bigger, bigger, bigger. I think he's saying in the hospital, you know, when you to stage them, like, four days later, you know, you just take the mesh out and leave them open. And then four days later do you fix it? Yeah. Yeah. Organ space. Yes. Perforated diverticular. Yes. You want to get Yeah, Yeah, yeah. Trump coming. Our trauma trauma guys have. Yeah. Yeah. Okay. Well, they just They don't have a lot of times. They operate whenever it's not necessarily the same surgeon. Someone else. Yeah. Yeah. Mhm your patients throw down? Yes, Very. Bring him back. What? Yes. What do you want? First thing. Mm calls Here. Come we compare. Why, yes. Your servants who like? All right, right. Yeah. So tired. How about this drama? It's easy or whatever is talking external oblique release is just too close. The trauma belly. Yeah. I mean, I'm talking about like like they were in the ICU there on event close it really? And they talk, hopefully just to get close. I mean, yeah, I think you gotta use mesh or currency would be too high, Man. Wouldn't be opposed to, like, a definitive reconstruction of an open abdomen. You know, early on, if you can close, maybe if you had to do a release. I don't see anything wrong with that. I mean, as opposed to leaving him open and guaranteeing a hernia. Yeah, yeah, yeah. Wait. Oh, you get some? Yeah, You probably do. Yeah. And so stickers back. Great. That's it. Say radio hold up there as well. We need an immediate acting boat docks. I mean, this sport is a type of kind of, you know, botulinum toxin that works a little bit faster, has a shorter, you know, kind of duration. But that would be that would be a perfect application there. I mean, And that that sense, you can get it approved. Well, they're in the hospital, so you can call the pharmacy, call in some favors. Just go. Just Yes. What? All right. It's a drop in the ocean. Mhm, Exactly. Well, thank you very much. Alright, great. Well, thank you very much, Dr Fisher. Published December 15, 2021 Created by