Chapters Transcript Video MIS approaches in hernia repair: review of best practices Where does the Lap IPOM fit in? - William Cobb, M.D. All right. So, um, my part of the talk was to go over the lap by Palm and is there still a role for it? And I certainly think there is. I mean, I do believe it's diminishing, particularly as we get better in our robotic skills and techniques. But there, there again, it still has a place in all of this. So talk a little bit about some of the advantages of the Lap II palm, the drawbacks and then some situations where I think it's still beneficial in the management. And so, you know, the lab decisional hernia repair. I mean, it's a really good repair. I mean, it's got great data. It's got a long track record, uh, you know, very acceptable recurrence rate. Um, you know, certainly as you get into more complex, morbidly obese, bigger defects, things like that. It does start to, uh, to fall apart a little bit. But, um, you know, and the properly selected patient, uh, it's still a really good repair, Um, particularly from an infectious complication standpoint. Um, but clearly, more and more now is is the robotic techniques are being developed, and the e type, which is, um, it is really cool for those of you that are kind of hesitant are waiting to get on the robot. That's kind of what pushed me, because there are some really, uh, neat things going on and reconstructing abdominal walls of the robot. Uh, certainly the laproscopic view or just the middle invasively approach allows you to assess the entire abdominal wall. Uh, I think even better than you can open. And you don't have to open up the entire fashion decision, uh, to assess to assess the entire the entirety of what's at risk for the hernia. And so, if you've got, you know, a stem to stern laparotomy incision and the defect is predominantly peri umbilical. You know, you put a lap scope or put a camera in, you can look and you look all the way up to the city boy to see if there's issues higher up. That may not be obvious on a CT or on exam. So, um, the nice thing about the laparoscopic repair to obviously, as you can very accurately measure the defect, um, and then size your mesh appropriately and place your mesh very appropriately and ensure that there's, uh, adequate overlap in all dimensions. You're not shifting it from one side of the other. So there's just a lot of technical, um, benefits. I think the to the view that you get from the newly basic approach and in Libra Skopje uh, specifically, um, the risk of wind complications and more concerning Lee mesh complications, um, is exceedingly low with Libras ka pik and then now robotic repairs. And that, obviously, as the sort of time tested benefit of a mill invasive repair is that you dramatically reduce the concerns of wind complications. Problems with the lab prepare Matt touched on a little bit particularly. You start trying to close the defect and sort of, you know, adapting the repair, if you will. Um, it is extremely painful, particularly closing the defect. We've gotten away from a lot of the trans abdominal structures that were initially described. I still think you have to have a couple to at least kind of position that mesh because at the end of the day you're placing a mesh on an intact peritoneum. I don't ever believe you get in growth through the peritoneum and magically through the uh, prepared meal fat into the post your fascia, so it's essentially always kind of a floating mesh. So I think you do need some trans abdominal fixation, and we can certainly debate that because a lot of people don't believe that. Um, and then any, as we've now kind of evolved and adapted and learned more about the physics of the abdominal wall and these repairs, Um, bridging larger defects is essentially, it's a really bad idea. And sometimes that's what you're left with with a standard laparoscopic repair. Because if you get in there and it's a eight by 12 centimeter defect, good luck trying to close that thing. Um, and your your left, you're going to have a bridge at some point when you look at the data that kind of showed some of this but the large studies that are out there So you know, we're talking studies uh, 8 50 over 1000 now, pretty consistent recurrence rate less than 5%,, and the wounded mesh infection risk. That's that's the take home message. And that's really where you gain the benefits from the middle evasive approach. Again, we talked about the pain will go a little bit about reinforced versus bridge does the size, the defect matter, and then where you put the mesh and the concerns with the intraperitoneal place in a mesh is one of the best studies that really, um, delineates the pain that you see after laparoscopic repair. And this is, uh, Todd and his group looking at the Carolinas comfort scale and the international hernia mesh registry. Um, and this is only paper I'm aware of that shows that early on the first six weeks, uh, patients have higher report of pain. The laproscopic versus an open repair. Um, and they have more limitations in their activity. Normalizes it a year. But at least initially, the laparoscopic repair really hurts. And I tell these folks, you know, is gonna be the most painful operation you've ever had. Um, and it's not like like lap gall bladder lapping when all things that we've benefited pain, I think we inflict more pain with the laparoscopic repair. You know, the functionality. Obviously, uh, you know, these are the folks in your office, but, you know, function means different things to different people. And so you know this fella, you know, do we need to reconstruct his abdominal wall? and let him start doing sit ups and get back to the gym where he hasn't been since grammar school. I don't know that that's really all that necessary. And so sometimes, you know, the bridge works perfectly fine. Um, there is a lot of benefit, however, and it's been touched on already talked about the importance of getting the fashion back together. I do think that is in most scenarios. Um, but does it always need to be accomplished? Um, you know, certainly the fellow of the younger guy There on the left. Multiple operations for, um, necrotizing pancreatitis. Big defect? Yeah, he needs his abdominal wall. Reconstructed. He needs an open repair needs. Rectus muscles brought back together. Mesh reinforcement, the retro muscular space. All that good stuff and the thought that he may need additional operations down the road to keep that mesh outside of his abdomen. I think is a good idea as well. The biscuit fed South Carolinian on the right. Very small defect. With T. Colin up there. You just don't want that patient landing in your er at three. In the morning with incarceration or strangulation. That's a fantastic I think. Patient for laproscopic consideration or mentally invasive consideration. Now, of course, this would be a great candidate, but, um, but something mentally evasive that you minimize the risk of recurrence. Because as you can see her B. M I is not, uh, less than 35. And so, you know you're gonna have a higher risk of morbidity. And so could you do something really evasive? Certainly has a role. So closing the defect, this was touched on a little bit earlier. I agree with Matt. I think you're just sort of, you know, trying to do just enough or get by. It's not ideal to do this. Uh, it hurts like all get out. Um, but the so called shoelace approach as Yuri Nowitzki is coined. And Eric Paul, I Orenstein, I think, was the one actually coined at that. But pulling everything together once you deflate the abdominal wall and then lay in your mesh sized too, what you would have used had you not closed the defect. And I think that's important is you're not really minimizing the amount of measure placing because if that were to bust loose when they cough in recovery, you still want to have adequate mesh covering that defect as if you had not closed it. When you look at some of the literature out there closing the defect versus not closing the defect, it all really just depends on what the author's biases. Um, so this is Neil Smart and his group were doing a meta analysis basically showing that there's a little bit reduction in, um, Ciroma when you close that dead space. But there's really no difference in recurrence or pain. Um, I kind of have a hard time believing that, but this is more studies now. This is Yuri and his group, which is, of course, huge advocates of closing the defect. This is actually a really nice study because it's comparing, like to like it's laproscopic standard laparoscopy with leaving the defect open versus the shoeless technique that I just demonstrated on that video. Um, that Yuri performs and you can see a significant reduction in Ciroma and recurrence rate, uh, as well as, um sso s overall in patients that had the defects closed. So that certainly makes more sense. That's kind of where I probably feel better about that kind of data, but it is conflicting. You can find sort of folks on both sides of the fence if there's a benefit to closing the defect. Um, but I think most people now doing laproscopic repairs, particularly smaller hernias, try to close that defect location of the mesh. I think this matters. No question. My partner, Alfie Carbonell, you know, he's very focused and driven, like, uh, like Todd. And, um, you know, he gets on a rant every now and then and just kind of takes it to the nth degree. And one of his big things a few years ago was in two abdominal mesh. He thought it was the bane of our existence. We need to stop putting mesh inside the abdominal cavity because of all the concerns that it caused with re operations, Um, and particularly younger patients less than age of 50. You know, he's like we shouldn't put mesh in any other abdomens because having to go back into the disaster, he's backed off a little bit of that. But there is some some data to support that. I mean, this is a study by Mary Han and her group looking at the VA patient population. Um, the only thing that predict in Iraq to me and and or unplanned Valerie sections, um, was an elective. Hernia repair was previous mesh. And so, um, you know, there are concerns with having mesh inside the abdominal cavity. Uh, can you guys have been there before? Make sure he's the license much more difficult. You can get to a lot of a lot of issues. With that, we looked at our own laproscopic series of patients. In our 10 year experience, we had a little over 700 folks, And you can see it's not insignificant that these patients go on to require additional operations of 17% of our patient population. Did have another abdominal surgery. For some reason, of course, recurrences were in their interventions for, um, gallbladders appendix, You know, having the colon removed later. Things like that. It was a 4% risk of an erotic Bierbauer section at that second operation, um, and then secondarily infecting the mesh just shy of 2.5%. So, again, these aren't I mean, they're relatively small numbers, but, you know, you start adding that up. That's a significant morbidity for these folks. So there are concerns with placing mesh inside the abdominal cavity. And so we do as best as possible. Try to keep it outside if we can. But there again, I do think still roll. There is a role for laparoscopy, and I think in folks that yeah, you beat on them all you can. You try to get them to lose weight. You try to get him to quit smoking, and they're just not gonna do it. And there's they're horribly symptomatic and you just don't want to be dealing with them in the middle of the night. I mean, I think it's a little bit and I'm gonna say a substandard repair, but it's probably not the Cadillac, but I'll have the conversation that we can go in there and just patch the hole and, you know, certainly a little bit higher risk of recurrence. But it's going to mitigate the moon morbidity. And so in those patients, I do think it's an outstanding, um, an option, and preferably more of the smaller defects. And those are two really the ones at higher risk for incarceration. Strangulation, anyway, is there a role in emergent cases? I'll show you some interesting data looking at that But I do think and I always like to at least Papa scope in even an incarcerated cases just to see what you're dealing with. You. Can you get in there how the vowel pop out and kind of assess it. If it's a little bit purplish or pink, you know? Well, it will pep up over time while you're doing the rest of your He's a license and things like that. I think you can save these folks big laparotomy, even incarceration and strangulation situations. When you look at again, this is some of that. The same uh, H s Q C data that shared with you earlier. You know, this is the folks that in our center that we are choosing for laproscopic I palms and you can see it's a higher B m. I. Over 30% of these folks have B m I greater than 40 smokers. We operate on them. If they open our laps, that doesn't really matter for us and then more diabetic. So the folks that have the wound issues, that's really who were kind of shunting more to lap I palms now the few that we still do in our practice when you look at laparoscopy and the results for lap incision, a hernia repair and obesity, um, higher complication rates, recurrences. You know, some folks do it very well, according to their data, and some it shows a higher. Of course, Rosen's got a higher recurrence rate, but but there is typically compared to a normalized weight, it's typically higher. Um, in the obese patients. Um, this was one of the early studies looking at this. This is Todd joining up with Ram Shawn Vela and kind of looking at their 8 50 data and peeling out the folks that had been my greater than 40. And the recurrence rate was very acceptable, but significantly higher than the non obese. And so, yeah, you're gonna have that high recurrence rate, but again mitigate some of the wound morbidity. Um, this is just a study looking at lap versus open. And you really start to see the benefits here again when, um morbidity, um, recurrences and things like that significantly less laparoscopically than open, um, in this series. But these were not retro muscular repairs. These were kind of all comers for the open lot of on lace and things like that in there. So, um, for the emergent patient again, I think it's a great opportunity with the visualization and the use of the camera. You can kind of match from their belly once you get them relaxed and, uh, sedated, and you can reduce everything and assess. And a lot of times it's a very small defect. And you can, Like I said, check out that bow and figure out If you need to do a bowel resection, you can minimize that incision. Just make a small incision and pull up that loop of bowel and respect it. It saves you from having to place a large incision on these people a lot of time. So I do think there's a a nice role for laparoscopy in the emergent ventral hernia. And so this was a nice, quick study. Pretty pretty interesting. It showed a significant improvement, Uh, and decreased operative time, length of stay s s I 30 day mortality in the laparoscopically approach to patients with emergent hernias. But it's very, very, uh, not utilized a lot. It's very underutilized, if you will, and you can understand why. I mean typically in the middle of night you know? Gosh, even when you have the A team, um, sometimes it's a struggle to get your laproscopic stuff all fired up. But certainly we've got the C or the D team at night, a lot of orthopedic text and so forth, and they don't have any clue as to how to work the laproscopic stuff. So which is interesting, because now we're starting to see with robotics Folks doing some emergent robotic stuff. I know our institution. We shut the thing down at, you know, 5:00 at the end of the day, and you can't get on the robot at night. But it's gonna have a lot of the same pills we've had to deal with over the years of laparoscopy after hours. So again, I still think there is a role for the lab risk opic i palm and it gets all back to the wound and mesh infectious complications. And so on. Those folks, you just can't mitigate them. And as much as you try to wrangle and wrestle with them, they're just not going to lose weight or not. Quit smoking. And they're a little more symptomatic than you're comfortable with watching. Um, I think it's a good option for those folks. Thank you. Yeah. Mhm. Thank you, Dr Goldblatt. Thank you. Dr. Cobb will open it up for any questions at this time. Um, if not, I'm gonna start with a question myself. Certainly. Uh, so you know, both you and Dr Goldblatt both say, you know, I palm still, um, something that's in your armamentarium. You sort of showed some good examples about that. Have you ever decided to do a hybrid? Uh, I palm where you make a counter incision in the skin and then sort of primarily close it, go back in laparoscopically and then just sort of put up the mesh? Um, absolutely. And I think in some of those cases, particularly with incarcerated or strangulated defects, and you get in there and a lot of times they have just a massive amount of momentum, and it's like a mushroom effect. There's a really small defects. There's all this momentum up in there, and you're starting to pull on it, and it's bleeding all over the place, and it's frustrating as heck. You can either obviously widen the defect if you wanted to help get it in or to your point. Make that little small counter incision is going to be a better closure of the anti R fashion anyway, because you're gonna try to attempt to do that and then just stuff your mesh in through that hole before you close it and then seal everything up and go back laparoscopically and attack your mash. No, I think that's a beautiful approach. Have been reluctant to do it because the the the whole, the undeniable advantage of a laproscopic repairs to avoid wound complications. And now you've just made a wound right over your midline. So instead of saying that that's a laparoscopic repair where you did it open, it's really an open repair that you put a bigger piece of mesh in laparoscopically. At least it makes me feel better that way. But, you know, because you couldn't get as big a piece of mesh in there open unless you did retrospective. But if you're if you want to do an eye palm to get that big piece of mesh in there, you're gonna have to tack it so that I think is sort of in an intent to treat. How would you categorize that? That would fall under an open repair, so you have to treat it like an open repair. You're gonna have to have to run the risk of a wound. Infection. Do drain that space now. So what if you get a big Ciroma there and you've got an incision right over the top? So now you have the benefit, you can actually strip out the sack. And so now you can take the time to, uh, peel out the hernia sac, which obviously wouldn't do laparoscopically. And I push back a little bit. It's It's not the same as an open repair because you're not doing a significant amount of tissue dissection. I mean, you're just opening up that space, maybe doing making your easy life a little bit easier, dropping a mesh in closing the hole. And it's, um I don't know. I think I think it's a whole lot better than what you're comparing to, like with a retro muscular or something where you're going in and raising flaps and planes and, yeah, it's not the same. I would I would agree. It's probably somewhere in between intermediate between, but to be closer to, uh, it's kind of like the house collecting me versus the laproscopic. I mean, the house data favors more towards the laproscopic than it does an open collective me. So to support the combined approach here, I'm a community surgeon. Have a little bit of that hernia hat on. So I'm not certainly not one of you fancy academic guys with a lot of data behind it. But I do have a pretty good series of patients with the moderate sized hernias with a small 2 to 3 centimeter cut down, Um, isolate the sack and then you see the defect. And rather than cranking it together, this is again. We're going for prevention of incarceration events. We're not going for full restoration of abdominal wall function, etcetera. So everybody has a dia Stasi's, but you do have a discrete defect. I found that and then release about three centimeters back on the rectus sheath poster Rectus sheath Evert that. So now you have a fashion covering in a complete, um, fashion closure. There, close up your subcutaneous space. It's a very small wound. It's not a full, full abdominal notes aromas. That's not really a problem because you get a full closure of it. Then go in laparoscopically and you'll see the bear muscle and then pick a mesh that will, you know, uh, support that whole area. So you're going beyond the point that you disrupted your posterior sheath. Found it to be incredibly comfortable and, you know, very effective. It had no recurrences, a couple dozen of. And so it is a nice little combined technique, But you you get all the things accomplished by getting their fashion clothes in a good a good layer between your mesh and the skin. So it's gonna be really behind all fashion, and there's no tension involved. But that's the beauty of it. There's no tension, and I think that takes away a lot of the pain. That's for about four or 56 centimeter defect through a tiny little incision. That's where you put your mission. Yes, sir. I agree. Because you support my opinion. I don't know. That sounds great. I'd love to see you guys try to Yes, sir. Published December 15, 2021 Created by
