Chapters Transcript Video Evolution of component separation - Matthew Goldblatt, M.D. our next presenter is gonna be Dr Goldblatt, and he's gonna present on the evolution of component separation techniques. Right. All right, well, that's a tough act to follow. Nice. Nice job, John. I'm gonna talk about component separation you're gonna get. This is a little bit of redundancy and all of these, um and so you'll you'll You'll hear these themes over and over again. And I think that's sort of the best way to learn is to do things over and over again. So, um, This is the Wisconsin six pack. We we strive to get a guy's belly. Looking as good as this. There's a lot of beer drinking, lot of smoking, and God knows what else. Cheese, Kurds. I don't know if you've been to Wisconsin, but that's what you get. Um, so we're gonna try to get an abdominal wall to look something like this. Obviously, with some skin, the the thing about the anatomy of the abdominal wall is that it's actually quite simple. Um, you know, there's only a few muscles, um, couple layers of subcutaneous tissue, and and, um but it's amazing how easy it is to get disoriented, and, um, and confused in there and for um, for those of you who see patients who have had previous repairs done elsewhere, Um, it's amazing how you can read an operative report that looks like the most perfect operation. And then you look at the CT and you look at the patient. You're like, I don't think that that's what actually happened. So it's important to sort of keep the anatomy straight. But essentially, there's the rectus muscle, which goes straight up and down in the mid line on each side of the midline. And then you've got the three oblique muscles. Anonymous was so kind to us because I was bad at Anatomy. I things like external and internal are very helpful to me. I now know where they are, and then the translucence of Dominus is the most, uh, the most internal of the obliques. I think if all of our patients look like this, we wouldn't be here today. But you can see where these muscles are outside. Um, and even in someone who's as skinny as this, um, but also in patients who are morbidly obese, you still, unless they've had a surgery, you can still get the c the center, the pulling of the skin at the semi lunar line. Um, and that's probably what's most important when you're thinking of component separation because the component separation has to do with releasing the obliques. So what? Why would we do this? And what's the point of this? Well, the goal is to facilitate primary fashion closure at the time of the hernia repair. And, you know, as John just mentioned, getting getting that diet Stasis, getting the hernia defect closed and bringing the rectus muscles back towards the midline again changes core muscle function, which is incredibly important for the rest of their lives. And we do this by dividing one of the layers of the lateral muscles, so we will either divide the external oblique or the trans versus of dominance. Um, and I believe that you should never divide more than one muscle on each side, even if it's separated by a large amount of time. Um, section between divided and the remaining layers is important to to make sure that the muscle actually comes apart and you don't just cut the tendon. But again, this relieves tension in the midline closure. There's some data to show that the remaining layers actually hypertrophy over time. So when you look at, um, core function and especially on the oblique muscles, um, it really doesn't change things very much. And I always my patients always look at me and they look concerned and they're like, You're gonna cut one of my muscles. Don't I need that muscle? Well, yeah, you do need that muscle. But you also need that muscle's not doing anything right now because it's trying to pull against a midline that isn't attached. And so, um, I I believe that when you if I can get your midline back together again and give the to obliques something to pull against, you're going to have a better core function versus having all three of leaks that don't pull on anything. So, um, Ramirez is gets credit for for describing this first in the literature. Although there's some, uh, data. You know, there's some older studies looking at at this being described before this, but we're gonna give Ramirez the credit. Um, it's a plan. He's a plastic surgeon, so we hate to get plastic surgeons too much credit, but, um, but we'll go ahead and do that, John. Um, so it was, and he arisen. Described it, um, in a hernia or event duration after a tram flap. So, um, this description you see here is, uh is the original, um, artistic drawing in his original paper. Um, and you can see here, here's the event. Duration through the tram flap, you take the post of your sheath, you bring the post your sheath together and even describe doing it, Um, an external obliques, which is the release we're talking about. So, um, so that's the release right there. Some of the data suggests that you can get about five cm up to 10 cm of of release and mobilization, um, through by doing an external oblique release. And we've all had patients like this. They've got a pretty morbid looking scar. Pretty significant, uh, ridiculous. And we're gonna sort of this. This is an older historical picture. I had this colorized for, uh, for all of us to enjoy here. It's that old, um, but here, you know, I'm working with one of my plastic surgeons. Um, and we've been able to expose We're gonna do a nice little skin flap. Give this lady a better looking abdomen. But here's the external bleak release. You know we'll talk a little bit later about the blood supply to that skin flap, but you can see here all the perpetrators have been taken. Um, and here's a nice release. I'll show you how old this is because here I am sewing in a piece of pigskin, And I'm doing it as an underlay. So that's, you know, it's just, um it's not a bad operation, but I'll show you some things that I think we've we've improved upon over the last 10, 15 years. But here we are. We're closed. We've got that that pig skin sort of sewn in every centimeter, taking some of the tension off the midline. The midline is back together again, and we've taken off a lot of that skin that it doesn't have a blood supply. There's a little bit of a flap going on here, but it's not too bad. And when we're all done, thanks, plastic surgeons do a lot better job making straight lines clearly than I do, but, um, but that's that's pretty good. Um, and she did really well. So About 10 years ago, maybe even 15 years ago? Um, yeah, clearly, about 14, 15 years ago. Um, I was at the American College of Surgeons meeting, and I saw this, um, this operation of a laproscopic component separation, and I thought it was just the greatest thing ever, and I sought out to go learn how to do it. And I've done this now A total of probably two times. Two times. Um, so I've done it. I've done I've done a laproscopic component release in more pigs than I have in humans because I this was part of our journey. Of course, we teach this all the time, but then I've done it twice. Um, and in the porcine model, uh, Mike Rosen showed that you can get about roughly the same release doing it laparoscopically as you could do it open. And this is some of the, uh, original artwork in his paper here. But, um, you know, you you basically get underneath the external oblique and you inflate a dissecting balloon and insert your trow cars into this space. And then you cut the ape neurosis of the external oblique, making sure you stay lateral to the semi lunar line. We've seen a couple of patients that had a complete release of the semi lunar line, which is fantastic for getting your midline back together again. But you've now got a lateral hernia. So if you're finding it unbelievably easy to get your midline back together again, you've done something wrong. And here's the patient. Ironically, had, you know, this is a a midline hernia, but has everything dissected to the right side. So when it came to doing an external oblique release, we didn't have to, you know, the hernia had dissected that plane for us on the right side. So I just did this on the left side. So this is one of one of two that I've done and see if we can get this to run. All right, So here's that dissecting balloon you have to manually get underneath the external oblique, making sure you're not in the underneath, the internal oblique. And if you're in the right plane, you should see the extra oblique above you and the internal oblique below You create this space. It's a relatively a vascular playing, thankfully, and then we take the balloon out, just like you're doing in England. Honey I put in some troll cars and then mhm just kind of jump ahead. And then we take the neurosis of the external bleak and take it down and you can see everything popped open and you actually get a pretty decent release. And, um, this is a case I did with, uh, one of my colleagues who really love to do only repairs. I'm not a big fan of only repairs, but this was a nice big piece of ancient polypropylene mesh and laid it as an only. And the guy did pretty well with this. This this is this is what happens when I close in abdomen. It looks more like a Franken belly, but, um, I'm not sure the plastic surgeons would have done a lot better job. Um, but this is this is the classic, uh, you know, picture in the literature of a nice, big external oblique release these massive flaps, everyone's high fiving. It's great. Um, this is what looks like at the end. And then the patient comes back to see you a couple weeks later, and this is what happens. The the you know, the skin is necrotic because you've taken all the perpetrators from it. So, um, it's very concerning to do this operation. And patients, particularly those that are of highest risk smokers, obese patients, diabetics. Especially if they've had prior aortic surgery. We know triple A patients have, even if it's done. Yeah, So I don't know how many of you know this, but we used to do Triple A's open. It's weird. Um, so anyway, so, um, but we don't see a whole lot of open triple A hernia anymore, but, um, but it used to happen. So the concern is the blood supply. Um, And if you remember the blood supply to the abdominal wall, most of the media blood supply comes from perforate Ear's through the rectus muscle. And so, um, if you're raising flaps to expose the obliques, you're taking all of these perpetrators to the rectus muscle into the skin. Now there's a nice cascade and sort of, you know, redundant blood supply to the skin. But certainly if you take enough of these perpetrators, you're gonna make this medial edge of the skin relatively ischemic. Um, and that's where obviously you need the most healing to happen. So, um so essentially, you know, What I try to do is I try to, uh, leave as many of these intact as possible when I do an external oblique release. I mean, I just quickly, um, show you or described a brief stop to repair or retro rectus placement of mesh because in some ways, I think that that is a component separation. Um, it's not technically because we're not doing anything to the to the oblique muscles, but we're cutting muscle and fascia to allow better her near Paris. So in some ways, it is, um, And again, if we're doing this open, we're gonna dissect the post your sheath bilaterally. Um and then we're gonna media lies the poster sheet put mesh in between the poster sheath and the rectus muscle and then close the anterior sheath sheath. And this, uh, sort of older drawing shows what you're doing here in an open fashion, you're you're just lateral to the linear Alba and the midline. You score the post your sheath and you get into that retro rectus plane, which is a relatively a vascular playing, especially immediately. Once you get laterally and start running into all those perpetrators, that's about where you should stop. You take too many of those perpetrators and you're gonna You're gonna basically paralyzed the rectus muscle in certain segments. And this this shows our best visually. For me, I i my head's so big that anytime someone tries to video something behind my head I got used to in light camera. You see the back of my head. So the robots nice and that and that at least allows me to show what's going on because we're recording it. But basically, if you look here, here's the hernia. Here's the midline fascia and then were taken down this little bit of fat pad right here. This is the are the false A form, and we're just opening the posterior rectus sheath and getting into that that layer within the between the posterior rectus sheath and the rectus muscle. Um, and so, um, you can obviously do this robotically. Um, this is this is, I think, the first one I ever did. So you're seeing this as a double docking approach? Um, we'll talk about the tapes and that type of thing. I'm sure later today, but this is, um, just getting into that retro rectus plane. You can see here. It's all that sort of glistening, sort of loose aerial or tissue there comes down easily. I'm using a little bit of Kateri, but you almost don't even have to. But as we get further lateral, we do start to run into the perpetrators. And so we want to make sure we keep those. And I wish I operated this fast, but I think I sped this up about 28 times or something like that. But so I won't get into the whole all the details about how to, uh, do a robotic repair. But essentially, that's the plane you want to get into. And so once you've done that, you close the post your rectus sheath. You lay a piece of mesh into this space here. This describes being used using a revered and needle. I don't typically do that. I just sort of so through the anterior sheath and secure my mesh. And when you're done, you get nice. This is just a regular city without a repair. But you get a nice, um, replacement of a mesh sandwiched in between the fashion and the muscle, and you don't have to worry so much about the mesh interacting with the abdominal contents. And it's also a very well vascular rised playing to put the mesh because you've got this rectus muscle, which is gonna absorb any fluid. You don't get some aromas, that type of thing. So it's a fantastic repair. The other release that you can do is a trans versus of dominance release, and one of the important things about a trans versus of dominance release or a tar to realize is that most of the anatomy books and drawings like this one here show it incorrectly. The Trans verses of Dominus does not run. The sort of the insertion of the trans versus abdominal is not a vertical line like this one, so it doesn't necessarily produce the semi lunar line like the internal oblique. And the extra oblique does, um, it runs more diagonally between just about to the typhoid, down to the iliac crest over here. So and you can see this on this is that same CT scan I just showed you. You've got external oblique internal bleak, and here, just off the anterior superior iliac spine, you've got this small little bit of a trans versus abdominal muscle. So, um, the release that you're doing out here is actually just the transverse Alice fashion. And this is you can see this on any CT scan. Here, here's a patient with a hernia, and, um, the trans versus abdominals is actually right here just underneath the rectus muscle. We continue to go down. You can see here is Trans versus Abdominal, basically coming towards the midline, just a little bit shy of midline. And then as we continue to go down, the trans versus of dominance starts to retract laterally and about halfway between her, even a third of the way down. Um, it does line up with the rest of the oblique muscles at the semi lunar line. And then again, as we continue to go further in towards the feet, you, uh you lose it laterally. So again, trying to do this so you can see what I'm doing. I'll use the robot to show it, so just try to jump ahead here, but just taking down some adhesions here to expose everything. All right, So here's the hernia defect. Here are the hernia defects. And then what I'm looking for here is So here's the midline. Here's the linea Alba, and you can see you can almost see through the post your sheath to see that there's muscle behind here and I want to take this post your sheath down as as as medial as I can. We saw this in the last video, so we'll jump ahead here. All right, so So now we're lateral. This is the semi lunar lion over here, and I'm looking at the the what? I what should just be the posterior rectus sheath, which should just be a layer of tendon if you look at the at the anatomy books. But what What is really happening? Especially the typhoid is up here. Is that the Trans versus of Dominus is actually part of this. And so we're gonna score. Um, and I learned this from Todd years ago that it's it's the posterior Lamelas of the internal oblique. If you remember, the internal bleak has two. As it comes to the to the semi lunar line, it splits into an anterior and posterior Lamela. And so you're scoring that posterior lamelo the internal oblique, and that exposes the blood vessels clearly. But it exposes the trans versus of Dominus muscle. And so we're going to then, um you know, if I'm doing this open, I'll typically use a right angle. Get underneath those, uh, those muscle fibers. If I'm doing this robotically, I sort of use the scissors. As you know, I'm using one blade of the of the shears as a as a right angle, and then I'm just cauterizing the muscle. And we're just getting into that plane that is, um, in this situation, I'm just lifting the muscle fibers off of the transfer salis fascia. Um, and I'm gonna take the muscle fibers laterally, and that gives me a lot of mobilization. This post your sheet, it takes a lot of tension off the midline. Probably takes most attention off of the post. Your sheath. Um, so I think if you're if you're trying to if you're if you have a really large defect and you really need to get the most mobilization of the rectus complex, I still think you probably get more mobilization if you take the external oblique versus two in the Trans versus Dominus. But again, if you aren't careful by taking your external oblique, you end up with a lot of skin esky Mia. So, um, doing guitar is a nice sort of compromise to get some mobilization of the midline without worrying about taking any of the any of the of the blood supply to the rectus. And so, ideally, once we've gotten on that plane, we can get lateral. You could follow this into the prepared meal plain. You could come and take this all the way around the kidney if you wanted to. So the advantage of the of A of a tar, especially if your if your hernia isn't right at the midline. So in other words, let's say you have a prior Ostuni hernia, and, um and that Ostuni hernia goes all the way to the semi lunar line. If you just do the retro rectus section and do an external bleak release, the farthest I can get my mesh is to the semi lunar line. So I'm not going to get really adequate overlap of that hernia. So in that situation, I may do a tar on the side with the former Ostuni hernia, and then I may do an external bleak release on the other side. Um, and to my knowledge, I don't have patients like walking in circles. I don't think I don't think that affects them in any way. They don't know the difference. Um, but it's a good way to get mobilization, you know, sort of a compromise to get the mesh lateral to the hernia defect far enough. And also to get as much mobilization as you can. The nerves to the abdominal wall are are very important, but thankfully, very redundant. Um, and so you you don't typically have to worry about anyone perforating fiber. But if you look closely here, the nerves run in between the trans versus of dominance and the internal oblique. Um, if anyone gets tapped blocks, that's what the, um, anesthesiologist or if you're doing yourself, that's what you're aiming for. You're trying to get into that plane between the internal oblique and the trans versus of dominance laterally, so that you can put a nice little wheel of our nice little pocket of of local anesthetic out here to try to anesthetize the abdominal wall as best as possible. We're not to talk about tap blocks today, but I think tap blocks miss the upper part of the abdomen. Because of that but it's really good for the for the lower portion. But that's where the nerves run. And then they perforate through, um, at the posterior rectus sheath, just medial to the semi lunar line. So you want to be careful about taking those nerves. If you take one or two, it's not the end of the world. But if you take the entire length, you're going to have a basically a paralyzed rectus muscle, which over time will atrophy and cause some problems, so try to keep as many of those as possible. So in the interest of time here, I'll just wrap it up. But in conclusion, remember, the anatomy of the abdominal wall isn't that complicated, but it's still easy to get lost. And you can. You can do some, um, irreparable damage if you're not aware of where the blood supply is, where the nerves are and where the semi lunar line is. So try not to get lost in there. There are two main options for releasing the obliques again, the external oblique and the trans versus abdominal. Um, no, this is It may not be the next talk, but knowing when to release him is coming up later today, so All right, Thanks. Okay. Uh, thank you for that. Thank you for that fantastic talk. Um, I'll start off with a question for you. I noticed that you started showing us your experience with some of the open abdominal wall reconstructions and then sort of in the latter. After the talk, we sort of saw transition of robotics. Can you tell us a little bit about your experience with that transition? Um, I mean, the robot is really pretty amazing in that, and we're gonna talk about that a little bit later today, but it does allow you to do operations that I thought were only able to be done open in a minimally invasive approach. There are some people who have been able to do retro rectus repairs and tars, uh, laparoscopically. But I don't think I have the patience or the wrist strength to do that because you're really working. You know, you have to keep your You know, if you look at the robot when it's happening, it's it's an awkward position for a human to be in. Um, so it has allowed, you know, to place the mess and a wreck correct is playing without having to open. Um, and so I think. But there's a learning curve. And, um, at first we were doing it where we were doing double document. You had to move the patient because we had the S i robot. I always wondered just how sterile that could be. So I'd be soaking my mesh in antibiotic irrigation and receptor, and you name it just to sort of try to ward off evil spirits. But now you know the X insistence meant to be a commercial for the robot, but the X I at least the nice thing about is that the robot itself can do 180 degree turn. So if you are double docking, But, um, we've now moved on to, uh, steps and that type of thing. But I still think an iPod is a great operation. Um, and, uh, and still get really good results with an eye palm. So I kind of it's nice to have a couple of tricks up your sleeve so that you can you can place a piece of mesh retro rectus, or you can do an iPod. Still, thank you. Anyone in the audience with any questions? Great. Then I guess we will move on. Thank you very much. Published December 15, 2021 Created by
