Chapters Transcript Video MIS approaches in hernia repair: review of best practices Where does the Lap IPOM fit in?- Matthew Goldblatt, M.D. okay. As we come back from the break, we're gonna just head right back into it. So we're gonna have, um, Dr Goldblatt and doctor cop people talk about minimally invasive hernia repairs next. All right, well, thanks again. Um, you know, for Gore for supporting this, this is a great educational opportunity for for all of us. And, um, I always learn a lot from these courses. As I've already mentioned in my first talk, I learned a lot from these guys. So hopefully you're all picking up stuff. I'm gonna talk a little bit about laparoscopic and robotic repair. I'm gonna save some of the laproscopic stuff for will here. But there's, You know, there's some pretty old data on laproscopic repairs, and And this is, you know, early 2000s at the turn of the century here, and it was looking at retrospective and randomized series. Uh, Mike Rosen put together this nice little review of, uh, of some of the papers out there, and basically, Uh, what they found was that there was a basic, you know, a higher recurrence rate with the laproscopic prepares, but lower complication rates. So, um, that was early on in the experiences. This is a study, um, that was published in annals of surgery. Uh, in 2011, looking at laproscopic versus open abdominal wall repair. Looking at this is sort of the beginning of the nice quip data explosion. And they tried to sort of normalize using some advanced statistics to try to reduce bias based on non random ization, which, as you know, is impossible. And certainly for those of us who do open and minimally invasive repairs, they're just two totally separate separate animals. And I don't think a statistician can normalize for that. But when you go through and look at these massive data fields and you can, you know, normal T tests and that type of thing, we're not designed for thousands of of subjects in each arm because it's it doesn't take much of a difference to show a, uh, you know, less than 0.1%. But certainly the laproscopic repairs had lower. Morbidity had lower surgical site infections, which makes sense. If you're not making a big incision, you probably have a less chance of a surgical site infection. Um, urinary tract infections were actually higher in the laproscopic group. But I would argue that if you've only got a 0.4 p value with massiveness quick databases than there, I would say that there isn't a difference. And then pes were were higher in the open group, which which also makes a little bit of sense. They're usually bigger repairs and more time on the operating table. But it also depends. So we know that this is not the patient that you're gonna do a laparoscopic repair. I mean, you gotta open fistulas and that type of thing. So if you're gonna do a laparoscopic repair, a lot of things have to happen. Skin's gotta be closed. Um, certainly if if you've got a skin graft on the bow, you you You may be able to peel that skin graft off the off the bow off the skin graft from the inside. But that skin is gonna die. And so that's not the not the operation you're gonna choose. And then we, um no, that's interesting. Same study, Um, fewer complications in laparoscopic and shorter hospital Stay. All right, so, um, some of the predictors of surgical site infection, um, is a post hoc analysis looking at ventral hernias in, uh, the V A. And this was actually randomized multi center. And and they certainly found that there was a higher rate of surgical site infections in the open repairs versus the laparoscopic, as you would anticipate. And they showed that the case volume of the surgeon Also had a big play in here. So if if the surgeon had less than 75 case experience, um, and they had a more blood loss, then, uh, then there's going to be an increased risk of infection. So so certainly there's a learning curve associated with any of these repairs. I'm not going to show. I'm going to skip past this, but, um, but here's a patient. Let me see if I can move backwards here. Well, have frozen in there. Look at that. Here we go. Um, so this is just a hernia repair. I'm gonna tackle laparoscopically, and you can see here. See if this place there we go. Um, so, just like any any of the first step you have to do is take down the adhesions, so we'll take down, um, these small ballot, he Asians, you know, I've I do most of my repairs, uh, robotically now. And so, um, it's just it's actually seems kind of weird using these primitive sticks. Um, but, you know, this is a piece of cynic or, um and, uh, you know, we sowed some some Esteban's futures to that, and we're bringing it up through some trans fashion, uh, incisions bringing the mesh up towards the anterior abdominal wall. Um, I and then we were able to attack the mesh. Um, using absorb, attacker. Um, we're gonna talk about cynic or a little bit later. Uh, today, but, um, it's a It's a nice hybrid mesh with a combination of an absorbable and a permanent mesh. Um, really great, um, strength and in growth. And in a situation like this, where I am bridging that defect, I think it's a great, um, great material for that. It's incredibly strong. Um, I have I've yet to see anything close to a a mesh of re fracture because it's just it's just unbelievably strong and and we'll talk about that later. I would have Yeah, and that's the big difference, I think. And now a lot of people do their laproscopic repairs and close the fashion. Um, I just have had just horrible experiences with that. First of all, you're using the Carter Thomason and taking multiple stabs through the through that right over that hernia defect. Um, you know, you end up having about six or eight of them, you're pulling it tight. I've seen a lot of them ripped through. I've had I just don't like that, um, that even that couple millimeter incision right over that thin hernia sac Because the whole point of doing a minimally invasive approach is to decrease your wounded complication. If you get even a little complication at that small little stab site, you're right over the mesh at that point. So all right. So what about the robot, then? Well, I've already shown a couple videos earlier about doing retro rectus repair with the robot, which is basically doing an open operation and converting it to a minimally invasive and in the history of of minimally invasive surgery, when you can go from open to M. I s. That's where the big advantages are found. So I think when you when you look at the robot and you say, Well, I'm gonna do Let's look at laparoscopic inguinal hernias and compare them to robotic inguinal hernias. I don't think you're going to find a difference. In fact, I think you're going to I still like to do my inguinal hernias laparoscopically. I feel like I do a better job as a step that I do as a tap because my biggest concern is when I lift that flap up to close it, that I could inadvertently fold the mesh and you're gonna get a recurrence Posterior lee. Um, and you're really splitting hairs as far as the advantages that we normally see length of stay, um, you know, return to work all that type of thing. So But if you can If you can look at taking an open operation and converting it to an M. I s operation. Now you're gonna see a massive change in length of stay surgical site infection. I put marketing on here because I mean, let's face it, if you're the only person in town not using the robot, a lot of patients are looking for the surgeon whose using the robot. So, um, you're gonna lose some of that market share to the guy down the road who is doing all their stuff robotically some of the potential drawbacks. It certainly takes longer. At first there's a learning curve. There's no doubt it's more expensive. I don't even like to get involved in the in the in the discussion about how well the hospital bought the robots. So it's really you can't advertise the cost of the robot. Her case. I'm like, Well, try to explain that to Delta when you're sitting on a seat on the airplane, you know, like you're flying to L. A. Anyway, I'm just gonna sit here. The seat was open like, yeah, you still have to pay for that seat. So I mean, and and it's amazing how, Yeah, it was one thing when the robots first started and people were using them as coat hangers. But now that everyone is using the robot, my hospital has now bought three robots, and they're looking to buy two more robots. So it to sit here and say that you can't use the cost of the robot is probably not a good a good argument. So just admit it. It's more expensive, but there are things I can do with it that are great. Um, I can get you know, some of these big ventral hernia is done and roughly the same amount of time. It probably takes a little bit longer because I am closing the fascia and I'm sewing the mesh in. There is no doubt in my mind that I can sit there and tack the perimeter of that mesh in about 5 to 10 minutes and it takes me, especially with trainees. It takes me usually a good hour to just so all the way around that thing. So it does take longer, but I do think there is a difference in pain. Those tax hurt a lot. Um, and if I don't take a massive bite with my stitch when I'm sewing around the perimeter, um, I really do think that there's less pain with the robotic iPod. So, you know, let's see you having trouble with this, All right? So just a quick little video here to demonstrate sort of the concept of closing the fashion. The first thing is that all that fat, which we all have, is just It's not in any way helpful to anything. Um, so I just take it down Now if you're gonna use it, you're gonna try to do a prepared meal repair. Um, then that fat and that parent he'll flap is your friend. But in this case, I'm doing an iPod, so I'm just gonna I'm gonna remove it. I'm gonna try to take the hernia sac out if I can. This one came out really nicely. Some of them don't. I don't mind leaving it in there. You get a little Ciroma. It's not the end of the world, but And I slowed this down so that you could see it. But this is a This is, you know? I mean, the nice thing is, you can close the fashion, and most of us are using these, um, these barbs futures the strata, fixes fixes and the locks. I don't really have any relationship with either of those two companies, and I think they both have their pros and cons, but they're roughly the same. And most of us just have a contract with one of the future companies, and they're pretty good. Um, and you can get everything closed. Yes. Let's show it again. Um, So, um, some of the data out there This is a decent study. Looking at robotic assisted abdominal wall surgery and a systemic review. And and they basically showed that, um comparing. So they compared robotic with open and robotic with laproscopic. And certainly when you look at robotic and open, it has a longer operative time but a shorter length of stay. And, um, and if your hospital is questioning the cost, I mean, I'm sure, like most of you are Hospital is is full all the time now between covid and flu season and and just trying to get, you know, the most out of every square inch of the hospital. They don't want to build new new wings. They just want to fill it to capacity. So we are. We are full and we have, um, I know they make any time. They give me a dollar figure. I know it's it's a lie. So they basically said, If you can take a day off of a hospital stay, it's worth about 1000 bucks, Which, to me means it's probably worth about 2-5 times that. But that's what they that's what they're telling me. So if I if I spend an extra hour in the operating room, but I can save two days on the hospital today. It's worth every penny of the robot and and my and my time, Um, and the and the patients do better. And and that's that's what we're in this for. This is that study looking at the operative time. When you look at at robot versus open, you've got a clear advantage to the open as far as operative time. Um, and when you look at robot versus lap, there's even, uh, an advantage to the laproscopic operative operative time compared to the robot. But when you look at length of stay, um, the robot length of stay is, um, is certainly favorable compared to open. But when you compare robot versus laproscopic, it's kind of, uh, there really wasn't a clear difference. So, um, they claim that it is a slight favor for the laproscopic, but I think it just depends on the type of procedure you're doing. I'm not going to show this video again. I showed it earlier, Um, but this is the problem if you're not careful, especially doing a retro rectus repair, Um, and you know, is that you get the patient who shows up with the early postoperative bowel obstruction. Um and so this, of course, this guy came in on a Sunday afternoon. I wasn't on call, so my my partner admitted him put an n g down. And the first thing I heard about when I heard I heard about this Monday morning was it was like, get a CT scan. Um, and they just said, Oh, no, it's just an alias. That's about it. Don't worry about it. And the CT scan showed that I had a break in my posterior sheath. Um, and you can see here a nice a nice little mechanical bowel obstruction from a sort of intra parietal hernia. So I'm not blaming the mesh. This is not this. That was a piece of self sticking mesh up there, but, uh, so here I here I spent all day. Uh, you know, this is one of my first robotic retro rectus repairs, and I'm telling them all the advantages of of not having, uh, you know, mesh in the abdomen. And so how did I fix this? I sewed it closed, and then I put in an iPod to fix it. But again not, uh, not the mesh your we're going to talk about today. But this is what you gotta do to try to salvage these things. Um, so it's less than ideal. So that's that's the reason why I would, um, strongly considered doing. Now I'm doing it steps. So I'm using the hernia sac and using that that fat pad as my post your sheet, Um, and my post your closure. Um uh, sometimes I'll sew in a piece. I'll even cut out and save that hernia sac, and so it in separately if I need to. But if I'm going to do it, retro rectus, I'm going to try to keep it, um, without having to put too much tension on that Post your sheet. If you are doing a traditional repair and you're doing a double docking and you're trying to get that post your sheath closed and the data there's some data out there to suggest that you have a much higher incidence of tars of having to do a tar just to get that post your sheath closed. And so you see these 46 centimeter hernia repairs with bilateral tars. That's probably wasn't necessary. So if you can have some of these other tricks to get that post your sheath closed without doing a tar. Probably better for the patient. So that's sort of my my half of this. Well, it's probably got some better stuff to talk about here. Published December 15, 2021 Created by
