Chapters Transcript Video Robotics in hernia repair: Management of hiatal hernias in support of quality outcomes - Cheguevara Afaneh, M.D. All right, we are going to continue to move on before lunch with Heidel hernia repairs. Okay, great. Um, so we'll talk a little bit about materials to start. Um, for those that are not familiar with by away, um, it is composed of, uh, p g a N t M c. As a combination, it's really completely re absorbable. It goes away in about 6 to 7 months, and it's replaced with your own tissue collagen at a rate of sort of 1 to 1. Um, as the materials get reabsorbed, it's, uh there's a by away Heidel hernia patch that's been around for a long time, and many surgeons have and continue to use it, and we used it routinely for our little hernia repairs that required mesh reinforcement. So I'm gonna sort of, um, move on to some video Of some of this use here. So this is a little bit of an older video, as we used by away. You can see it's a fairly large Paris official hernia repair. Um, I probably do about 90% robotic surgery at this point, and the rest is really, um, open for some hernia repairs and some middle of the night work, but for four got surgery. It's obviously all done robotically. At this point. This is a patient with a giant parasol for Jill Hernia. Fairly older patient, very classic where they tell you that they're gastroenterologists has been following their Paris off Jill Hernia. They've been watching it, so I always say, watching it grow over time. So, Um, they get their, um, they usually come in the age of 70 or 80. They usually come in with some kind of evolving this picture, and that's usually when you get called. And so this was one of those cases patient came in the middle of the night. The residents were kind enough to place an NG tube and decompressed and we did it the next day. Um, you can see here that we routinely respect the hernia sac and any type 23 or four Heidel hernia. So all the Paris office deals, um, type ones don't really have a hernia sac, um, to respect. So not the case. The nice thing about using the robot in these cases is that you can clearly identify the vagus nerve. Most of the time, the posterior Vegas is usually pretty consistent. Coming right at 6:00. If you think of the esophagus like a clock, The Anterior Vegas usually runs it around 2:00. Not at 12:00. So you have to be careful on the left side as you do that. It's always good to take off the hernia sac so that when you do your fund application, you're not sort of sewing to hernia sac, your sewing stomach around actual esophagus and G junction. Um, in fact, nowadays, um, as a bariatric surgeon to get reimbursed for a concomitant Paris off GL hernia or hiatus hernia at least in the state of New York you typically have to show proof that you've actually removed a hernia sac. Otherwise, you won't get paid for it. Um, so you can see here we're just closing. Um, we, uh, used to routinely use silk sutures to close. This is a bunch of interrupted, but you'll see the evolution of the videos that we move on to the locks futures typically two or 30, depending on the thickness of the muscle that we're closing. We close both anterior and posterior to try to get a balanced closure of the esophagus and to prevent sort of that hill effect as food goes down and may stop. And then you can see here we're using a sheet of by away, and we are fixating it to the cruise. The bio. It comes in a shape that's almost like a you, um, and so people placed it as a you as a C as a reverse C. And then it's typically fixated in three or four places, and there's our wrap in place as well. Um, we used it for hernias greater than five centimeters or recurrent hernias. Um, you know, the sizes are somewhere usually between five and 10 centimeters. For the most part, patients did well with it. Um, recurrence rate at one year was just over 2% And at last follow up was about 7% or so. Um, you know, the follow up is pretty good for about two years or so, and then they typically fall off, then came in form, which has been around for a few years, and it's really sort of a better processed form of by away. Uh, if you actually feel informed compared to buy away, it's really soft. It's pliable by always, sort of has that stiff field, and you can really see the strength of it as we're going to sort of pull this future through the material here. The mesh doesn't give, but the future will break, and it really is a testament of the strength of the material we're using here. And so once we saw something like this, we quickly transition that our institutions start using inform at the hiatus. Um, when you take a look at inform, it's made of the same material as by away. The PGA and the TMC again, completely absorbed, gone at seven months, and it's replaced with your own tissue collagen. I use a robot like I said routinely so that I get really sort of full autonomy in these cases. I assist myself when it comes to retraction camera orientation. Anticipating the next move. We are at a teaching institution, so we have fellows and residents routinely, and it's very safe. And the biggest value, especially in Forgot, is the improved visualization and obviously the precision of suturing. Patients are placed in pretty steep reverse trend. Ellenberger. Somewhere between 20 and 25°, um, poor placement begins at the typhoid, 15 cm below that and then just slightly off midline to the left. We use a liver, a tractor, and we target right at the hiatus. Um, the liver attractors of laproscopic. Uh, Nathan Sin or Thompson, Whatever you wanna call it, we make sure that we keep this close to the patient, and then the arm clearances are really important to make sure that arm to clearances up because of the liver bar. Here's a sleeve patient just to sort of show. Um, this patient was averse to being converted to gastric bypass or links, so we really just sort of opted to repair the hernia. And this is what it looks like with a sheet of inform. We typically do a reverse C configuration for these cases, and then we typically pixie the sleeve to recreate the angle of his to try to prevent reflux afterwards. This is a paper we did early on in her learning curve with forgot surgery. Um, roses are *** and myself. Um, we're really using the S. I and, uh, we wanted to make sure that, um we're able to recreate our outcomes robotically, um, as our laproscopic outcomes um, By using the new technology. And one of the big things we found is that when we did it laparoscopically, um, we were about 30 minutes faster. If we had a fellow assisting us versus a third-year resident, we did it robotically. We found really no difference in our operative time, depending on who was assisting. Um, so I'll show you here. I believe this is going to be a patient who ends up with the links device. Um, for their reflux young, healthy patient. You can see very sizeable, uh, replaced. Um, hepatic there. Um, typically, we start off by dissecting along the right cruise. First, always go from known to unknown. You can see that this patient once we finished dissecting as a fairly reasonable size title hernia somewhere in the seven or eight centimeter range. Um, the nice thing about really sort of using the robots, you can really come up close and personal to the hiatus. Now that replaced vessels, something that laparoscopically would probably just sort of blast through. But I think with the robot and the precision, you're able to really navigate around it without having a sort of compromise from that standpoint, and you can see we're really sort of operating in a tight space here. Um, for my non bariatric Heidel hernias would typically use tip up grasshoppers to manipulate the stomach and then a vessel seal extend for the dissection. For the most part, you can see the anterior. Vegas is right underneath The vessel seal right there and again. Sort of running right around 2:00 is pretty classic. Now, we'll sort of do our retro esophageal dissection here, and you can see we'll expose the left crews from the right side. And we've already exposed the right cruise. So we've exposed both cura. Typically, we try to bring the post your vagus nerve up with the esophagus. Um, and I do that as much as possible in the event I ever have to come back. At least I know that'll be sort of stuck to the esophagus, and I won't have to worry about injuring it in any way. Uh, not always feasible, but I'd say probably about 80 or 90% of the time. That's the case. Um, so now we're just really sort of clearing things off. There's a post geo Vegas, since this is a lynx case. We have to drop the post your Vegas so that the length device goes between the esophagus and the post. Your Vegas, we measure how much space we have circumferential e around the esophagus. And then we also measure the circumference of the esophagus, which you'll see here, um, in a second, so that we can really sort of shape our n for mesh to match the dimensions of the Curragh Plasticky. At this point here, we're gonna close using V locks futures as opposed to using the interrupted silks like you saw before. This is a non absorbable Villach future, and you can see here that we're making sure not to tag that post your Vegas will lock the future when we used to be locked Future at the end. Um, And then, um, typically will at least put a stitch or two, um, anterior early, just to sort of let the esophagus sit where it naturally wants to sit. It's really important when you do that interior closure that you really expose where the actual edges of the cur R and I think most of the strength when it comes to hide all hernias is really in the posterior closure, as opposed to the anterior closure, and there were going to sort of lock it in place. Now, once the hiatus is closed, we're gonna sort of reinforce it in here. We sort of measured out our sheet of n for mesh coming through and we'll pull it through. Sits nicely. You don't have to sort of tackle around circumferential e. We learn that with by away with the Haida hernia patch. So, you know, typically, we'll just sort of, uh, fixated to the cruise and, uh, three, maybe four places. Sometimes we won't even break off RV lock future, and we'll just sort of continue to extend using the V lock future to help fixated in place here, we're just gonna put a couple of silks to just sort of keep it in place and not move. And then once we've fixated, the mesh will sort of continue our anti reflux procedure, whatever that may be. In this case, it happens to be a lynx device. Here. Looks like the mesh. That's nicely. We have, uh, good reinforcement of our cruel repair. At this point, we have good length on the inter abdominal esophagus here, usually somewhere between three and five centimeters, and then we place our links. Um, one of the things we found using sort of robot for anti reflux surgery is dropping our dysplasia rate for all the redo, redo forgot stuff we did. Uh, this is a study that really sort of looked at that, and I'm just going to sort of break through. But we were able to, um, reduce our disclosure rate by about 50%. And I think we really appreciated the tissue planes a little better from that. This is more of an obese patient. Um, same thing, though. We've already sort of dugout are hiatus. We mobilized their esophagus, uh, inter abdominal e at this point. And now we're just sort of taking our measurements to get a sense as to how well, fixate the mesh to be efficient with timing. Here, we're sort of doing those measurements, um, and the fellow or the resident I'm working with maybe closing while I'm sort of cutting out the mesh to match the dimensions that we just sort of measured right there again. This is a B locks future. That's not absorb all that we're using here Occasionally you may have to do a relaxing incision. Um, just because there's too much tension on the kora, Um, robotically, I think, with the ability to really sort of dissect the esophagus fairly high up in the chest and bring it down, I've not really needed to do a call is to try to increase is soft shell length intra abdominal. Um, we're probably more aggressive in terms of how tight we close as well versus laparoscopically, and I think it's something we've learned sort of over time. Um, patients are routinely sort of placed on, uh, standing anti nausea medications for a week. And in patients who have dis motility pre op, we typically even put them on steroids for a week, right after surgery to help with some of the swelling so that the dysplasia is a little bit lower. Here's another sheet of inform, and we're just sort of fixating it in the same way. I'm sorry. That's it's eight x 16 is the smallest size, so we end up using about 8x8, and we use about half of it. And there's another fixation. It really sort of sticks nicely, a lot softer than by away, so it really sort of conforms a little better from that standpoint. Um, because of the bariatric side, Uh, I do a lot of obesity work as well. Um, and it's pretty common to do, uh, sleeves, probably more bypasses. And Paris offered deals usually go hand in hand. True, Peres. Usually, we do not do a sleep at the same time, but same sort of concept here. This is a This is a bariatric patient who developed para soft gel hernia. That sort of we're fixing. Same thing, though. We're identifying the vagus nerves. Um, really, um, important to clear off the space that you're going to sort of put the mesh. The free nasopharyngeal membrane typically sort of sweeps cephalopod relatively easily when you're in that right plane. Um, if we feel like there's a lot of tension, we will, um, open up the pleura to release some of the tension. Um, as sort of, um, Easter has sort of advocated in the past. Um, as well, um, little small holes, but not too much tension. We typically won't close those and I really stressed to the residents there's no need for a chest X ray and pack you. Otherwise they're gonna be chasing chest X rays. Unless the patient's having some kind of respiratory issues, you can see it's good mobilization again of the esophagus. typically, it's about 4,4 cm five cm or so here and Then we're going to sort of close it again. It's about 80% post your closure and probably about 20% into your closure. Obviously, those ratios change based on the shape and the way the esophagus wants to sit. But to sort of determine that will really sort of grab it close to the G fat pad. And in armed four pull it out and a little lateral to see which way really sort of straightens the esophagus, and we'll sort of run this down and lock it in the same way. And you can see that the anterior muscle really looks a lot thinner than the posterior muscle, which is why probably the majority of the strength comes from closing post eerily. Um, sometimes you know it's the other way around, but I'd say 95% of the time, it's really the post your closure that gives you more of the strength that interior muscle usually looks pretty thin, and then when we're sort of done, we just sort of lock it in place. And there we go through the loop, lock it and then sometimes we'll even keep it attached. And we'll use that to help fixate the mesh. Using that same V locks future, we'll measure it the same way you can see a bigger patient obesity standpoint. So bigger liver sitting right on top of us, really sort of smaller working space here than some of the other videos the lower B m, my patients more reason to reinforce this repair with, by the way, we've with the in form. We've had no erosions of the mesh. We've had no mesh related complications. Really. The thing that we've been sort of monitoring more than anything is what the recurrence rate looks like. Um, and, um, typically, the four got patients. Um, we see them post up in about three weeks. Um, and then we typically do a one year follow up. Um, our follow up probably dies off right around two years, especially if patients are doing well. They don't usually, uh, want to come back in to see you. We sometimes try to have them at least. Um uh, answer. Sort of a questionnaire to get a sense as to what's going on. Um, we've used probably over 100 pieces. Now, inform at the hiatus that, uh, pretty good outcomes the recurrence rate looks like it's probably going to be a little bit lower than by away. Although we don't have long enough follow up to say this definitively, but so far, the outcomes are very comparable. Um, at one year, we haven't had one recurrence yet. Um, but we started to see a couple of recurrences. Um, I think a total of four now, um, and they've been sort of showed up right around 18 months. Um, three of the patients were obese. Elevated B m. My same problem we have with abdominal wall mesh that as the weight goes up, the recurrence rate goes up. Um, so I'll really summarize Here is that larger hernia is more than five centimeters and recurrences, we reinforce. We find the right cruz first, just like everything else go from known to unknown relaxing incisions. Pretty rare, but sometimes need them. If we do a relaxing incision, we tuck the mesh into the cut edge, and we typically do it on the right Cruz side. So we can really sort of hide it from there to avoid a potential hernia in the diaphragm laterally. And then when we close, we do drop the new mo. If we think the case is going to go along, we dropped the new MO. Make sure we communicate with anesthesia regularly. Um, and that's because they can get some crevice as the case goes on, especially in some of the giant parasol fix deals. Alright, I'll open it up to questions. Thank you, everyone. Yeah, point friend. Your element. Leave off one of the things that I actually your ligament off the diagram believing a tache lab. Such wow and mm hmm. Cause you can't go higher. I'm trying. Yeah. Flatow, much higher coverage. Pull the triangle back. Slipping up. Right. Actually. Place much bigger into your That's great. Thank you. Yeah, it's good. We'll do what? Pro tip. As John said earlier? I think so. It's like Home Depot. I noticed you mentioned you used the in form I P. What? Why do you feel like you need a barrier coating in this? And you know. Is there a Is there a difference? Have you seen a difference? It's a good question. And it's something we brought up recently. We talked about it. Is that by a way, we were using it to hiatus, and there's no coating on it. So why now? All of a sudden use coding? I don't have a good answer for you, except for potential medical legal ramifications. Since there is an alternative option now, in the event there is a problem, Doctor, why didn't you use the alternative that you know would not have a problem? Maybe. Although if you go back in on by way, it doesn't usually look so bad. Yeah, but I mean sometimes for Paris often. Jill Hernias. People describe using G tubes to purposely scar the stomach to the abdominal wall. So why wouldn't you want scarring up there? Wouldn't you want to lock everything in place so they can't recur? Good. This is hypothetical. I'm not the part, though. That's against the diaphragm is uncoated. So the scarring this will happen on that side, which is where sort of the scarring you want it to be. You say you use the in form my what? Large class. And why? For we know in obese patients, regardless of you, have a small you should. Mm, yeah, that use this, uh So costs are obviously going to be calculated. Important. If you're going to put a piece of mesh in for a two or three centimeter hernia, eventually, the hospital is going to say, Hey, why are you using this? Those aren't the hernia. Is that usually recur either? As a hernia size goes up just like we saw with abdominal wall. The recurrence rate goes up, so it seems like it may not be good use of sort of resources to put it up there. We do a bariatric case can competently We might sort of Make our cut off a little bit lower just to protect them after bariatric case. Because the Bmi might be 60 when we operate. It's just repair these recurrences by radiological endoscopic. Come on. Mhm. Yeah. Yeah, Well, the next day, smaller. Yes. Yeah, I hear what you're saying, but I think you're the size has to sort of factor into it. And obviously reimbursements are going to factor into it, too. It's just gonna be a lot of money to sort of put up there for really small hernia. Um, you may not get reimbursed, but what guys? For years, we get I Yeah, For 1- two senators. Okay. Smaller girl, right? Versus, like this. I mean, you know what? We're Army group. Yeah, but it's kind of late, no less and less like compared to a massive like building. Yeah, of course. Fish comes up with the open, open work here. It's the importance of following your you know, your outcomes. I mean, if I think, You know, uh, eventual hernia has a 50% chance of failure if you only do a future repair, and if the mesh drops it down to 10, 12, 15%, that's a pretty substantial savings of, you know, recurrence. But in these smaller hiatus, hernias, if the recurrence rate is 3% with without mesh and 2% with mesh, is it worth using a piece of mesh every time? You know, and especially when it's not even a pair, it's just a slide of two centimeters. Sliding hernia. That's gonna come together pretty easy. And probably not, you know so And you wouldn't go after operating those unless there's a concomitant reflux. Right? So green. Yes. Yes, despite yeah. One. Yeah, Your stomach. Mhm area of the media. Yeah, Yeah. You know, you're venturing into the retro peritoneum, and I do mean ligament releases so familiar with the space. But I think the concept is you have to recreate something of an angle, and we're talking pretty much lateral versus of posts or your angle. Um, I haven't found that it's extremely helpful to even do the lateral stitch. I think it helps with symptoms, but if they're going to get reflux, they're gonna get reflux. I think what you're saying, um, lends itself to, like, a ligament. Um, Terry's, um, sling operation, so to speak. And so I've done that on sleeve patients as well, and it helps with the symptoms the same concept and probably done a little more than a handful of the ligament. Um, Terry's. But my experience with that is that they still eventually reflux at that point. And so you haven't really fixed the dysfunction at the lower esophageal sphincter by doing any of these techniques. Hence the need for something like magnetic sphincter augmentation conversion to ruin y gastric bypass or in patients who still have their native stomach. Some kind of fun application to sort of fix the dysfunction at the l E s. I don't think any of the annual ation fixes that just might decrease some of the symptoms and more esophageal symptoms. But if you test them with Bravo, um, there's still probably end up being positive. Dr. McGinty, the Sir? No, Look at this goes away. Yeah, it goes away. Been using it for years and years. But to buy a way was never an issue. You know when you're ready. Yeah. No. Yeah. All right. Thank you. Everyone will break for lunch. We'll be back. Published December 15, 2021 Created by
