Chapters Transcript Video Considerations for preventing wound complications in VHR - Matthew Goldblatt, M.D. So if you look at the agenda we're supposed to we're about 45 minutes late, but we're also I'm supposed to do to talk, so I'm really going to kind of combine those two and just kind of talk about different options for wound complications. Which really, um, Todd has already kind of covered, uh, and some of his talks and then the use of some of the these new advanced materials in in hernia repair. Um, and as we were talking about and we're talking about this at lunch and we were talking about before lunch, there's hernias come in different flavors. Um, both hi, Edel and and ventral. This is a little umbilical hernia. I'm gonna fix this with, you know, probably under local Max sedation with a couple of permanent futures Trans Firstly, versus you know, this is the other extreme some guy with, um, immuno suppressed with, you know, a couple of inter continuous fistula. And my goal for this guy is to get things put back together in the continuity versus trying to get, uh, get the most awesome hernia repair ever. So when we look at different materials, these are some of the things that that you have to think about as far as the strength. Is it? Is it going to be strong right out of the box? Is it going to stay strong? How long do you need it to stay strong? Is it resistant to infection now, as we talked about earlier, none of these materials are indicated for anything other than a C D. C. Class one wound. But we all know that there are infections can happen and off label use in contaminated field also happens. Do we need an anti adhesion barrier? We certainly, whether it's an anti adhesion barrier and anti fistula barrier are two different concepts. But the same, I really think mostly as adhesion barriers are really anti fistula barriers and some of the older biologics you had to, you know, defrost and rehydrate and all this stuff, and they smelled like litter boxes and all this type of stuff. So it really was important to make sure that you have, uh, something that's easy to use and cost effective. So let me just go over some of the options for mesh. We know those macro porous, micro porous, coded versus uncoated the weight of the mesh. There's no sort of standardized definition between light, medium and heavy weight. But it's sort of like, you know, when you see it, um is usually a pretty decent idea. And then the three most common polymers that are used are probably properly and polyester and P t f e. Um, so this isn't sorry. This isn't coming across the way it's supposed to, but they're supposed to say different types of biologics. So there's an animal and human biologics. Um, this video didn't work, so anyway, so some of the things that I think about it and we've talked about this all morning and now we'll go into the afternoon with it is that if you think about the most important things about hernia repair, you know, some of it has to do with your technique and your approach, making sure you maintain sterility. You don't do and making an erotic me. You get good dissection. You know, your anatomy. Um, how you gonna close that hernia defect? Do you need to do a component separation? How wide of an overlap with the mesh? What type of fixation? And then, even though it's you know, it's sort of at the top of the pyramid, but probably has the least amount of direct determination of how things go is what you use. The only thing is that if you use the wrong material in the wrong situation, things can go horribly wrong and the entire pyramid could topple over. So it is important. But sometimes don't tell anyone from gorgeous. But sometimes I think we make too big of a deal about the mesh. Unless there are reasons you've got to use certain meshes. Don't talk about that. So again, off label use of any type of, you know, FDA approved material in a contaminated field. But this is some data. Um, Will was obviously part of this study and his partner Alfyed looking at, um, I mean, business partner not, you know, anyway, So So Okay, so they looked at using permanent synthetic macro porous mesh in contaminated fields, and they followed these patients for just less than a year. Um, you can see they had real numbers of surgical site infections, and unfortunately, they did have to remove four of the meshes and had to re operate on 12 of the patients. So that's you know this is the glass half full or is the glass half empty? If you're one of the patients who did well with this, then great. You got away with a less expensive piece of mesh and and everything is good if you're one of the people who had to have a re operation or had to have their mesh removed, I don't care about those other 96 people. I had to have my mesh removed, you know. And so what's the What's the cost benefit ratio there? Um, Mike Rosen, uh, and Jeff Blavatnik did this study looking at Biologic Meshes and looking at 128 patients in contaminated fields, clean contaminated and contaminated. Very large hernia defects. Mean follow up rate is, uh I mean, follow up was about 22 months and the recurrence rate was pretty high 31%. Um, and so that's that's a pretty big deal. But we're talking about some bad hernias here. And so if you've got a contaminated field and then you've got a clean recurrence, that's a little bit easier to fix. So and some would consider this to be a win, then the next sort of study. Along that line was the rich study, the rich trial sponsored by, um, The makers of stratus. And there they found in contaminated fields 28% overall recurrence. So getting a little bit better. And then one of the first studies to really document that if you can get fashion closure, you can get a better, better result. And now it seems very obvious, right? But we used to When biologics first came out, they were touted as being like, You know, if you if you put a biologic next to the long it turns into lung tissue and you put it in the brain, it becomes, you know, you can increase your memory storage, you know? So it's not quite the stem cell of mesh. Some of the concerns of biologics are that they are really expensive. There's nothing more frustrating than to have my Stratus rap in the are talking the entire case talking about his his beach house in his boat, knowing that he was gonna get paid more for that case than I was and and, you know, and and having to listen to him the whole time. Um and they did require some sort of back table prep now, admittedly, they've gotten pretty quick. If you just do a couple couple minute rinse in the back back table, there they are. You know, you do have a little explaining due to the patient. They want to know what kind of animal this was from. Human always freaks people out a little bit. Um, different religions may have different concerns with different products. They used to be pretty limited in their sizes. Now they've gotten to be pretty massive, but collagen is cross linked. So there were some collagen products that were additionally cross linked in the lab to try to give them some more durability. But all colleges cross linked with human collagen and animal collagen has crossed like that's what makes it durable. And so that cross linkage helps to stop the breakdown but also helps to inhibit tissue in growth. And so, without tissue in growth, you get encapsulation. You get Ciroma formation so that those can be some of the biggest issues with the biologics. And if you don't think so, aromas happened with biologics, then why did they make biologics with holes in them to stops, aromas so they it does happen. Um, but and you know, there are ways to deal with these things, and and I probably use about one or two pieces of biologics a year, typically if I'm in such a horrible situation that I'm not. My goal is to get a patients, get a patient out of a bad situation and not worry about doing a definitive hernia repair. Um, sometimes you don't want to go for the home run. Sometimes a single is okay, and, um, and so I'm a bridge with a biologic. Try to you know, if there's a high risk of a leak or official to get them through that and then take them back a year or two later if they have a problem with a hernia, Um, and do a more definitive hernia repair. There are other absorbable materials on the market, and some keep coming every day. Tiger matrix. I haven't seen a lot about Tiger matrix lately, but it's really two different different materials is a fast resorting fiber and a slow resorting fiber. The fast resorting fiber goes away in about four months, and the slow one goes away, and as long as three years, which, you could argue is why does that not then react like a permanent piece of mesh. So if you get contamination of this, is that really going to be resistant to infection when it lasts? As long as it does, Um, every single company will, including, including Gore will show you fantastic slides of H and E stains. And and, um, you know, we're just smart enough as physicians to know that that's an H and e stain. But we look at it, we're like, Yeah, okay, that's that's good. Look at that. You can see stuff. Um, so, you know, But here you can see there that the polymer is there and that there is a host response to it. Um, I'm not sure that that necessarily indicates you can extrapolate that into an outcome. Physics mesh is came after the bio, a product it's made by barge or B D. And it is a polymer of poly four hydroxybutyrate, which is derived from A and E. Coli bacteria. It is. It takes about 18 months to fully resort and again H and e staining here at a year, so it's still present in a year And so it again also sticks around quite a bit. Um, And I was involved with a study looking at physics in clean wounds with with high risk wound. So smokers, diabetics, patients who were obese but not morbidly obese. So we have this, like 30 to 40 BMI range. Um, and what we found Was that I can't remember if this one has, but the recurrence rate at three years We published was 15.7%. A little bit of a funny math here, If you look at it. There were 121 patients in the study, But only 82 had follow up at three years. and when you take the 19 recurrences, Show you this in a second here, the 19 recurrences and divided by 121. That's how you get your 15.7 recurrence rate. So you're basically assuming that the 40 patients that didn't follow up didn't have a recurrence. So, um, we've since done a five year follow up, and we were pretty insistent that we are. We used Kaplan, Meier, um, sort of estimate for those that didn't follow up and and the recurrence rates a little bit higher. It's it's actually in the 20 something percent. So, um, but again, these are these are these are difficult patients. These are sick patients. difficult journey is to repair 20% recurrence rate, and I'll show you a little study that I've just published may not be the worst thing out there. So what is by away by away? If if you're unfamiliar with what Polish glycolic acid is in tri methyl carbonate is like, I mean, I don't understand why you wouldn't know that like a household term. But, um, it's basically the same polymer that's used in Macs on future. Um, it's It's not just a maximum future that was put into a loom and made into a mesh. It's on a microscopic level. It's a very different structure, but that's that's what the polymer is. Um, they've created the pore size to be sort of a sweet spot between too small that only bacteria can get in, but your own your own host cells can't and too big that nothing really has a scaffold to grow into. So it's a that's a good poor size. Um, things grow into it very quickly. It degrades primarily by hydraulic Asus and, um, cells infiltrate and form of a nice, pasteurized soft tissue. This, uh, this is a study that I did a number of years ago where I looked at 81 patients of our own patients and compared the by away place in a retro rectus position to that place as an underlay that we were able to get primary closure and everyone and these were sort of your typical abdominal wall patients, you know, we had, you know, Mean age was 56. Mean Bmi was about 35. Number of the patients were former smokers. The actual smokers were just technically not. They hadn't quit smoking for 90 days, but they were within 30 to 90 days. I do have everyone quit smoking. Um, these were not all clean wounds. And so I don't want to condone that idea, because again, that's off label use. But when we look at the material, it goes in very, very well. It's in a retro rectus position here, And, um, one of the things I used to do with the bio A If I put it under a lot of tension, I used to sort of reinforce that back side of the bike away with a with a pledge it made of bio A and I'll tell you about the in form as being a little bit, not necessarily having to do that. But just because if I put under so much tension, I've been able to rip through biologics, I've been able to rip through, probably propylene, and I've been able to rip through by away in these massive repairs. But if you just look at the Class One patients, there are 49 of them. In the retro rectus group. We had four recurrences at about a 22 month follow up. So about 88.2% um, in the intraperitoneal placement, we had 50% of recurrences, so there's been a number of different studies looking at this. They weren't designed, you know, they weren't randomized and intraperitoneal and retro rectus. But there's a clear difference between putting a piece of material in the retro rectus position than putting it in as an intraperitoneal in these in these types of repairs, maybe it's because the intraperitoneal with the sickest patients are the most difficult abdominal walls to deal with. Or maybe because there's something about putting that material up against the rectus muscle and sandwiching sandwiching it in there versus putting it up against the peritoneum. So then I took those those 49 clean, retro rectus patients and followed them out. Now, I just We just published this a couple of weeks ago, um, looking at the long term outcomes. And this time we did use Kaplan Meier, uh, recurrence estimates. So now the mean follow up is just over five years. But we have some patients that went out as far as I think, about eight years. And, um, if you look the the four year, five year and six year recurrence rate starts to go up a little bit and each one of those three ticks, you see there is just one more recurrence. It's probably shown best here with the capital. Meier curves. So, um, you know it basically, at the time between this is just one more patient was found to have a recurrence, But, um, you know, we think that's pretty good. And when You would say well by 18%, recurrence rate sounds actually pretty bad. But if you look at some of the data out there. I just kind of ran through and did a quick evaluation of the literature that's out there. There aren't a lot of studies that go For a long time, but when you look at permanent mesh in open ventral hernia repairs, you have some. Here's a study that goes out 48 months with a 25% recurrence rate. One study that claims to go out 11 years with a 13.6% recurrence rate that was Open Access journal I hadn't really heard of. And then, um, here's a 52 here's 52 month follow up with 23%. So I would argue that absorb all product works just as well as a permanent product, if maybe even a touch better. And some of it probably has to do with technique. Yeah, I think it's, uh, you know, again, I think the product has a lot to do and and patient selection, Um, so by always been really nice, it's got really good favorable recurrence rates compared to even permanent mesh. Where it's placed, it's pretty important. Retrospective positions is a big deal. So what is informed by the way is so good. Why do we need to inform? Well, some of the problems with with bio A where that, um it's a little bit stiff. We already talked about how the in form is a much softer, pliable material. Um, I never had a patient complained that their abdominal wall was too hard with the bio A, um but nonetheless, uh, inform is, is a little bit more sort of soft and pliable. Maybe better. Certainly better to have such a softer material at the hiatus. And it's really strong that that stitch pulling video that was seen before is pretty impressive. I've had a lot of trouble trying to pull a number one PDs through, uh, inform, whereas I could pull one through by away. So it's incredibly strong, Um, and yet not any thicker. Um, if you were to try to place it down a track car if you were, it goes down pretty well, by the way, is pretty tough to go down to Trow car again, potentially off label use at this point. Um, so what's what's so good about uh, informed is that it's it's not any different than by away. It's the same polymer. It's probably like colic acid and tri methyl carbonate in the same ratio. But it's just the way that they formulated it. That's made it a little bit softer and easier to work with. Um, This is what it looks like 20 times above. That's the 20 times magnification of the in form. That's what this down below here is a biologic. Um, you know, if there are pores, it's basically the old blood vessels and old skin structures like hair follicles and that type of thing. It doesn't really have a porous nature to it. And when you implant it, here come those h and e stained I warned you about. But you know, you can see the sort of that purple in growth is the host native cells growing into when you implant in an animal model of biologic, which is up here, you get like a layer of of host and growth. You don't really get it into the whole tissue. and as you go 30 days out again, looking at the in form compared to the the biologic, it doesn't get all the way through. And then Something funny happened with the slide here, but at 90 days, very similar, um, almost completely grown in with the host cells versus just a little bit and most notably around old blood vessels, where you're going to see that skip through a little bit of this. When that's quantified, you can see that there's a significant more, you know, increase in the in growth All the way up to 180 days, which is actually when the material's actually going to go away. So you still are seeing dense collagen fibers in the in the area where the, by the in form was once the material's gone away. So here is Here's the implantation of a piece of inform. This is actually kind of a small little umbilical hernia. There was some question about whether or not the patient had some drainage coming from the umbilicus. Every once in a while, I still consider it to be a clean case, but I was a little bit worried about what was going on in there. Was there a former stitch for stitch, you know, um, contamination. So I wanted to use something that wasn't a permanent piece of mesh, and I try to bring the fashion together with a little bit of tension on the material. So this is, uh this is the extent of my artistic skills here. Um, So what I'm looking at here is here's the post your sheath, Here's the material. And then here's the anterior sheets. I've gotten the poster sheath closed. I've drawn a midline mark down the middle of the material and I'm gonna now, so the anterior sheath to the material. But I sort of I see where I can go through the material with my stitch, and I measure the distance between the midline and that stitch. And then I measure the same distance between the midline and where I'm gonna go through, except I cut it in half. I do it 2 to 1 ratio, with the goal being that when I tie those down, it's going to really bring the fashion alleges together. So they almost overlap. They never actually overlap, but they should sort of lay next to each other. So I'm measuring where it's going through and again, that's a 21 ratio measure that same distance off the edge of the from the midline of the mesh. And then, um so that down. And for this small little hernia, I ended up having six stitches. You got one of the top one of the bottom and to each laterally put it all together. I'd like to make sure that that space where the that retrospective space is nice and dry and put a drain there, put a drain in the sub Q space. The retrospective space and this lady came out the next day. She went home the next day, and I even think I took out the sub to drain the next day. But I just want to make sure that it's nice and dry and has a chance to sort of have good fashion to mesh opposition. So when it comes to absorb all synthetics we have by away, which is a great product has proven safety. Excellent results. Um, and the in form product really just builds on that and the success of the By away, it's it's soft as pliable has excellent tissue in growth, and we'll take We'll take any questions. Yeah, okay, yeah, mhm. I realized this this talk didn't have a an image that I'll show. I'll probably try to if there's time at the end of show where, um, I actually have a pet scan of a patient that is three months out from their inform placement. Um, and they had a pet scan because they were being followed for, you know, surveillance from their colon colon cancer and three months out, the entire piece of end form just lit up like a like a hot poker with all these active, metabolically active cells within it. Um, and it's really pretty impressive. And people always ask like, Are you sure there's not cancer in there? But it's Actually it was There was a follow up study. It's everything's fine. He's now, like, five years or three years out from his replacement. But it's, um, it just goes to show just how metabolically active this is, but it's not like it's it's hot or it doesn't. Patients don't complain of pain, but there's certainly more. There's more to this product than just laying there passively and holding everything together. Interesting, not surprised, considering that at about seven months it's all pretty much gone at that point. So do you have any questions from the audience? Um, what types of cases do you currently use end form in at this point, Um, so if I'm doing, if I'm working with are my plastic surgeons that I work with and and we're and they're doing a particular ectomy even though it's a clean case, I just, you know, we all have seen, especially if they're aggressively going at it and trying to get as much tissue off there that that's oftentimes under a little bit of tension. There's oftentimes just a little bit of breakdown. And even though I'm placing whatever product I use, I'm placing it in the retro rectus position. It just makes me nervous to have a little bit of a wound issue. Sometimes those little wound issues turn into big wound issues. And, you know, I don't really worry if if I've got a piece of inform in there, so I'll use it in a clean wound like that. A lot of those those patients that were, um, you know what? I quickly brushed over on those patients that I had that were clean a lot. Most of them were, um, the ventral hernia working group grade, too. So the former smokers, the former wound infections the diabetics, you know, in the obese. So anyone who has a high risk like that, the other group of patients that probably all seeing more and more of our the patients that are I don't want mesh. You know, you talk about mesh, and they just say, I don't want mess. They've either had a bad experience personally, or the lawyers on TV have gotten to them subconsciously, and, um, and they just they're afraid of it. And any little glitch in the results they're gonna say, I told you I didn't want to use metal, you know? So I can I can say, Look, look at the data would suggest that if we don't use anything, it's just going to fail. So how about we meet halfway and I use an absorbable product, and, Oh, by the way, our results are that you're going to have just about as good maybe even a better result than if using permanent mesh long term from what you showed. Absolutely. Yeah, health. Go ahead. Sure. Four. So, yeah. So, um, number one, um, if you're ever asked to sit on the whatever the back or whatever committee, even though it's a pain in the butt, they meet at some odd time. Definitely volunteer for that. I I actually have been on that committee since I started, and it's amazing how much more you can get when you're on the committee. Um, it's, you know, it's a lot of volunteer time, but at least I get the products I want. Um, number two is, um it depends what you're comparing it to when when we were using biologics almost exclusively, and then bio a came out and I said, Hey, I want to bring this product into our hospital and they're like, Tell me what you can use it for, like all these complex cases that were using Stratus for right now, I don't even think it went to the VAT committee. It literally was on the shelf the next week because they say they saw how much it was going to save by going from biologics to bio A. So when you go that way, it's like, let's get it on the shelf if you're going from, You know, $150 piece of, you know, cheap barred soft or pariah T or whatever. This you know, macro poor stuff, which is 100 bucks and you go to something like this, they're gonna look at it and go the opposite direction and think how expensive it is. So it's really you're taking your most complex patients where you otherwise could use a biologic. Physics is really the only other one out there, And I don't think people fully realize just how expensive physics is. When you look at the entire spend of mesh with bard, they sort of blend it all together. And they say, This is how much money you're gonna spend with with your your mesh products. But when you pull out physics physics is almost the same price as a piece of a biologic. Um, and and and form is not that expensive. This is mhm. Well, because All right, walk with me. Yes. What? The excuse issues? Yeah. Work call. That's all for us. Six. No other group Stop. Yeah. Then you're sure? Yes. Hurry. The first. Yeah. Uh huh. Yeah, pretty quick. You're like you're going mhm long. We got expert all on at our hospital because of that, I said, let me just try it in 10 patients and see what happens. We did. Expert tap blocks compared it to Epidurals. And we saw a 1.3 day shortening of length of stay, which is much cheaper than the cost of the experts. Like, fine, we'll get expert, you know? Great. Just Mm, that's I'm saying, compared to compared to the biologic. Yeah, how they work. Like sedition. Yeah. Moment separation linked to that is problem. Follow these cases for certain at all? Not? Yeah. Um, I guess it depends, you know? I mean, if if they if they were a very complex hernia and most of the time when they have a recurrence, if they had a eight by 15 centimeter defect, when they have a recurrence, it's oftentimes a two by two centimeter thing at the top or at the bottom. So, one is it really something that you even want to have fixed at this point, but to it's usually something I'm gonna fix, you know, and especially if they're willing at this point, you know? Listen, we tried this without mesh. Without permanent mesh. I think maybe it's time I'll go in and maybe do a lap or robotic repair with a little, you know, a smaller thing. Um, I have gone back and done sort of re retro rectus. You can get back into that plane. It's pretty tough, though, that the rectus muscles pretty tightly fused to the posterior sheath where the material was. But you can get in there. You end up scraping a little bit of muscle off of their, um, a little bit more bloody, but it does work. I've done it again with with with the the inform. I've also done it within a permanent or the cynic, or which is we'll hear about in a second here, which is a nice kind of hybrid between the two. Um, steer separate yourself. You mean like a tar and and yeah, I Even if it's separated by years, I still would be very nervous. Even though they've hypertrophy, I still be very nervous, leaving just the internal oblique as your only lateral support. Yeah, yeah, I mean, maybe I didn't see it. Yeah, do a natural go. The skin flaps muscle, You freak. Three, 100%. Yeah. Wait. Public relations redoing a tar charge because I don't want you to try. Yeah, Much injured. Secure. And Todd, show that CT where there's you could tell that even though it had been dictated that they had done an external oblique release, it looked like it was all completely intact. I've seen a couple of those where I'm like they didn't even do it. And you look really close and you can see Okay, maybe they did. But the muscle is still way up there. And if you go in there and take down that scar tissue and separate that external oblique off of the internal bleak AP neurosis, you will still get some mobilization. Yeah, just scratched. Actual. Illegal. I think sometimes they cut Scarpa's, you know, they they're and And I think thankfully, people are very nervous about cutting the semi lunar line, which is catastrophic. But I think sometimes people get up there and they just cut. They kind of they're blind, they're doing, and they Oh, yeah, that's good. Yeah. Good. Good. Um, I try to follow them up, you know, unless the patient is in a study where we pay them a little gift card to come back in. I have a lot of trouble getting patients to come back and see me. I have to charge them even just an established visit. You know, which is a couple 100 bucks. And they're like, Wait, you asked me to come in, Fill out your form, and you charge me $200 for $200 for it. So we do. Um, we do a lot of try to do some telehealth. Um, we have, like, you know, these medical students that come and work with us in the summer. So they'll do a lot of phone calls. There's some validated surveys that if they answer no to all three of the questions, the chance of them having a recurrence is pretty slim. Um, and Ben Pollack is validated that a number of years ago. Yeah. Please. Okay. Yeah. Pair of Yeah. The shelf two. Right. That's it. Yeah. Risk. No. The lower risk groups are all right. What is this is a crisis from direct. Yeah. First look at sugar prices. Yeah. I mean, doing a randomized prospective trial with materials is really tough to do. Um, we're talking about doing it other. You know, some people have tried to go down that road. It's tough. It's tough to get patients to want to do it, too. Um, but, um, so I'm not aware of any direct head to head with an absorbable against a permanent, you know, in a in a randomized trial. But it was quite vs. Okay. No. Yeah. What was it? Person? No. And small. Small, small. More. Yeah, right. That's pretty. It's pretty good. It takes me. But, um, yes, I think that whatever, there wasn't, like, a huge difference. Think of the culture. Okay with okay. You ready? You really study careful. Mhm cost factors. Yeah. I mean, every hospital, as you probably know, every hospital negotiates differently with everything. But, um, you know, If if a 20 x 30 piece of biologic costs $15,000 and a 20 x 30 piece of probably appropriately and costs $150. Um, you know, the I know that the physics is is pretty on that spectrum. The physics is pretty close to the biologic. The bio a was probably, um, closer to about a quarter of the way down towards the mash. And then think the inform. They've priced somewhere in between those two. But it's, um you know, it's interesting to try to figure out why physics is the most expensive and the highest volume. And, uh, you know, I think part of it is because it's on the same shelf. And And if you're a Bard hospital, you've got shelf space. Um, it's like Frito Lay bringing out a new potato chips. They got all that shelf space in the supermarket, and they can just put it where they want it. Um, and doesn't Doesn't quite make sense. Why pay more for similar, if not inferior outcomes? So uphill yourself? This is I mean, those are clean cases. Yes. High risk. Yeah. Okay. Last two years or three years? Yes, The that while the 15.7 was two year, three year was up to almost 18%. So so yeah, yes, yes, here, but also rather wide. Be careful. All right. Mhm Just now. The physics. They also had some. Only that was the other indications that and the only had took up a disproportionate number of the recurrences as well. So, again, retro rectus is is the way to go, no matter what you used. All right, So it's one more question. Yes, Erotic. Oh, God. Right, right. Okay. I mean, without sounding, I'm just going to repeat the question. So everyone can hear it. What would you use to close an acute hernia that has potentially about compromise? Yeah, it depends if it's an incarcerated umbilical hernia that, you know, you just do a quick little reception, put it back in. That may only need primary closure. Or you can do a quick little retro rectus if it's these big, huge things. And there, you know, yes. Sometimes you just need to get get things closed and get out of there. It depends what time of day it is. Depends how sick the patient is. Um, you know, and how much work you're gonna have to do and who you're working with. But so it depends isn't a very satisfying answer, but yeah, yeah, I'd say one and out, come back and fight another day. Don't burn any bridges and violate any tissue playing. So you come back and sort of deal with version tissue. I'm very reluctant to do a component separation in a patient that's urgent or emergent because that's that's a one and done thing. You don't get to do that again. And so if you hate to do all this wonderful work and then have the patient leak. And now you're left with an open abdomen and a vac and, uh, you know Yeah. Alright. Great. Thank you. Okay. Published December 15, 2021 Created by
