Chapters Transcript Video Video session: Open AWR techniques and best practices - John P. Fischer, M.D. Dr Fisher, it's gonna show us some of the open abdominal wall reconstruction videos. Alright, great. Let's talk about open surgical component separation. Um, an important tool. Um, kind of where we're using it in challenging patients, like some of these kind of shown here where we need to get the fashion clothes as you already heard, and also access what I would kind of call a privilege and atomic plane where we can place mesh away from the viscera and away from the outside world. I think a great article, maybe just for reference. This was from the plastic and Reconstructive surgery, a WR supplement from September 2018. That I think really kind of gives us perspective about the history behind interior and post your component. Separation is kind of the evolution that I think frames kind of, you know, kind of where we are currently. Um, with respect to, um, you know, perforate or sparing and your component separation and also the evolution of poster based techniques, I think most notably the Trans versus of Dominus release. So just kind of up there for reference. Um, So what are the goals of a component separation? You know, I think in my mind as we already heard from several of the faculties, is get the fashion clothes. That's probably the most, um, kind of fundamentally important, um, and predictive factor associated with return and regain a function and the risk of recurrence. Then I also think kind of very subtly. Um, these techniques are enabling techniques to access privilege and atomic plane. So the retro muscular subway position, um, you know, either using a traditional post to your based release or, um, you know, an extended posterior release with the tar. So it's really, really important. Um, and so kinda just put some put some data behind this really quickly before I jump into some videos. You know, if you look at this data from MD Anderson, you know, you don't want to be on that red curve. That's the bridge cases. Those all will eventually recur. Um, as well as we already heard, physics and physiology will always win. You know, you bridge a bridge, critically sized hernia defect, and you know, you cough 1000 times. You do, you know, walk a million miles or what have you, um you're gonna you're gonna ultimately fail. Um that that that bridge is gonna ultimately fail. So getting the autologous fashion closes, it's critically important also where we put the mesh. We know this, but But that retro muscular plane seems to be protective. That retro muscular or that prepared meal plain, I would kind of call them almost equivalent. Those are protected both against recurrence and see. So before we talk about the releases, we kinda have to understand the anatomy. And I think, you know, Matt laid this out perfectly. And so So I think that just thinking about the abdominal wall as a series of lamb Mina And if you know where those nerves are, as we already heard, we know the nerves are in the layer between the transverse abdominals and the internal belief. So we have to do our releases around that anatomy. So that's just simply it. Um, and I think we can close some really challenging defects with component separations, you know, closing almost unclos herbal defects. And I think restoring function. So So what is the external oblique released? Because I'm gonna start talking about that first. What that does is basically, it expands intra abdominal domain. You're able to kind of fit all the clothes inside the suitcase. Um, and it's almost like, um, as as Dr Dominions article suggests, you're basically expanding intra abdominal volume, and what it does is it allows for all the vista to go back where they should be without changing the position of the diaphragm and without causing necessarily increased intra abdominal pressure. Here's a case example, um, really big defect over 20 cm wide. That that cat scan doesn't give the size of this justice. It's it's bigger on different slices, but you can see pretty, pretty big size defect. So you get these big defects closed with external oblique release, which I think is the best way the best way in the most effective way to advance the anterior fashion. It's the most powerful tool we have because you know, when you raise a skin flap and then release external leak, then separated. That's going to give you maximum advancement, but it's also gonna carry carry with it some soft tissue risk another case example, and you can kinda just see how powerful that tool can be. You can see how far those two laproscopic trow car sites have come. It's like they're, like, miles away. Um, so really, really effective tool. Another quick case example. This patient got pre operative chemo d innovation with Botox, followed by mechanical release four timer. Current defect came up from Baltimore. Um, and big repair and and this is her post op. So here's Here's the technique. Um And so So, um, this is gonna be Let's see if this plays this place. So this is an open, open book type release. So what we're doing here is we're raising a skin flap. Um, and then we're going to identify the linear seminaries, the lateral edge of the rectus. It's a critical landmark. We're marking it. We're making it happen. Arata me in the external oblique. We're confirming that were in the correct plane. So we only want to release that one layer. It's very thin. It's not that thick. And so once we're in the right plane, we should be able to slide up, slide down, slide out, but not medial, because we're lateral to the rectus complex. And then you just unzip and the external oblique is AP neurotic everywhere but the chest, like on the chest wall, it's it's it's It's muscular, Um, and you can extend onto the chest wall, and you can certainly carry this towards the external inguinal ring. Um, and it becomes very open erotic, um, and you'll be visualizing the internal oblique muscle fibers, which are vertically obliquely oriented, whereas external oblique is kind of in fairly obliquely oriented. And, of course, rectus muscle is vertically oriented. So if you're seeking vertical fibers, your to media, we gotta go lateral. So kind of just some simple tools and and and and tricks. So Step one is released. The muscle Step two is separate, so it's a component separation, and this is obviously very aggressive in terms of the release, and you can spare perforate as you can do peri umbilical sparing, but you get The idea is, this is what we had to do to close this guy. And so the endpoint for stopping is when you start to see those little tiny perforating vessels going through the abdominal wall into the external oblique. This is a trauma patient with a significant amount of scar tissue. This is the resident now doing the contra lateral side. You can see he's a southpaw, so that's that's not me. But, you know, this guy's got a lot of scar tissue, and so we're just checking in the same way and doing the exact same thing on the contra lateral side. Okay, so So one of the things that I think we've learned over time is that you know the amount of soft tissue work as we kind of already heard. Um, it kind of correlates with the risk of wound events and complications. So so minimizing the invasiveness of the soft tissue work is going to reduce the risk of complications. But I also think, um, kind of how you prophylaxis against it matters, too. So if you raise big skin flaps, you don't just staple the skin close, you irrigate the space, perhaps even irrigate with some antibiotics, you leave drains. You do a marginal skin resection To make sure your skin's healthy, you do a layer of soft tissue closure plus minus some negative pressure wound therapy. RCT showing that you know Praveen A not to be an advertising guy here, but or negative pressure wound therapy reduces the risk of surgical site occurrences from 29% to 16%. R c t uh in annals of surgery just a year ago. So all those things when you do these massive flaps can help avoid those complications. So it's really, really important. This article, which I think is a great article published in PRS and popularized by the folks at MD Anderson. You can create tunnels or as we kind of already heard, you could try to do it minimally invasively with balloon dissection. Bottom line is the more soft tissue that you leave attached to the abdominal wall, the less likely the wound event. But the less advancement you get. So just, hopefully you guys understand it says you. Raising skin flap off of the abdominal wall actually helps you advance fashion, but it comes with a cost. It comes with surgical site risk. Um, so what happens when you release the muscles? Well, you know, we kind of learned this in plastic surgery when you do a Lotus Elise flap for breast reconstruction, which I do routinely, you get compensatory hypertrophy of the Terry's major and the separatist anterior in the exact same way as as these guys sorted this out when I guess there were there were boys. I guess Novitzky and Rosen back in the day, you compensatory hypertrophy of, uh, of the abdominal wall. So you get compensatory hypertrophy of the internal bleak and the transverse abdominal the rectus complex expands. Um, and so I think it's kind of cool. So you actually can tell patients that in the office, And when you when you're explaining well, I'm gonna reconstruct your abdominal wall To do that, I gotta divide a muscle to get the faster closer to act as a plane. And they say, Well, what's going to happen if you divide a muscle, Doc, basically, you can explain to them that you're gonna get compensatory hypertrophy of the other muscles. You're not going to lose function. You're actually gonna probably net gain function. I'm going to skip this live because Doctor Hereford already, I think, explain this most of your release when you're doing a posterior release kind of switching gears actually comes from that first step of releasing the posterior sheath. So when we're talking about how much advancement you get, most of the tar in terms of the anterior advancement comes from the initial first step of dropping the post your sheet down. There's another great article that I think kind of shine some light on which release gives you what, um, posterior releases give you post your advancement. In my opinion, a little anterior anterior releases give you a lot of anti advancement. Maybe a teeny bit of post your advantage. That's just that's kind of my opinion. And it kind of gives you a framework to work off of here. Anything about 10 cm probably needs a component separation, so it's kind of simple rule. Uh, if you need anterior fascia, usually external oblique release. If you need to post your advancement, you know, kind of post your work is probably the way to go. Here's a couple quick videos again. This is basically review the first step when you use a cadaver just just for the record, Uh, not a patient. That's an important note. Um, mobilization that post your sheet. This is kind of this is this is a workhorse technique. Just you separate the post tear sheets from the rectus complex. Stay flush on the post tear sheets so the epic gastric artery goes up with the with the rectus muscle. Stop. When you see the nerves, there are nerves. That's the head to the right. And those are those mixed motor sensory intercostal that are penetrating the internal oblique and entering the rectus complex, providing segmental innovation to the rectus muscle. Very, very, very important. You can bag one of them. Maybe you can bag too. But if you bag three, they're gonna bulge, guaranteed. So I just gotta be careful. Argument line important, because that's kind of, you know, distinguishing the transition and the composition of the post your sheath. And so, um, it's an important landmark space of ritziest and space of both gross and fairly. You guys know this from all your laproscopic work? Um, so, uh, let's see. So how do you do this? Um, I kind of just show this, but in size, the post your sheath separate, but stop. You can separate up to the Linnaeus exonerees. Look for those perforating, uh, intercostal vessels. Um, we saw this video just a couple of minutes ago. Um, but I think the benefits of the tar speak for themselves, and And if you can do this robotically even better, I think that if you can get the same clinical result and do it minimally invasive, minimally invasively you're doing a better operation. There's no question. I just don't know if you're getting the same clinical result, and we'll hear about that later. Um, post your sheath is mobilized here, and you can just see the huge plane you can put the mesh in, Obviously a big cut for this guy. We're below the nerve layer. Epic gas tricks are up and we're able to realize the post tear sheets. And so the steps for the tar um, this is the patient's right side, and we're at the almost at the linear seminaries and sizing the trans versus at Dominus and dropping down into a pre transfer salis plane. And they were able to kind of create this really, really nice parrot Neil surface where we can place our mesh on top of. And so the question is, which one is right and which one is better? If the answer is, I have no idea. Um, as long as you achieve your surgical objective and get the fashion clothes and put the mesh where you want it, I think you've won. Um, and I think the patients will do well. That probably is going to account for 90-95% of the variation in outcome is if you put mesh in you close the fashion you put match retro muscular. I think that you're you're you're basically good for the most part. Um, here is a large, um uh, subs typhoid like it's like an M one m two type defects 16, wide. The cat scan does not give this. This justice obviously looks much smaller. Um, we I think we Botox this guy, um, in a in a minute, you'll see inter operatively. What I think is is the key maneuver in deciding which released to do so. He's got open wounds. History of Mersa failed repair. He's obese. Um, probably couldn't do this minimally. Invasively. At least I don't think you probably can a lot of tension. Um, so we're just kind of marking our tentative particular ectomy. He's gonna lose his belly button. We're not going to remove the skin just yet. That's a defect. 17 centimeters wide. Subs I foid And here's the critical maneuver. Ladies, I can close anti r fashion, so I know I can do tar, which means it's nice. So if I can close anti r fashion. I don't have to jump to an external oblique release Fully paralyzed. I just checked for that. We unzip the post here sheath mhm. And we we we tested If we could close it, Obviously, we can't. It's gonna be too tight. So we then progressed to doing guitar first on the left side. We're going in front of the nerves. First, the fashion layer is the poster lamelo of the internal oblique. Then you go through the muscle of the transverse Dominus, Um, bogeys on, like, 20 switch to a right angle after we kinda have scored this. And we just lift the muscle off the parrot Neil surface. It becomes tenderness once you reach a certain point just in and around the belly button area, and it becomes totally, totally tenderness as it as you go through the argument line. And so we just kind of lift and separate the muscle. Um, and this is just the first step. And once you establish your plane of dissection, you can use a sponge stick or Metzenbaum or whatever whatever you like. So we're below the nerve layer we're gonna sweep laterally. You know, if you look superior you'll see some inter digitization with the diaphragmatic muscle fibers. And there is one of those big nerves, uh, that we preserved. We preserve the nerve, it's going up. So this is a functional repair. Those are the diaphragmatic muscle fibers. This is the resident doing the contra lateral side. Um, obviously, I'm suggesting he needs to put a little more attention The post tear sheets so you don't buttonhole it. Um, and then we go layer by layer through the muscle. Um, and this is this is the kind of the the important part, right? Just it should just peel if you're in the right place, just peels right off. That's what everyone you know likes to see. It just peels right off. And you're you know, you go away back to the retro personal space there just peels right off. Okay. And then here's C I guess I can't fast forward it. We'll just We'll just kind of let it just keep going. I wanted to show something because this guy has diced ASUs, which is very subtle, and so he's got a four centimeter diets theses. So you have to extend your dissection above the defense. Otherwise, this guy's going to get a recurrence. So So we extend superior early. We release The Post to your sheet, and we dissected a prepared meal plain in the linear album. Because, of course, we're not inside the rectus complex. So we're just extending our dissection superior li um, so we can extend our mesh way way above it. That's an important little. It's like a pro tip there, as it took me a while to figure that one out. So this is this is a great little tip to so once the post to your sheet is closed, Um, this is like a great technique, So this is like a tailor attacking technique. It takes some forceps and just kind of put the skin together and staple it. Then you can market. And what that does is it kind of defines the redundant skin. This is kind of a common plastic surgery trick and see how we're just marking it. And then we take the staples out. You know, we kind of know what we can close. There's a great way to clean the skin, the skin up before you close. Excuse me. Hopefully you guys can see that you guys don't need to see me cut skin out. But, um, you know, that's kind of the idea. Get, you know, nice, nice bleeding skin before you close for these big cases, it's definitely worth it. Um, you know, because I just I don't think you want to be dealing with chronic wounds. Um and so I kind of maybe kind of put things in perspective, kind of which released. You do. Um, you know, Todd already shared this, but basically the reason why and your components or associate with wound complications because you have the rate of skin flaps. So if you can do it very carefully or preserve perforate urz, you're probably going to normalize risk in his data. Confirms that as so does this paper, which was published out of the University of Washington, Uh, in plastic and reconstructive surgery. Atar versus a perforated sparing and tear component. Separation showed no difference in complications. So what that tells me is simple as it's the skin flap in the mobilization of the soft tissue that accounts for that risk. So so answer component is not bad, you know? Don't be afraid of it. Um I think it's It's totally fine, um, to do. Um, just gotta be very careful with the donor site. See if I can play this video. I'm not going to go into the the, uh, slideshow books. I think that the videos crash this whenever it's plugged into HTML, which is so bizarre. This lady has a bridging biologic mesh and she's got, you know, pain and an unstable wound that opens and closes. And she's tortured by this and so, so pretty. It's a pretty big cases, some of the biologic that we took out, and so we do the same thing. I just show the video real quick cause it's kind of a fun case. Her rectus complex was super narrow. Like, I'm not kidding you. This is This is what erectus complex looked like as as opposed to like a an obese male like my rectus complex. Like that wide. No one laughed. That was not after all that bacon I eat. It's probably like this line now, and so this is this is my resident to go leave to, like, reattach someone's finger or something. So I'm here with a medical student, drawing out this release and then doing it with this young medical student. And just look at how narrow the rectus complexes. That's really the size of the rectus complex like that was it. And so you can't close that you can't put matching that space. So naturally you're gonna tar this, Uh, so we're right in front of the nerves and the exact same thing in the video. Um, just score that layer. I put a towel in the belly, Um, and just layer by layer. We're just doing it and kind of one of my favorite attendings. When I was training at Penn, Ben Chang said, There's time to go slow and there's times to go fast. This is the time that you go slow like slow, methodical. Establish your planet Next section when you peel the tissue up, you can go fast there. But this is the time to time to go slow. There's no need to rush here. Just must have a fast forward button. We're rushing here now, Um and so we just establish our planet dissection right angle, just like the previous video. And we'll get right into this plane and you'll see kind of the benefit. This was This was totally unclos herbal. You couldn't close this post to your sheath, and when the video concludes, hopefully you'll be able to appreciate that The post tear sheets is totally liberated, completely liberated. This lady has had a ton of surgery, too, so this was pretty painful. That's that maneuver. You just you just peel with your hands and you know that trans Verses of Dominus peels right off of the Parrot Neil surface. There's there's two planes you can be in the pre trained for Sallis plan. There's a little kind of advantage in there. I like to kind of keep that down with the peritoneal surface, if you can. I just want to pause and just just show you. You saw how far those posts to your sheets were before the same patient. We're pulling the towel out, and we have. We've closed that post your sheath, which is just wonderful, and you know that's her clothes. You can take down the round ligaments. I think I always do it. I don't know if it's bad or not. You're just just gonna clip them, retire him and cut him and you can open the space and it kinda is later. I don't know. I think he's on camera. Yeah, I think it's okay. Why not? Um and so this is just a piece of cynic or that we put in this patient. And again, I would just reiterate some of the comments earlier. This stuff is really freaking strong. Um, you know, some of the strongest stuff that I've used is really thick biologic. There's, like, a four millimeter thick biologic out there. That's really, really strong. This is really, really strong. Um, and so that's what we used here. Um, and it fits great in this plane. I'm gonna show some data on my cynical experience later, but I think a nice result for this patient, this is a tricky case. And, uh, I usually don't do super fixation. Um, you know, I just I don't I don't I don't do it if I don't have to. She needed trans factional fixation to medialive erectus complex and to be able to close the entire fashion. But frankly, I haven't done this in a long time. I usually do fixation free repairs. So a tar and just lay the mesh in, get the fashion clothes and spray some fiber and gloom. We've published that no difference in recurrence. The caveat is, as long as the anterior fascia can be closed, tension free. And then this was her post operative result. And that's it, I guess. All right, Right. Yeah, yeah. Any questions? John Gray, talk. I have a question for you. Do you ever do just a unilateral release at any point? Yeah, it's a It's a great question. I think I've done the unilateral releases before. Um, and I don't think it's a bad thing. Um, you know, I think that if you if you if you feel like it's helping you enough with one release, I think that it's it's fine. Um, I have done, you know, tar on one side and external oblique on the other. I think, as Matt had said, kind of unusual to do it. I kind of now, basically, I just keep it very simple. I'm gonna either do a bilateral tar. I'm gonna wrap the patient in a big piece of mesh if I know I can close the anterior fascia or I'm gonna jump to, um if I have to typically, like an online type situation, external oblique release and Usually that's in the setting of, like a particular ectomy, Um, or I guess, the other alternatives where I just do a standard retro muscular repair. Those are kind of the three variations that prepares that I do open. And, uh, usually it's a function of how big is the defect? Um, and kind of inter operatively like Is the post tearsheet available? Um, they've had a lot of certain. Sometimes sometimes it's pretty beat up, and it also kind of a consideration, too, is if you're doing a big panic collected me. Everything's right there for you. So it's kind of becomes really easy to do kind of an external oblique release, which I think you have to be very careful about. You have to kind of responsibly do it. You have to own the soft tissue space that you create, and if you don't own it, you will be punished for it. But if you do, it works out. Okay. I'll be honest with you. I think you know, extra police had a really bad rap, and I think probably shouldn't have it was gonna be really judicious will meet when we address the donor site. Bill. Yeah, process. Three makers? Yes. Where you're sure? Yeah. And yeah, favor more than really here, Reconstruct post here. Looks like back. Yeah. So the situation I think that really doesn't happen. It hasn't happened a lot for me. Usually, if I commit to Atar, I'm always getting post tear sheets close. It would be weird that I couldn't. Or if I'm having trouble or there's holes, you can use momentum or hernia stack or by a recordable kind of patch to close post your sheath. I think that if the poster she doesn't look right on my God, man, it's gonna be painful to close. I would just kind of gravitate away from that plane and gravitate probably towards like an only base plane, which it doesn't sound great, but it works just fine if you close the anterior fascia. If it's a really, really big defect, and I'm not sure if I can get the anterior fashion clothes, I usually shy away from post to your base releases because, in my opinion, the fundamental goal is getting the anterior fashion clothes. And if you do tar and even if you do a small bridge or a full bridge, it's not function well. And if you look at Rosen's data, they just publish it a year ago, where they bridged a bunch of people with massive defects and guitar and couldn't close the entire fashion like a 30 35% of recurrence. And so I would argue that if I had done full anti air released on on Lay my recurrence probably between 10 and 15%. So so again, it's just I don't think my approach is right. I just think it just kind of what, What? What? What makes sense to me in the O. R. And it's a really, like the The external oblique releases a super easy, super fast approach. But yeah, okay, a lot of you guys are Judas Flat, these kind of big come on and so smart. Anybody used that? What had the skin when Sure, guys, basically, what you're buying mash for smaller defects as just that I haven't done that. I mean, I think the issue with that is if you reinforce a hernia defect with like human skin and kind of the same issue is like an alligator like, And so we studied Allen from years ago, and the the elastin content is very, very high. So it'll stretch and it may recur. And so I mean, I think that, you know, that works for, like, breast reconstruction and kind of reinforcing the lower pool for breast recon and using, like, a like a dermal, like a human dermal base. Reinforcement for that. But but I think it doesn't work for absolutely, from what I've heard, um, you know, so So probably I probably say, Probably not. But yeah, please. So, bigger cases lot of yeah, separate. Reinforce that work. It's pretty. Put it straight forward at work. Rest. Yeah. Yes, yeah. And it's great. It's probably best repair you can possibly do. I mean, it sounds like you're describing a Ramirez repair, which is a open interior component with a retro muscular subway, which is like, it's like maybe the gold standard. I mean, the question. Yeah, and so So I guess. No, not at all. I mean, I mean, I think you can extrapolate. I mean, the Cobra data that was referenced earlier. Obviously, it's it's kind of, you know, off label to put something in a contaminant field, but we do it anyways. So you're talking about clean cases. I think the recurrence with retro Moscow subway with bio and the Cobra City was like 12 or 13% you know, two years. So it's a really, really good. So I think if you get retro muscular, absorbable mesh, I mean, you can get your recurrence rate, you know, anywhere between five and 10%. About 2 to 3 years posed up, which I think is pretty darn good forever. We have Yeah, right work. Okay, cool. Alright, great. Thank you very much, Dr Fisher. Okay. Published December 15, 2021 Created by
