Open Parastomal Hernia Repair with KeyBaker Mesh Placement Technique

CHAPTER 1

Okay, everybody, my name's Michael Rosen. I'm a professor of surgery at Lerner College of Medicine in the Cleveland Clinic at Cleveland, Ohio. I'm gonna share with you guys today an open parastomal hernia case. I think this case has a lot to teach us about abdominal wall reconstruction, some of the challenges that can be around patients that have stomas during abdominal wall reconstruction, and some of the options and some of the innovative ways that we're trying to reduce recurrence rates from these type of hernias. There's also some, we'll have some discussion about what is the best option, whether it's minimally invasive or open, and how to kind of overcome some of those challenges in the operating room. So, well first, we'll start talking about the patient. So this patient is a 79-year-old female with COPD. She's a little overweight. Her BMI is 33. And I think you'll probably see that in the operating room, some of the challenges of operating on folks with a little bit extra adiposity. Her history, she had multiple complicated childbirths at a young age and had a rectovaginal fistula and she's had three to four local advancement flaps that ultimately have all failed. And about two years ago, she had a laparoscopic-assisted end colostomy where they did divide the sigmoid colon to not do a lot of resection. So we may or may not find some of those challenges in the operating room as far as getting the distal segment off. And that was all done laparoscopically. And now, she has a fairly large parastomal hernia. We'll look at her CT scan right now just to go over some of the challenges that we see. So this is her CT scan. As you guys all know, this is starting up with the chest and as we come down, you'll see her only abdominal surgery is laparoscopy. So no other scars other than one in her midline. And you can see here, she is here, she has a small hernia in her umbilicus where they cut down and you'll see her, this is her sigmoid colon, parastomal hernia - it's fairly large, a lot of small bowel within it. You can see right here is the stapled-off distal sigmoid colon. And that's usually a good clue that things are gonna be right at the brim there where these two things are separated. And also, just one other little key point is if you trace up her proximal colon, you can see that it kind of makes a fairly circuitous root up. And so in the operating room, one of the key things hopefully we'll be able to demonstrate is how important it is to mobilize up that sigmoid colon to allow us to do our Sugarbaker-type approach for this. And then really nothing down too low. Again, always should consider whether or not a minimally-invasive approach is appropriate. I think she's on the cusp for that. She has a fairly large defect. You know, this could be done as a laparoscopic Sugarbaker, no question about it. In my hands, it's a little bit less reproducible that way. I think my recurrence rate's a bit higher doing it that way. So my preference usually is to do this through an open incision. But certainly have to take into consideration that now we're putting a midline incision on this patient to fix a parastomal hernia defect. And one of the ways that we try and adjust that is on the other side, we'll do a retromuscular dissection to allow us to cover the midline with our piece of mesh. But again, all of these have to be weighed as pros and cons of coming up with the best approach for these patients. So, what we'll expect to see in the operating room is we'll start the case, we'll make a midline incision. It is important that patients understand this has to go several centimeters above the umbilicus in order to get enough space to work above the stoma and below the stoma as we work around it. Because one of the unique challenges doing retromuscular surgery if you leave the stoma up in the abdominal wall, you need to be able to dissect the retromuscular plane without injuring the intestines that are there. You can just take it down and then bring it back up. That's another perfectly acceptable way to do it. My preference, if possible, is to leave it up because it keeps the case really more of a clean, contaminated, almost clean situation versus if you take it down and we're typically using synthetic mesh, a little bit more risk of wound morbidity and challenges around that. But those are all things that can be kind of a game time decision depending on what we see and how difficult it is to get everything outside of the stoma. More often than not, things reduce pretty easily. We'll see what we see in the operating room. And then a lot of this is just about, again, traction, counter traction, exposure of the abdominal wall. And then the other thing, we have quite a bit of experience doing parastomal hernias. And hopefully by the time this is out you'll see recently we completed a randomized control trial of 150 patients with stomas that were randomized to a retromuscular keyhole or a retromuscular Sugarbaker procedure and a two-year follow-up, and almost 92% of the patients was available. And unfortunately, the recurrence rate was the same. It was about 16 to 18% in each arm. So really no advantage to doing one or the other for that. And so, our group since then has modified the retromuscular Sugarbaker approach into something that we call a KeyBaker. And that basically takes advantage of both the keyhole approach and the Sugarbaker approach. And so hopefully, if everything goes well in the operating room, what you'll see me do is I'll leave the stoma up, I'll do my retromuscular dissection, I'll work around the stoma, and then I'll make a lateral slit in the posterior rectus sheath and the peritoneum about five to seven centimeters, close that back up so that my stoma makes that gradual S, and then when we put the mesh in, that will accomplish the Sugarbaker. But often if you stop at that, and this is what we think was wrong with the originally described retromuscular Sugarbaker, is it's almost like a turtleneck where the mesh kind of crimps up at the bowel and you don't really have any lateral coverage. So we made a modification where we slit the mesh and then we wrap the tails around the backside to make a true keyhole. That can also be done if you take down the stoma, you could then make a small cruciate incision in the peritoneum and then a small cruciate incision in the mesh, bring it up through there and then allow it to do the Sugarbaker. So it's both a keyhole essentially at the peritoneum and a Sugarbaker in the muscular aperture as it's going out through the anterior abdominal wall. And that would be my plan. Obviously, with any operation, things can change. We can come up with different findings, we have to manage the stoma. And I would say the last piece, as you'll see in the operating room for all these patients, we mark them with at least one side opposite and preferable one side above. I happen to know this patient only had one choice for the other side, and that would be less than ideal for me because bringing the sigmoid colon to the right lateral abdominal wall is difficult to do a KeyBaker or even a Sugarbaker. And the same thing, bringing an ileostomy to the left side limits your ability to angulate the bowel. So again, if I'm forced to bring it to one - to the other side, I often will just do a keyhole in that setting. So that's it for this patient. That's kind of what's going through our mind. We're gonna go ahead and do the operation and we'll come back and talk about what we found.

CHAPTER 2

So one thing, you know, she doesn't have an incision here, so it's a little bit, you know, could this be an MIS approach? The reason it's not an MIS approach is the hernia ends here. It's really hard and the hole's pretty big. It's not impossible to do this minimally invasively, but just it's less than ideal. So, I think this is their best shot at a good repair. We might end up just doing a unilateral retrorectus over here and TAR there. We'll kind of see how it goes. But you need a big enough incision to make this bend. So if you're gonna do this open, you gotta commit to exposing it. Otherwise with the stoma there, there's no way you're gonna get it adequate. Adsons pickup times two. But this, if it was a smaller, isolated stoma, hold opposite me, then this would be a good candidate, I think, for MIS approach. See how the hernias right here already? Yes, I see. Dry lap, please. Keep it up there. Come on up here. So what do you think you'll be doing with the other hand? In there and pull, all right? There you go, see? Just a little bit. Everything goes smoother. That's the belly button there. Go ahead and pull, pull, pull, pull. Big sponge in there and lift up. There you go. You can always use the belly button. It's like a landmark to sometimes cheat. See how you could be just a little bit more effective? Like, you're not quite thinking like a surgeon, right? Like, that's the hernia so protect it, right? You're kind of there but you're not like, "Okay, what can I do to make this operation?" You're just kind of passively hoping I get you there. Bovie. It's like really when you watch, when you're operating, it's almost like my hands are in your way. I'm trying to help you so much. You'll never just see me kind of disinterested. I'm trying to make it better. And that often - just that drive is what makes you become a good surgeon and just fighting for every little bit. Like, let me correct you for not doing the right thing than not doing anything. Okay. Okay, T-berg, please. Pull here. Ready. That's good. You're good? And there's the hernia sac. And we're gonna try and stay in the midline and not drift off into that hernia. Let's get down here. We're always cognizant of the bladder. We take it in layers. Okay, yep, hold up right here. So here's gonna be the hernia. A couple of Kochers, please. Move your finger. Uh-huh. Kocher right there.

CHAPTER 3

All right guys, so here's the parastomal hernia. We're gonna make this all come out. And then we're left with colon here. And one key little thing for doing what we're gonna do here, you must mobilize this colon really well so that we don't leave a bunch up there. So you'll see, I'm gonna really kind of try and straighten it out a bit. You don't need redundant loops in there? Yeah and I gotta, we're gonna do what's called a KeyBaker, which we like to call it. Yeah, yeah. And this is kind of taking advantage of the Sugarbaker. But we have a study that will probably be published by the time this is done that shows that the electromuscular Sugarbaker really doesn't work that well or no better than a keyhole, so we modified that to take advantage of both. And if you watch those other videos, you'll see here I'm trying to stay on that line. I'm not just dividing stuff. So we're gonna take advantage of both the keyhole feature and the Sugarbaker feature. Okay. So unfortunately, we've got the remaining bowel that's close. So this is the distal because they just divided it. I don't think they resected much mesentery. So we'll see if we have to do that to do what we need to do. So here is the distal sigmoid, right? And I might need to mobilize this off just a little bit. Yep, Bovie. Just to get it to separate off here. Do you have a Tonsil? And a 2-0 tie. So this patient, we'll talk about it and we talk about this, she's had a rectovaginal fistula. So this is her distal sigmoid. And you know this one, I would not do what we're gonna do if it was a loop. It's too hard to fix these as a loop. I would convert it to an end or do something different. So, I need to get this out of the way for my mesh to work. Scissors. Try that there. And the other kind of, I can't stress it enough, this has to all be mobile. So you gotta take your time and mobilize this and get it all the way around and mobilized, so that when I work in the abdominal wall, I know what's safe. So right now it's kind of one of the most important parts. You can't compromise getting this back edge. I think actually we might not be quite in the right spot. So that's the skin, that's the edge of your thing here. And then this should be pretty takeable. Blood supply to this guy is where... All right, there's that guy. Hold this right here. I'm gonna mobilize the distal segment off just a little bit. Pull a little bit harder. All right, here comes some blood vessel. All right, so that should probably get away from me there to let that fall. And then I need to make a quick assessment here of how far over I can get this for my eventual Sugarbaker. And it looks pretty good. If you can see that for the Sugarbaker aspect of this, I need this all the way over there. And I really, really, really... Right back here, get your hand right here. No, this way. Yep. I need to get this freed off. No, get your hand effectively there. See, I'm trying to get this back edge. I need to get this back edge freed off so when I come around the back, I know I'm safe. I'm gonna go this way now. I think this is just hernia sac to be honest. Okay. And one thing you could do is just take it down, right, and then bring it back up, but to me, it's a little bit cleaner if we leave it up. So if you watch here, right, like I know now I'm gonna be able to take this bowel and make it go up here. So I'm gonna keep in my mind's eye, I want this at about the 2:00 position. So that's the way my KeyBaker's gonna be. And then, here's the hole. That'll probably end up closing this way. And let's let the bowel pin over over there. Okay, anything on your side? Not really, huh? Can I see four Kochers, please? I'll take a wet blue towel. You're gonna take these two in this hand. I'm sorry, in that hand. This hand holds these two. Okay. And then, could you hold the bottom two up for us, if you don't mind. And then, we'll do our blue towel. Okay, I'll take a ruler, please. Relax, relax, relax. So we'll say 7 by 14. Okay, could he take the Bookwalter post? Can we get a hand with the Bookwalter post, please?

CHAPTER 4

All right guys, so now you can kind of see - there's the stoma, there's the hernia. This is gonna be our - Sugarbaker's gonna go off this way. Can I see a Bonney, please? So the hardest part about this is you have to be able to do this operation with the stoma up there. So, you know, to not get stuck or get caught or get into the bowel, you have to, like we did in our other case, if you take a look at that video, where we gonna encircle the enemy. George, can you fix that bottom light? There? Yeah, there. Huh? Nope. So we're gonna look for that muscle. I lost it right there, so I'm gonna retry it up here. Yep, there we go. And again, I'll always keep in mind, between these two is where my stoma is. A bunch of Kochers, please. And these Kochers will also mark my hernia area. One more Kocher, please. So again, we're gonna go find a lateral edge. Okay, just looking for a little pocket up there. Haven't quite seen the nerves yet. Let's try that here. Okay, so we're gonna kind of work our way around. I haven't quite gotten as far lateral as I want to be 'cause I can't quite see my landmarks. But way off down there, you can kind of see there's inferior epigastric and some intercostals. I'll come back to that later. But I need to be down there eventually.

CHAPTER 5

All right, that looks pretty good. I'm gonna see if I can make it happen with the TAR here around the sides. We'll see. That's probably her nerves right here. And I want to take a second and make sure I'm lateral enough. There's a nerve. Because if I'm not, I'm gonna start making a bunch of holes and it's gonna get really complicated really quick. So there's probably a main drag nerve right here and that's a back branch. That's a real nerve, I can push him over. So I'm pretty good out there. So I'm gonna go ahead and take my posterior mallet right in front of these nerves. You can see I'm right about where we lose the transverse abdominis. There we go. You can see there's peritoneum. So we'll just sneak up onto this guy. And I can't stress enough, the key is not what's happening here, it's my left hand is smoothing everything out and providing counter traction. There we go. Can I see a Kittner, please? I'm gonna try and work this little spot right here. This is really good. I don't know if you guys can see this or not, but this is posterior sheath and this is peritoneum. And it seems like right here, we're on peritoneum, but you see how there's transverse abdominis there so we're not actually. Right angle. We were on the fascial part of the transverse abdominis, so I need to get below that, there we go. To get myself on the peritoneum. Can you take that guy there, George? See if you can buzz me. You can see there's an extra layer. Can you see that back there? Just go halfway. Okay, let me see this guy here. I am gonna keep working to get behind the stoma. And now, I'm gonna be right here around the backside of the stoma. I am gonna just leave myself a sponge back there. That'll be my target when I come around. And if you can see this, there's gonna be my inferior epigastric right up here. So I know if I let that stay up about one centimeter lateral to that. And if you can tell here, see that's actually arcuate line right there. So I know I'm below the arcuate line. So I could take advantage of anatomy and know that right here, if I just cut one layer... A lot of people think there's not another layer here, but there is. If I just cut this transversalis fascia... I can work my way back up. And now below the arcuate line through the transversalis fascia, I can be in my plane. And there's where I was, my sponge is gonna be right there. I can feel it. I don't know if you guys can see it, but it's right there. And I'm gonna come on down - on my psoas which will be right here. And then right here is my round ligament. I'll take clips, please. Because there's my inferior epigastric. Big clips. And there you go. Now, I got the pelvis and I'm around the backside. And actually here I'm a little lucky 'cause it's through the posterior rectus sheath. So, see, okay, just so everybody's oriented, this is retrorectus, and I'm gonna complete my TAR. I've got the stoma in my fingers, there's my sponge. That completes that. So now I'm all the way around the stoma and then all I gotta do is join up my planes.

CHAPTER 6

George, hold this right here. Can you fix that light too? And now because I mobilized the stoma, this is where people kind of freak out, they start resecting hernia sac and stuff. I wouldn't do that. What I'd do, I'd just open it. So now I see the bowel. I see the edges of my hernia. I mobilized everything up really well at the beginning for this exact moment. I come right down along the edges. I control the bowel. Pull the bowel towards you. So again... Just use your finger, just pull it. Again, right, I'm gonna come right along the edges and the hernia's up here. And you see there's my other edge, so I'll just kind of keep going. Release everything. And this is why you had to have mobilized that piece of bowel so well at the beginning so that this part's safe. And now if you look, right, we're all the way back there. All the way back here. And here's my stoma free from all of this.

CHAPTER 7

So in order to do my KeyBaker, which is half keyhole, half Sugarbaker, and just to demonstrate for everybody, we stopped doing just Sugarbaker, retromuscular Sugarbaker, whatever paper that will eventually be published. It shows as no better than a keyhole. So we've decided to combine both of them, and it's a modification we call the KeyBaker where we make a lateral slit and we'll Sugarbaker the bowel but then keyhole this lateral aperture. So everything's gotta be lined up really well in order to do that. So, as you can see now we're all in one space. So now George, you're gonna hold this here. And remember I said I want to go at about the 2:00 position for this bowel to lay out. So hold on, let me go up this way. So I'm gonna now make, I call this like a VY advancement flap. I'm gonna take a 3-0 non-pop in just a second. And I want this as lateral as it will go. But I do think that this amount of overlap is really critical. You know, I mean I think you want to go as much as you can, but there is a little bit of a trade-off between overlap and erosion. So you know, you can only go so far for the bowel. I like to kind of get it all the way to the retroperitoneum if I can. Another thing you can do if you want is you can take the stoma down and you just make a cruciate incision out here through a cruciate in the, let go, in the posterior sheath and bring it up. And that sometimes that's even a little bit nicer of a KeyBaker. So now you can see I got myself all set up here. I'll take the 3-0 non-pop in just a second. And I'm gonna just bring this back to offset these two holes. And everybody always kind of wonders how tight to make this. I don't have the perfect answer to that question, but you want it tight. This is another point of obstruction you can have. Hold that bowel up with the DeBakes, maybe with DeBakeys. Because this is one kink point essentially. Just lift it up. Let's see if it's too tight or not. If I made this too tight, I'd probably just extend my slit out laterally. Can I see three, cut the tail, can I see three number 1 PDS's on the not-so-big needle? PDS? Yep. DeBakeys for me. Hold me, follow me. And we're just gonna run this back up, and that this will give us our tunnel for the Sugarbaker. You can see we got a good five, six centimeters of tunnel there. So that should hopefully be enough. And again, I think you want as much as you can. But always remember that a Sugarbaker is essentially a balance between, same for a keyhole, right, is erosion versus recurrence and it's impossible to hit it perfect. If you make them all big, you'll never have an erosion... Cut the needle, tie it up. But you might get a bunch of recurrences. If you make it too small, you're gonna have some horrific erosion. Scissors. So just to give you guys kind of another view of what this is gonna look like. So that's from the bowel coming up, it traverses there, goes in. I'm gonna have my Sugarbaker stop here and my KeyBaker wrap all the way around the back there. And the problem with the Sugarbaker as it's kind of described is you get like a turtleneck issue here where it bunches up and you're exposed out laterally.

CHAPTER 8

Can I see the local, please? So we'll do a TAP block real quick. Local. Okay.

CHAPTER 9

All righty, let me just think about this for a minute. All right, so we're gonna kind of maybe try and accentuate it a little bit more by bringing it over this way. I'll take the suture, and they'll be the number ones. Now one little trick about this is put the suture closest to the bowel first. Same thing if you do it minimally invasively. A lot of people like to sew towards that, but the problem is this is the one you might hit the bowel. So you want to see the bowel best and sometimes you can't quite see it as well. Mm-hmm. Schnappy. Another stitch. Needle back. That looks pretty good. Hold this guy there. I'll take a Bonney, please. Needle back. Then we can double check, make sure we're happy. Mm-hmm. So fits a finger. I like it on the more snug side. And so just to reiterate, because it might be a little hard to see without the - as good of retraction as we have, but the mesh is gonna go like this. I'm gonna get it right here, I'm gonna slit the mesh, and wrap my tails around like a true keyhole, not a cruciate, okay? But you could have made a cruciate if you'd have brought it up here, but then I don't have to bring the bowel down. So now, I'm just feeling around here at the other side real quick. Am I good to go up here? Am I going to go too crazy up there? Yep. Now you can kind of tell I got my midline to come back to the middle, so I'm probably not gonna have to do a TAR on the other side. I'll just be able to go retrorectus.

CHAPTER 10

So now on this side, because we don't really have a midline component, this is about just kind of, Bonney, please, this is about reinforcing the midline just so we don't get a hernia there. So because my posterior sheath's gonna close, I'm probably just gonna go retrorectus here. So this would just be a basic retrorectus dissection. We can open up... Let's just do one drain and Parietene 30 by 30. So for mesh, we're gonna use a medium-weight polypropylene. We've done a lot of different studies. I think if I'm gonna create this pocket, I'm gonna use a permanent mesh. We've looked at it, it doesn't look like, you know, still the recurrence rate's high regardless of what type of mesh you use. It's just part of it. Our recurrence rate for kind of Sugarbakers is about 15, 18% We'll see about with KeyBakers. We're currently evaluating this long term. Couple Kochers. One more. You can see the anatomy nicely here. There's your arcuate line. There's probably nerves coming up about right here. And again, just out of a matter of habit, there's your inferior epigastric. Always one centimeter lateral to that is your nerves probably, like, right there. There's a nerve. I always want to take it until I see the nerves just so I know I've got, you know, my maximal overlap. Okay. So here, I'm gonna do my little move. There's my inferior gastric. If I come medial to that... I'll take a big clip, please. A little medial branch. Another one. Uh-huh. Do you have a Crile, please? Crile. George, can you? Yep. If I work medial, I should, just like we know for our lap inguinals, get right onto Cooper's. You can kind of see it off there in the distance. Let me see if I can get a light in there for you guys. So right down there is Coop's. So if I just work my way across Coop's, and then I come up on this side, all I'm left with is just a little bit of flimflam and I'm good. Can I see a big Rich, please? I'll give you guys just a quick look in the pelvis. Yeah, right there. So that's left Cooper's, right Cooper's. We've already taken. There's inferior epigastric, psoas. On this side, we're gonna stop at the retrorectus plane, so we're going to do that. You can tell we'll be just fine with our posterior closure and we'll get nice medial coverage there. Okay, why don't you... Actually, I'll swing on that side.

CHAPTER 11

Okay, two Kochers, please. So now we just gotta get a way for the mesh to land on the top. So, if you look here, we've created this window. So just for everybody's orientation, this is the midline, that's her right rectus. So I'm gonna drop the insertion of the right rectus muscle right off the midline and I'm gonna leave all this fat so I don't have to deal with it later, which is essentially the falciform, and I'm not gonna injure the midline. Same thing on this side. Right at the edge, take it off its insertion. And now we're well above the incision, almost to her xiphoid, that's plenty. And we'll have nice pocket to do all that.

CHAPTER 12

George, jump in here real quick. I'll take a big Rich, he'll take a local. Do your TAP block. I'll take local. Just get right near those nerves in the rectus. Just don't hit the inferior epigastric, okay? Get lateral, right? It should be right at the edge. You just, you can almost see the nerves. Just pump it right in the nerves.

CHAPTER 13

Okay. Needle. 2-0 for me. All right, we're gonna go maybe like roughly there. Go ahead and tie this guy up. Now, it's gonna be a little bit tight. And you don't have to do all the whole top part to me. As long as it's extraperitoneal, we're fine. Go ahead and, can you get that, yep. Scissors. And just watch it come together, yep. Then I'm gonna take, can I see two number ones on the not-so-big needle for fascial closure? I'm gonna run it. All right, so remember we talk about both hands always doing something. See if your hand just did this, now take your left hand, pull that. Okay, T-berg, please. I will take care of this side, yep. Mm-hmm. Okay, I think that'll be good. Let's just stop there for a second. Now, we'll take out our towel. And I always just use this to help me. No, don't pull up so hard. No, no, no, no, no, no, no, no, no, no, no. You're gonna pull... This up? This guy here. And my side here. Yep. And then, I'm gonna bring this over there gently up. Yep, don't pull too hard. I'm gonna come back this way, hold on. You're gonna put this guy? Yep. Tie him up. Mm-hmm. Two needles back. Okay, can I see two Riches, please? I'm gonna see what you got here. Let's see if you can show it to us or not. I'm gonna put you on either side of that stoma, so I don't want you to kind of bugger up the stoma.

CHAPTER 14

Okay, so you can see now that's a nice view of everything closed. Can I see the mesh, please? Okay, so this would be a 30 by 30 medium-weight polypropylene mesh. Often, I always use mesh as a diamond. I think in this situation I'm gonna use it as a square. So, this you'll see here is the entire problem with the Sugarbaker as described, is when we want to get all the way, oop, oop, oop... When we wanna get all the way out there, you'll see the stoma kind of makes the mesh buckle up a little bit. I'll come back and deal with that in a minute. Mm-hmm. So like this is what a normal Sugarbaker would look like. We kind of got the mesh around, but like right here it's all buckled up, right? And that's the problem with the retromuscular Sugarbaker as previously described. So our modification, we just call it a KeyBaker, is we're gonna bring that right there, okay? We'll have enough mesh. So I'm looking at the stoma and I'm gonna go ahead and cut my way right up to it. I'm going to give myself a little cruciate. So you see I maintain my principles of a Sugarbaker by having this part. But now the KeyBaker is that I'm taking the mesh and I'm gonna wrap it around the back. We don't tie these tails together, we think that might lead to more erosions. And then, we'll just trim it up just a little bit. So again, the tails now are wrapped around the back. So we have ourselves a keyhole out here laterally and a Sugarbaker right here, and that's what's giving it the name of the KeyBaker. All right, we'll just trim off - scissors. I'll take the drain next, please. You want the trocar to stay on? Yeah, the trocar stays on, yep. Okay.

CHAPTER 15

So there you have it. We'll take the... And I always put the drain in the opposite side. Both of them, if I need two. I think for her, one will do. Put the light in there for me. Scissors. Sharpie back. We'll take a Tonsil? And then he'll take two Criles.

CHAPTER 16

Can we do a little T-berg? I'll go this way, you'll go that way. Two Criles, number 1 PDS, please. Think about that. Is that the best you can do? No. Come back a little bit. No, no, come back right... There you go, right? Nope, you're blocking it, nope, nope. You see that, right? Bonney. Do you have a snap? Thank you. I always do 11 if I run it. Scissors. Go ahead and follow me. Makes sense? Key is always the setup, the setup, the setup. That's why you're kind of, even assisting, is do you get in the surgery that it's all about making it easy, right? Not I refuse to struggle, I just won't. I'll take a minute. As soon as I find myself, and try and fix the situation instead of just trying to barrel my way through it. So that's kind of the mentality, how do I make this easier? And here I'm starting at the bottom 'cause these stitch are gonna get close to the stoma. So I want to see them. So I want to end well above that stoma 'cause your bites, the last few bites you put are harder to expose, so you never want to be where it's dangerous. Let's get these guys there. We can level out the table, please. That's great, thank you. Table down, just a touch. That's great. Just for video purposes. The other, like throughout this case, if you saw, I'm constantly moving the bed position, always trying to maximize my exposure, get the viscera out of the way. And I'll never end at the belly button because that's where it's always hard to get good bites. So here, I definitely wanna come up above it. Mm-hmm. She did have a little umbilical hernia right there, so that gives us the midline component. Okay, he'll take a stitch. Too much grabbing and regrabbing, man. Go, one time. Go. Too much like oomph, oomph, just grab it the right time, the first time. Set it down and tie. Don't make a tail too short. Don't make it too short, don't make it hard on yourself. Too far to go. And importantly we have these patients marked, always be able to move it to the other side. It's much harder to move a left stoma to the right. It's harder to move the ileostomy to the left. Particularly if you want to be doing a any kind of Sugarbaker approach or KeyBaker as we showed you here. So you gotta kind of be thinking about that. If, sometimes if you have to do that, it's gotta just be a keyhole, which is probably fine too or as good as anything else. I think time will tell how good the KeyBaker is. I'll take a 2-0 Prolene, please. Tie them up, yep. And that's it, guys. We're gonna close up skin and be done. Needle back.

CHAPTER 17

So she should be NPO. Okay. One little thing about managing these people post-op, there's usually like a little early obstruction at that angulation, and so you wanna go slow with these people. They don't, they're not to be fast-tracked. Do you want them, do you want us to put an NG in? No, no. I don't think she needs that. Go ahead and cut right here. And the bulb, and 3-0, 4-0s. I'll take the 3-0 chromics. All righty, guys.

CHAPTER 18

Okay everybody, so hopefully you enjoyed the operation and you got to learn a little bit about parastomal hernias. Again, just to recap, I think number one, we need to make a reasonable incision in order to get exposure. Again with the BMI of 33, that incision needs to be large enough and that should always be weighed in whether you're choosing an open or a minimally-invasive approach. As you saw, because we did have to make a midline, although she did have a small umbilical defect, we were able to cover the whole midline by taking the posterior sheath down. On the other side, if there was excessive tension, I could have always done a TAR on the right side as well or if there was also a midline component. Otherwise, in the side of the stoma, you got to see that KeyBaker-type approach where we're able to do the Sugarbaker with the lateral slit around the mesh to get excellent coverage. As we talked about in the operating room, there is always a balance with these operations with mesh. And this is true no matter what mesh you use, where the mesh must come in contact with the bowel. And it's important for patients to understand this. So there always is that balance of not making the hole too loose where she is, they're inevitably gonna get a recurrence, and not making it too tight or that kink too far with the Sugarbaker, where eventually you're gonna get an erosion or potentially early obstruction. But importantly, whenever you're doing a Sugarbaker or a keyhole, early on, there's always edema around that bowel. So the post-op management, you must be patient with these patients. And again, we don't always put NG tubes in them, but we will wait, wait until at least gas, if not stool. And we do not put these patients on the ERAS program. About 20% will get an ileus. And so very importantly, we just need to be patient. Patients needs to understand that and plan for at least a probably 5- to 7-day length of stay unless everything goes very well. Otherwise, that's it for the operation. The choice of synthetic mesh, we've published on this extensively, we use a medium-weight polypropylene mesh. Some of my partners are experimenting with heavy-weight mesh. But again, I think the data supports medium-weight mesh right now. And again, like everything, all these meshes can erode, but we haven't seen it any higher than with biologic mesh or absorbable synthetic. So our choice is permanent synthetic mesh. And that's it. I hope you enjoyed it.