Open Incisional Hernia Repair with Mesh and Unilateral Posterior Component Separation with Excision of Unstable Scar

CHAPTER 1

My name is Hany Takla. I'm a general and bariatric surgeon here at Mass General Brigham Wentworth-Douglas Hospital in Dover, New Hampshire. I'm a general and bariatric surgeon. I do a lot of complex hernia repairs and abdominal wall reconstruction in addition to bariatric surgery and foregut surgery as well. So the case that we have today is actually a very interesting case. So it's a 51-year-old gentleman that had a gastric bypass many years ago and developed some issues from that. It was done all at an outside hospital, but had an internal hernia that was strangulated, so he had to have a laparotomy for that. So he had a big midline incision and they had to resect the portion of his small intestine and did anastomosis. That was all done elsewhere. And he recovered from all this and subsequently developed a hernia through his midline incision that was actually repaired before with a biologic mesh. So he kind of developed a recurrence. So I saw him about four or five months ago and we sort of talked about it a little bit. He had also from his weight loss, he had some, you know, excess skin and the scar in the midline was a white scar. So I had him talk to Dr. Bean our plastic surgeon. So we sort of decided to tackle this in two ways. One is to excise the midline scar or the white scar and some of the excess skin and also repair the hernia. For the most part, I do these repairs in a minimally-invasive fascia, usually robotically. But for this patient, we chose an open approach because we were going to do the scar revision and excise the excess skin so it made sense to basically use the same incision and do that. Now one important thing to point out for these complex hernias. So the posterior component separation was first described by Yuri Novitsky in 2012, and that technique I think is very, very important in the armamentarium for surgeons that do complex hernia repairs because it allows you to close big defects without tension and be able to set the mesh in the retromuscular space, which is a well vascular space. So that allows for better mesh integration, et cetera. So for this patient, usually for all of these ventral hernia patients, especially the complex ones always get a preoperative CT scan to assess and measure, you know, the size of the defect and basically what we're going to deal with anatomically. So when I first saw his CAT scan and usually we measured the size of the defect and it was about nine and a half centimeters. So from a logistics standpoint, usually defects or hernia defects that you know are above five to seven centimeter, most of the time you cannot, you know, close those primarily, up to five centimeter, you could potentially close them primarily, but when it starts to get above five centimeter, then you'd have to start thinking about using posterior component separation or actually retromuscular repairs first. And then once the size of the defect gets higher than, you know, 10, 12 centimeters, then that's when you think about doing either a one side or a unilateral component separation. When it's above 12 centimeter, then most likely you would need a bilateral component separation. One thing is important also when you're looking at these CAT scans is to, you know, sort of try to predict whether or not you're going to need a component separation. And a good rule, there's a rule called the Carbonell rule where if you measure the size of the defect and the size of the defect measures equal to or more than twice the size of the retromuscular space on one side, then most likely, you're going to need a component separation. Now this patient had that 9.5-centimeter size defect and each side of his rectus muscle was about eight centimeter. So he kind of is at a point where you think most likely he'll need a component separation. That's why planning the surgery is important. So when I talked to the patient, you know, I realized after looking at the CT scan that he's gonna need at least one side of the transverse abdominis muscle released at least on one side, if not both, just because his defect size is nine and a half centimeter and each of his rectus muscle is about maybe eight or less. So the size of the defect is big and we wanna really avoid tension as much as possible. So the first step of this separation is to actually do a complete lysis of adhesions. So you need to basically take down all of the adhesions or scar tissue from previous surgery. The reason that's important is because if the small intestine or the large intestine is stuck to the perineum on either side of the abdominal cavity, that actually will reduce the ability of the peritoneum, or the posterior components to slide over. So usually the first step is to get safely into the abdomen, whether that's, you know, minimally invasive or open. The second step is to take down all of the adhesions that you could see or could take down safely, whether also that's open or minimally invasive. That's step number two. Now step number three, once that's all done and you sort of made sure that you know, the bowel looks okay and there's no bleeding of any sort, then you start to basically dissect the retromuscular space on each side. So the way to do that is that you'd have to open the posterior sheath a few millimeters away from the midline because you want to give yourself at least a good five or six millimeter of linea alba to close in the midline. And then the trick is to try to open the posterior sheath and that goes north and south, so cephalad and caudad, until you open the whole posterior rectus sheath and then you start the retromuscular dissection. So the retromuscular dissection is easily done either bluntly or with electrocautery or a combination of both. And where you want to reach in the retromuscular space is actually the semilunar line. And there's a few landmarks to reach the semilunar line because the semilunar line is one of of the stabilizing lines of the abdominal wall. So you don't want to cut through that. You really wanna preserve these lines, linea alba, as I mentioned, and also the semilunar line. So a good landmark is actually the neurovascular bundle. So the neurovascular bundles come out between the internal oblique and the transverse abdominis muscle and they sort of penetrate into the rectus muscle. So these will come out actually at where the semilunar line is. So when you've reached these neurovascular bundles, that's a good landmark to stop there because that's probably where your semilunar line is. So you don't wanna go lateral to that. So we do that on both sides. And after you're done with that, you sort of assess the tension and that's kind of what we call a Rives-Stoppa approach, or retromuscular repair without a component separation. Now if there is still too much tension or the defect is big, then that's when you need to do a component separation, whether on one side or both sides. When you start doing these components separations, it is very, very important to familiarize yourself with the anatomy. So there's a lot of courses out there that sort of talk about this, but basically when you start the component separation, there are two ways of doing this and in component separation that we're dividing is actually the transversus abdominis muscle and what that allows you to do is that it allows you to slide the posterior elements of the abdominal wall medially and it also gives some release to the anterior elements of the abdominal wall so that you can close the midline at the end. So usually you can start either top-down approach for the transverse abdominis release or a bottoms-up approach. I prefer the top-down approach because the transverse abdominis muscle is easier to identify in the upper abdomen, so you're cutting through muscle fibers so it's easier to see and identify. So for people that are beginning to do this operation, it is better to try to start from a top-down approach and that's how Yuri describe this operation to start from the top down. So basically when you're doing that, you have to divide the posterior lamella of the internal oblique first and then you'll start seeing the muscle fibers of the transverse abdominis. And then usually we use a right angle to sort of define the fibers and cut them with electrocautery. And you want to try as best as you can to preserve a layer of fascia transversalis on top of the peritoneum, especially in the upper abdomen because the peritoneum and the upper abdomen is actually very thin. So you'll wanna have a little bit more substance to that because that's gonna be covering your mesh. So what we usually do is that we would try to reserve a little bit of the fascia transversalis on top of the pertineum, especially in the upper abdomen. Once you're divided the transverse abdominis muscle in the posterior lamella of the internal oblique the lower part of the abdomen, you're gonna find that the transverse abdominis muscle starts to become more of a aponeurotic part rather than just muscular fibers. That's important to understand because as you go down in the lower abdomen, you'll feel that the transverse abdominis muscle is getting thinner or becoming more aponeurotic and that's very normal. That's normal anatomy. And then once you do that, then you start to get in between basically a plane between the fascia transversalis and preperitoneal space and the transverse abdominis muscle. And most of that dissection is actually done bluntly. And you'll see in the case that we're doing most of that dissection bluntly, it's very easy to do and if you get in the right plane, it's usually avascular and the dissection is very non-bloody at that point where you basically try to, you know, separate and it's kind of a sweeping movement where you try to push down on the viscera and the visceral sac and then try to push the transverse abdominis muscle away from you. And there are two important points here when you're reaching the upper abdomen and the lower abdomen. The upper abdomen, there's a few landmarks you're gonna wanna be careful with. One is that when as you get to the falciform ligament, you try to use that as your crossover to the opposite side where you try to dissect in the preperitoneal plane in that location, add the falciform ligament, so that's your friend. And also one important landmark is that you know, as you get in the upper abdomen, you're gonna see that the insertion of the fibers of the diaphragm and transversus abdominis muscle interdigitate in the upper abdomen. It is important to make sure that you don't divide the fibers of the diaphragm and you keep the fibers of the diaphragm up on the abdominal wall as we're gonna show in the case. And then in the lower abdomen you also wanna use the peritoneum of the medial umbilical ligament similar to when you do an inguinal hernia dissection to be covering the mesh in that area. So you want to transition from that preperitoneal plane that's deep to the transverse abdominis muscle to the preperitoneal space and the medial umbilical ligament, that can get you all the way down to the space of Retzius, down to the Cooper's ligament up in the caudal direction, and in the cephalad direction, that dissection can get you all the way up to the central tendon of the diaphragm and that gives you a very good mesh overlap cephalic and caudad.

CHAPTER 2

I'll take my local, please. Lidocaine with epi. Procedure starts at 10:50. Another. All right, very good, I will take a 10 blade, please. Cutting. Incision at 10:51 Come down this side. Bovie and an Adson, please. Yeah, you can go ahead and put under little tension there and we're ultimately removing this other skin edge, so it's nothing critical. Okay, let's come down the other side. There we go. I'll see that marking pin again please. Mark the edge of this defect here. So I can make myself aware. Bovie. Hernia sac right under there. Let's go ahead and open these lower limbs here. Let me have Lahey thyroid clamp, please. Lahey tenaculum, if you don't have that, just gimme a... I just want something to get a hold of this scar. It's not really necessary. Stay really superficial over this hernia here. There's one spot here that almost looked like sac. That is sac, I think, curved Metz, please. More superficial than I thought. That's okay. Is that sac? Yes it is. The sac is stuck down to the skin all the way up. Dr. Bean, can I get any sutures open for you? I am gonna want a 3-0 Monocryl in a bit just to, I'm just gonna tack that little hole in the sac closed. Can I get a 3-0 Monocryl, please. Thank you. Mostly above it now. That's your first specimen. Just call it midline abdominal scar, unstable scar. I'll take that Monocryl and a DeBakey now, please. Right on the knot, back to you. All right, let's open up our limbs here and get down to fascia now. Get your DeBakeys and grab some of these please. Now start to elevate this flap as I find these little perforators, you grab them. Yep. Down here we're coming to known to unknown so we know there's no hernia or bowel down here. And then we're gonna sneak right up on our hernia. So when we get there, we can go ahead and divide this and just kind of start laying things back out of our way here a bit. And it makes it easier. Let's have a couple of double prong skin hooks please. And I'll take Metz and DeBakey, see if I can find the plan around this sac. Looks a lot like it right there. DeBakey. We just laid out our hernia sac on this side and starting to take it down and once we get it identified, we'll come back from under here and lay out the fascial edges. Not as stuck down as I thought it might have been. Once we get outta this midline scar. So there you can see the hernia sac developing here. May I have an Allis clamp, please? It's kind of fortunate that's a nice heavy sac. Can tug on it and get some tension on it. Doesn't rip on you. Yeah, some of them can be very thin and kind of papery and they just fall apart but it's pretty good. We're almost down to a hernia. I want to get this upper edge off though before we go play down there. If you wanna come about right there. That's perfect. See that's a fascial edge coming up right there. So let's just do a little more of this, DeBakey please. I got it. Okay. Allis clamp. That's the upper margin of our hernia. Hold down on that one right there just to keep me out of trouble. Another little hernia, tiny but it's there. Let's have you put your skin hooks in right there again. I'll clear off this other little one about right there and right there. Dissect out this little one here too. DeBakey, please. I'll take the Bovie for a moment here. Ask the hernia about a margin. Curved Metz. Big hernia here. There's another little one and a half centimeter like right up here. See there's our fascial edge right there. So we just wanna clear this off some more. Show you another trick here. Could I have a tonsil clamp, please? When they kind of retract back in the fascia like that, just grab a tonsil and reach right in there and get it. Fresh sponge, please, pretty good. Yeah, you got that one? Oh it's the other end of that one right here. Just kind of pull, there you go, straight up. The other end of it too. And we're well beyond our hernias. See what's bleeding right up here. There. Can I get more laps, please? All right, there's still something oozing here. Something hiding up here. It's right there. Okay, let me have a moist lap, please. You and I are gonna swap sides. I'm gonna do this same thing over here. Put something damp over all of that. Yeah. Like that 15 blade, pease. I'll leave a nice little cuff here. And I'll take an Adson and curved Metz, please, sort of tilt the whole business over toward me. Until we mobilize the belly button, we really don't know if it's viable or not. It may be all splayed out in this hernia. So now we're back down on our hernia side. Okay, let's switch your skin hooks over here again now. See that's a normal fascia again there so we just gotta get it released from the scarred stuff up here. I'll have you hold up right there and I see if I can discern a plane in here. Looks like right there. Abdominal wall dissected off and the entire periphery of the hernia. I would say his belly button is gonna be extremely questionable because the entire, we might be able, actually lemme see if I can dissect that out a little more. Adson but it's really splayed out on the hernia. You get another Adson hold it up like that. There's still a stalk there. Yeah, once Dr. Takla does his thing, we can always look at it. If there's question, we can use the Spy machine on it too. Let's have some damp sponges to lay over our flaps here. Take another sponge over here, Kendall, and lay it over all of that, irrigation on there and keep this stuff from drying out. So one big hernia, belly button, another small hernia here, and it feels like another little one trying right up there. And with that I'll leave it in the very capable hands of Dr Takla.

CHAPTER 3

Okay, so you guys kind of dissected this sub-q and this is the hernia sac, can feel the edges of the defect here on this side and on that side. So the reason we chose to do sort of a retromuscular component separation for this is because according to the Carbonell rule, you know, in order to avoid a component separation, you'd have to have the hernia sac or the hernia defect, the diameter, it has to be less than twice the size of the retromuscular space. So this hernia defect is about nine and a half centimeters, and his retromuscular space on each side is about maybe, when I measured I think it was about eight or so. So it's kind of equivocal. That's why I wasn't sure if we're gonna do you know, either just a retromuscular, or one side component separation, or both sides. So right here we're gonna try to get into the abdomen is the first step. Try to lyse all of the adhesions and dissect the retromuscular space on each side. So that's kind of what we're gonna do. Lemme try to get in here. I try to usually go into a virgin area of the abdomen that I don't want to get into the sac because there might be bowel in it. This is preperitoneal fat here. So the reason it's important to do a complete lysis of adhesions is because that actually helps mobilize the components of the abdominal wall a little bit better. That's probably thick peritoneum. So now we're in the abdominal cavity like right here. So extend this way. There we go, I can see some adhesions there. So this patient had a couple of previous laparotomies. One of them was for a strangulated internal hernia. He's had a history of a gastric bypass and then had a strangulated internal hernia. So that was done open. They did a bowel resection so it had to do a laparotomy and then he also developed a hernia from that. So he had a previous hernia repair with mesh. I'm just trying to carefully go in through into the abdomen. Just some interior abdominal wall adhesions here. I'll take the Bovie. Just taking down these adhesions. Figure out the plane. Can I get a DeBakey? All right, so just kind of looking inside there, I can see the sac, I can see a loop of bowel that's kind of stuck there. There's also the remnant of the biologic mesh. I'll take the Bovie. Okay, so this is all free. What I'm cutting through is the hernia sac and the previous biologic mesh that was placed. Doesn't biologic mesh dissolve? Usually it does but I mean it leaves kind of scar tissue behind. Oh okay. So just so we see, so now we have to open it til the edge of the muscle. You can see this is rectus on your side. This is rectus on my side. This is lower edge of the defect. So we have to open it. We need to get the preperitoneal plane to kind of do the crossover from one side to the other below the arcuate line. And that should take you to like space of Retzius eventually. So that's good there. So that's kind of the lower edge of the defect. So let that be. I think we need to take those down. I'll take the Bovie. So a sac has a lot of omental adhesions in it. So just take those down. I see a big vessel here so I'm just gonna be cautious. I try to preserve the sac as much as I can 'cause sometimes it can help you with mesh coverage if you don't have enough posterier sheath. It seems like we'll have enough posterier sheath here, but still, it's always nice to preserve some sac. I mean a big part of these component separation procedure is the lysis of adhesions. If the lysis of adhesions doesn't take too long, the surgery itself doesn't usually take very long. So now it seems like we took down most of the adhesions. Can I get a Metz, please? You know when these patients come back for bowel obstruction for example, it's important to know the reason for the bowel obstruction. Is it actually the hernia or is it intra-abdominal adhesions? So this is looks like his JJ, some interloop adhesions, always with taking down these adhesions, it's always important to do traction, counter traction and so that you know where the highest tension is. So that this is where you need to cut. So it looks like here. So that's the JJ, it's kind of dilated. The JJ usually dilates over time. Get the Bovie for a second. There's greater momentum there. There is the rolling, right here. So it's rolling. It's this way. A lot of interloop adhesions. Maybe hold this. Actually this is the retro-Roux space, a Peterson's space, so they closed it so we don't want to reopen it. Goes into this anastomosis. So it must be the JJ. Okay, hold this, okay, so here's what I think. So that's the Roux limb, goes this way, this way, and then they did a small bowel resection before. So I think that's where that is. That's BP limb goes into that anastomosis and then keeps going, going, going, going to this, which this is the JJ and this is the common channel. It's right here. All right, so just a few more adhesions to take down. At least we know what the anatomy looks like. And can you guys get us some Seprafilm too? Maybe if we can get four sheets or something like that. Four sheets of Seprafilm. Four sheets of Seprafilm, okay. Yeah. We're slicing some more adhesions at the common channel. Hopefully after we're done with this we'll be done with this part. And for the lysis of adhesions, the easiest thing is to do traction, counter traction, sharp dissection, in the right plane, it should be relatively avascular. It goes into the terminal ileum there, it's a cecum. I think that loop just stuck here. Get the Bovie. So I think we took down all the adhesions. I'm just gonna lay the omentum over.

CHAPTER 4

All right, so now we're gonna start the retromuscular dissection. So I'll start on my side. You can see this is the edge of the rectus here on the other side. And this is the edge of the rectus on my side. So it kind of, that's the hernia defect. And up here, this is the falciform. All right, so, so we're gonna try to preserve the hernia sac a little bit. So I'm gonna try to get in here. I'll take a Bovie. Get in between the hernia sac and the posterior rectus sheath, connect them just to keep it just in case I need it. Okay, can take that off. Take it off? Yeah. All right, so I'm gonna try to find rectus muscle. You can see the contractions there. So I'll leave a little bit from the edge to open the posterior rectus sheath and see that's the rectus muscle there. Just try to use this hernia sac and just disconnect it from this area. All right, I'll take a snap. So this is the posterior rectus sheath. This is rectus muscle, I'll take a peanut. Can I get a pack of peanuts? So when you do your eTEPs you're in between this? Correct. It's a tiny space. It is, huh? That's why it's not easy. I'm gonna try to push the rectus muscle. And out. I'm just gonna keep pushing a little. See that's the rectus muscle there. Can I get an Allis? I'm just pulling on this side Kendall, if you wanna take the Bovie and just... I'm just opening the posterior sheath along the whole length of the the incision. I think we can get a preperitoneal plane here. Do you want me to get any PDS or Prolene? Yeah, so we're gonna need some like 2-0 V-Loc and 0 absorbable V-Loc. Okay. This is the hernia sac. I got rid of it because it's kind of in my way. I wasn't able to preserve it, which is okay, I think, if we do our bilateral TAR it should be okay. So I'll just keep going with this. If you wanna take the Bovie... Just opening the posterior sheath all along there. As we kind of reach this upper part and also the lower part I'll show you. But this upper part we're getting to the falciform ligament. So this is where we need to do the crossover to the other side. I'll just go a little more north until there's very little posterior sheath left. So this is the falciform. I'm just gonna cross over to my side sort of in the preperitoneal plane. Okay, I'll take that peanut. So this is preperitoneal right here. This is the transverse abdominis here, so I'm just gonna... Resect the rectus off of it. All right, you can see this is the transverse abdominis muscle. It's the posterior rectus sheath. I'll take another Allis. So now we need to dissect all the posterior rectus sheath off the rectus muscle all the way around the incision. All along the incision I mean, so the lateral end of the dissection should be the neurovascular bundles because that's where the - or the semilunaris is - we don't want to injure that. Stuck here. I dunno if this is port site. So then neurovascular bundle here. I'm just kind of sweeping the rectus away a little bit, sweeping it kind of movement, you can see that's kind of a bundle right here. Try to preserve it. So same thing on this side or on the bottom part that we have to cross over to the other side in the preperitoneal space. So we'll do the same. So this is peritoneum there. I'll take Bovie. That's kind of part of the plane that we dissected early on. I have to be a little careful with the epigastrics. You have an Army-Navy? Okay, so just gonna do this. So this is getting us into the space of Retzius. You can see that's the rectus muscle there. Just pushing it away gently. Can I get a peanut? That's pretty good. I'll take the Bovie for a second. I think that's neuromuscular bundles there. Okay, so maybe here. A bundle here. Okay. Let's leave that one. Okay. Yes, are you ready now? So now, need to start dividing the TA on this. I'll take the Bovie. Yeah, so this is TA where we basically need to be medial to the neurovascular bundle. So, here, here, away from these because the semilunar line is right here. Okay. So and then we're gonna curve the cut edge of the posterior sheath a little bit to the midline. So like this. Now it curves towards the midline. Yeah. It's like robotic. I'm just kind of marking it. I'm just gonna have my finger behind it and then pulling on it a little bit going medial to the neurovascular bundles. Just marking it where I'm going to be dividing. Okay. All right, can I get a right angle? All right so we're gonna start from the top down. Okay like this, so if you wanna take the Bovie from me. This is the transverse abdominis muscle we're dividing. It's always easier to go top down because the transverse abdominis is very well defined in the upper abdomen. So it gets you in the right plane. You can see this is the transversalis fascia. Okay. So in the upper part it's important to be careful with the diaphragm 'cause the diaphragmatic fibers attach here, I'll show you in a minute, but what I'm pushing away is the fibers of the diaphragm. Yeah, I'll take care of it, you can take off. So that you don't cause a more hernia. Have a good rest of your day. Okay, let's get back. See these fibers are the diaphragmatic fibers. So you don't want any muscle fibers on the floor of the dissection. It always has to be on the ceiling. And what kind of hernia did you? Okay, so it's a diaphragmatic hernia. I'll take the right angle. You can see my finger behind here. Just gonna keep going down until we reach the arcuate line basically. Can I get another lap pad? Okay, I'll take a Kocher. And in the lower abdomen there's some peritoneum so it's easier to - can I get a peanut? So now I'm gonna try to get into the preperitoneal plane here and caused a hole in the posterior sheath. So I gotta fix that later on. And then can I get a snap. Get the Bovie. So let's try to find, so this is the arcuate line right here. See it? That arch. So we need to go there. So right here and connect that. Take a peanut. Can you pull that up a little? Okay. Okay, hold on one second. Kind of in the groin area there. All right, so let's let that be for a minute 'cause we caused the hole there and let's go back here and try to find the plane this way. Can relax on that. Can I get a Metz, please? I'm trying to get into the preperitoneal plane but the perineum is very thin so trying to see if I can get some transversalis fascia. Okay. Now in the preperitoneal plane it's kind of doing that blunt, pushing the transverse abdominis muscle away. I'll take the Metz, please. Alright, so it's a good plane there. Just gonna try to make it with the bottom. Just trying to create a cave behind the dissection and just the peritoneum is very thin here. So again, this is the line of division. I have my finger behind it and I have the peritoneum on my side. And then the transverse abdominis on Kendall's side. Take the Bovie. Just kind trying to sweep as much peritoneum as I can towards me. That second hole, it's right here. All right, can I get that Army-Navy? Do you have a Rich or something? Can see as I'm pushing away the transverse abdominis muscle right here with my index finger. That's the retroperitoneum that I have on my left hand. These are the cord structures here. So take a feel. So if you take a feel, that's the ASIS there. It's right there. The ASIS. Yep, that's the retroperitoneum. So I'll go back and sort of do this. Be careful a little bit with energy here because the colon is like under my left hand. So you want to use less energy and more blunt dissection. Just getting into that pretransversalis plane. So I have more substance on the peritoneum to be a little thicker. You can see I'm pushing the TA away. Just pushing the transverse abdominis, mostly blunt. Just trying to create a cave behind here. Take a peanut. I'll take the Kelly, I mean sorry, right angle. And do you have a blue towel that I can put inside? So I usually like to put a blue towel here to protect the viscera, the colon so that it's behind when we use Bovie. So this is courtesy of Dr. Yuri Novitsky who invented this operation. Let's put the Rich in. So this is pushing the TA up, transverse abdominis and then peritoneum and fascia transversalis are down towards me. Sorry, know it's a cave but... Trying to bring that back. Okay, we'll take the Bovie. We just finish dividing the TA here. Hold this. And remember that landmark that we always talk about. So this is the rib cage if you feel here. This is the costal margin, right? There's always a fat pad, which is this yellow thing between the TA and the fibers of the diaphragm. It's a good landmark. You can take this up to the central tendon of the diaphragm if you need to. So again, this is the TA here, just pushing it away. You see Kendall, all of these are diaphragm. I don't know if you can see it, this is diaphragm. Okay. And this is TA. And that's the yellow fat between the two of them. Can I get a suction and can I get a Yankauer tip on? All of this is diaphragm fibers. Get a DeBakey please. Buzz me. That dissection should be able to take you back to psoas muscle if you need to, which really don't need for this but can feel the bony landmarks in a second here. Bovie. This is transversalis, so I'm just gonna transition to preperitoneal plane. Make it easier, so transversalis fascia, preperitoneal plane, and transition into it because in the lower abdomen, I don't need transversalis. That makes it easier to sort of push it away. See here, all the way to the patient's back. Okay, all right, so take a feel, Kendall. So, this is actually his 12th rib right here. The tip of his 12th rib. Yeah, and the ASIS is here. So you're literally in his back. And this is a transverse abdominis muscle. So a good critical view of the transverse abdominis release is to see naked fibers of the transverse abdominis muscle, which is here. Okay. This is cut edge of the TA muscle. These are the neurovascular bundles here. We preserve them. This is a semilunar line. You can see, and this is all preperitoneal fat. And you can see how much medialization this is the preperitoneal, the peritoneum and posterior sheath kind of. This is the divided posterior sheet and this is all peritoneum. So we sort of are able to medialize it all the way to here. So now we're gonna do exactly the same thing for the other side. But let's close these holes first. So I'm gonna need some 3-0 Vicryls. I don't see any holes back here. So we'll just close these ones that we can see. Then maybe I'll take also a 3-0 V-Loc. Sure. Nine inch. Can we also have a 3-0 V-Loc, please. And a 3-0 V-Loc? Yep, thank you. So what do you think compared to robotic? What's easier? Well robotic's much easier for me. Yeah. I mean I think it's easier for everybody. Don't you think it's easier? It is easier, yeah. I think you see a little bit better. Like here most of, as you saw like most of the dissection is like blind blunt dissection kind of. And the exposure is not easy. But it's cool to see it open. Yeah, it's the same thing though. Didn't really do anything different. How long did it take you to learn how to do? We did some in residency and training and then, you know, we didn't do any in fellowship but I did take, after residency I did - we, I did them only open in residency. And then the American Hernia Society has a course they teach robotic component separation. But you have to basically know how to do open first. So I went to one of those courses when I first started practice it was like 2015. It is very important to close well these holes in the peritoneum and the posterior sheath because it can cause an intraparietal hernia where the bowel gets stuck between the posterior sheath and the anterior closure. Lemme give you this. Is there something? Yeah, this one here or I'll take - yeah, if you would yeah, I'll take another Vicryl. All right, can I get the 3-0 V-Loc? So why couldn't you have done this robotically and then had Dr. Bean do the skin excision? You could do it on two stages. But then the patient wanted one stage. One. We have actually another patient coming up that we're doing two stage. So I'll do the hernia first. Robotically? Yeah. And then Dr. Bean will... But then they have to wait a certain, they have to wait at least three to six months. I think we closed all the holes. So for these absorbably barbed sutures, we sort of lock it and go back on itself 'cause it can unravel, This little hole. Can I have that Vicryl back? If this is anything, maybe reinforce it. Okay, all right, so now we're gonna do exactly the same thing on the opposite side.

CHAPTER 5

It's like deja vu. I will take the Bovie. Can you get a peanut please? All right, I'll take a Kocher. Say it again? Kocher. Some here. Let's excise this. And the same thing first removing the sac here on the side. Do you wanna send any of this? No. Trash. You can see rectus muscles here. So posterior sheath, just opening. Can I get a peanut and a couple of Allises? Can I get DeBakey, please? So this is diaphragm here. TA there on the... And then the fat pad. And then this is the fat pad. Yeah, so this will stay on the abdominal wall. So we're gonna go here and curve it this way. So this will all stay up on the abdominal wall, the diaphragm and the fat pad. You can see here you could almost do it with just one unilateral. So maybe we don't need to release the other side. So we'll see how it goes down here. Just kind of opening the rest of it. Does it matter if you start on the left side of the right side? No. Get a peanut, actually I have it here. So again, rectus muscle, just push it away, away. So you see I have right finger in the retromuscular space on your side and then left finger and this is midline. Okay. So we just gotta be pre peritoneal in the midline and retromuscular on each side. So this is midline, we're gonna lift that up. Again, put one finger on each side. Just try to stay preperitoneal under the linea alba as much as we can. Usually lower midline there's not much diastasis, the rectus muscles are joined together in the midline below, below the umbilicus, usually. Fresh peanut, please. You see the epigastrics on your side are right here. See, your epigastric vessel. So those you always want to keep on the rectus. Keep them on the rectus. Can you guys do a little bit of a T-burg, please? Okay, that's good. All right. All right Kendall, so if you put your hand here, you'll feel Cooper's ligament. What's that? Cooper's ligament, bone. And that's rectus muscle. Rectus muscle, right? So this is where we do an inguinal hernia exposure there. So that way the mesh would reach down to here. Okay. And then we just need to sweep that below the bladder. So you hold this. Can I get the peanut please? Thank you. Just pushing the epigastrics away. So have you hold this, see this side? Just kind of doing the same there. You can see Cooper's ligament right here. I can actually see it. See that white thing over here? I know it's a little deep. So now we're gonna have to assess if we need to do a transverse abdominis release on your side too. Just kind of assessing how much tension there is. We can get a little more length here first. You have that peanut. That's where we start. Okay, let's go up top.

CHAPTER 6

All right, so now I have to assess the tension in the posterior sheath and also in the anterior sheath. So this is our edge right here. So, it's actually pretty good. We do this and then can I get a Kocher, please? It's always a subjective thing to, you know, assess tension, like how much tension you're pulling. And that's very hard to do with the robot, but you can, you know, sort of gauge it. It's not too bad, not under too much tension. And then this is the most middle part, so that's pretty good. Not under too much tension. And then the bottom part. Not under too much tension. So now basically like we don't need to do a TAR on this side 'cause we don't need it. We have, you know, enough mesh overlap behind and then you know, we're closing without tension so there's no need to do a transverse abdominis release on both sides. 'Cause also the defect is nine and a half centimeters. So that usually doesn't need bilateral. So that's good. That works in our favor.

CHAPTER 7

So, do this. So we're gonna start closing the peritoneum if you wanna do a prelim count. Let's look at all this bleeding. Quick count, we're getting ready to start closing peritoneum. All right. Oh, definitely something bleeding. Can we get some warm irrigation too? Okay. All right, well let's irrigate and see what's going on. And then you guys have that Seprafilm too? Yes, we do, we got four sheets for you. Perfect. That's weird, huh? Warm irrigation. Okay, go ahead. And can we get the other suction, please? I'll take a dry lap. All right, can we get more irrigation? Can we get more irrigation before you guys count? Can we turn the section up too if possible? Just take these, get the Bovie. Thank you. More irrigation. I'll take some more of that saline, please. I'll take suction. Irrigate on my side a little bit. Can I get a sponge, please? Or a lap? Can I get a 3-0 Vicryl? Down here. Can you divide that with the Bovie? All right, I'll take it. Have DeBakey? Just looking for hemostasis before we start closing the posterior sheath. Okay, I'll give you needle back. So let's look for that area that had blood in it - get a dry lap? All right, so let's just walk it back - can I get suction? Suction on the sponge here. This is the pouch, this is the remnant stomach. With the Roux limb. Can I get the Metz, please? I'll take the Metz. It goes into that small bowel anastomosis there. Goes back to the BP limb. Some extra adhesions here. Some extra adhesions. Get the Bovie, please. She said you're getting ready to start closing. Yeah, pretty much the component separation on this side, but this side it's just the tension is not too bad. Yeah, so it's pretty good. Just had like a few adhesions. You gonna put mesh in too? Yes, yes, yes. Yeah, so maybe another like hour. I'll keep an eye out. I think maybe another hour or so, I think. All right. Hold this. This is the mesentery closure. So I'll probably just leave it alone. Just make sure there's no bleeding anywhere. All right, so again this is TI. I'm just making sure that, you know, everything is hemostatic. It seems like a permanent suture here so I'm not gonna take it out because it probably is closing, you know, the mesenteric defect, okay. All right, I guess we're good. Put the omentum over. All right, can we get that Seprafilm?

CHAPTER 8

That material was what? What does that mean? It's seprafilm. It's made of collagenase. So just prevents adhesions. Just in case we need to go back here for any reason. Last sheet on the field. Thank you. Let's see here, there we go. Can I get the Bovie for a second? The last part.

CHAPTER 9

Okay, all right. So we'll take the 2-0 V-Loc. 2-0 V-Loc. So we're just gonna release the preperitoneal space up top, that in the midline. Okay, I'll take it. Can you guys get us more of those 2-0? 2-0s? Yeah, the V-Locs. Any of the hernia sac that was removed? No. Can we cut that? I'll take another one. Let's start from the bottom. Now it's just closing the posterior sheath. You can take that out actually. Okay, you guys bring in that 30 by 30 Bard soft mesh? And then you can put the Tisseel to thaw too. Take another 2-0. Can I get an Army-Navy? Yeah, thanks. I'm just gonna do a count with Chelsea. And can I get the Bovie? Okay, so this is gonna be like this to close this part. I think there might be a hole on this side right here somewhere. All right, we'll take the 2-0 again. Okay, 2-0, just a little larger of a needle. Just keep closing this. I'm just saying just keep closing here. We're also gonna need to change gloves when we're putting the mesh too. Okay. Okay. All right, can we get some irrigation? No, that's fine. Okay, continuing a quick count. We give them that blue, we gave them that blue towel that was inside. I can't remember. I think I didn't see it when we were doing the... I didn't see it when we were having the bowel. Can you just check with them to make sure? Can you guys let us know when you're counted and everything? All right, I need to switch places with you I guess. So again, this is kind of like showing the critical view of the TAR or transverse abdominis release. This is the transverse abdominis muscle. Naked fibers. This is the cut edge here. You can see the neurovascular bundles. We preserved them here, here. That's the linea semilunaris. This is the visceral sac. It's all closed. You can see it goes way back here. Sure this is all... I would like to confirm that we have the blue towel, it is over here... All right, great. Thank you. All right, so can we get a ruler first? Yes.

CHAPTER 10

So now we need to measure this retromuscular space. Figure out how big of a mesh we can put in. So let's start with length. We're gonna cut it? We're actually don't, I don't think we're gonna need to cut it. Oh okay. So that's 30. So that's 30 length and then 15 here. And about 15 here, so that's 30. So we'll take that 30 by 30 mesh and can we change our gloves? Yeah. And do you have a blue towel? Yeah. All right, we'll take the mesh. So we're gonna put it like complete configuration. Just gonna push it on my side a little bit. All right, so can we get the Tisseel, and we need the CO2 sprayer too. Yep. They can see it's kind of there. It goes way up here. Down to almost Cooper's there. And on this side... A little folded. Can I get scissors for a sec? I put that - yeah, I mean, and then we'll need that big Rich. Yeah, the red thing stays open to air. Okay, take the other one. All right, yeah.

CHAPTER 11

Can I get the Bovie for a second? Yes. So I just kind of, define this a little bit better. All right, I'll take that 0 V-Loc. We're gonna close the anterior sheath. A little too much tension. All right, I'll take one more. Too many tonal workouts. Get one more? Yeah. I'm gonna go back. Okay, take this, I'll take another one. I should close this separate. One more time. Probably should close this separate little hole in the fascia, It's interesting that the tension, you can feel it when you're doing open, but you still break the suture but not so much robotic. Sorry 'cause I don't do that much open, so... Gonna need one more of those 0 guys. And then can you get me a 0 Ethibond too? Zero. And then if we can let Dr. Bean know we're gonna be ready for him in a like 10 minutes maybe. Okay. These barbed sutures make it efficient to close, but you have to make sure that you lock it and go back so it doesn't unravel. And this is 180 days absorbable. So it's like PDS, similar to anything that you close a laparotomy. I'll take that Ethibond. And you guys can let Dr. Bean know that we're ready if he wants to come back. Can we have some irrigation? All right. So that looks pretty good, that's the closure. I dunno if he wants to plicate that more, but... All right, good work. He's gonna do this, probably...

CHAPTER 12

As you saw from the case, one of the things that we did that I wasn't, you know, anticipating very much is that the patient had, you know, some additional adhesions that we weren't expecting. Although, you know, most of the time if someone has open surgery, then you would expect that they have a lot of adhesions. So we try our best as best as we can to take down all of these adhesions, even the interloop adhesions. Because these patients, if they, you know, develop a bowel obstruction of some sort, then it becomes, you know, hard to go back in and do more procedures for them. Especially, even if you're doing it laparoscopic or robotic, you're gonna have to go through the mesh that sort of covers the whole abdominal wall. So it's easier to try as best as you can take down all the adhesions. And the case overall went really well. I think, you know, once, you know, our plastic surgeon sort of did all the initial dissection, we went into the abdomen safely. We sort of did the retromuscular dissection as we discussed. One decision point that I wasn't sure before surgery was whether we were gonna need to do unilateral or bilateral component separation. After we released the left side, I sort of dissected the retromuscular space on the right side and sort of gauged the amount of tension that there is, and there's not much tension. So we sort of decided not to do a component separation on the right side, which for the patient is better because you don't really want to release both sides if it's not needed. If you have closure that's not under tension, you have adequate mesh overlap, which is five centimeter on each side of the defect. You don't really need to do an extensive dissection on both sides. So that's one intraoperative decision that we made that we didn't know before surgery, which way we were gonna go. One important thing I also wanted to point out is, you know, not knowing the anatomy for these procedures, it can be very complicated and dangerous. 'cause sometimes if you don't know the planes where you're in, I think you have to stop and then go back and assess where you are and try to basically reorient yourself. And you'll find that sometimes during the case I did that, that you know, I know the anatomy very well. I've done this procedure so many times, but it's always good to stop and show yourself, show your assistant where you are, do some more checks and balances, make sure 'cause these are long cases, so you wanna make sure you reorient yourself where you are because it's very easy to get lost in these spaces because remember that you're doing this operation in between muscular planes. So it's not a very, you know, natural anatomy that we're all used to. And also there's a lot of, again, there's a lot of courses to do for these. If you think about doing these procedures, you have to know the anatomy very well. You have to do these courses that familiarize yourself with the anatomy and the technique of the operation. It is done in a very similar fashion, whether it's minimally invasive or open, it's just that you have different instruments. So you have to train yourself on how to use different instruments for different techniques. One last thing I wanted to talk about is like, you know, a lot of these patients that will come to see us, they'll have other medical issues that are going on that we need to optimize before surgery. So you don't want to jump in and do such a big operation for someone that's not optimized because that will affect their outcome. So, let's say a patient comes in with a large hernia, they're overweight, they're diabetic, they're smoker, you don't wanna operate on this patient right off the bat. You want to basically optimize them. You want them to stop smoking, you want them to control their diabetes, control their A1C as best as you can. If they're overweight, you want to really get their BMI under, you know, a certain number so that you know, the risk of recurrence is less. So these are important considerations to think about surgery. I think you know, the key points for this operation to be successful is to know the anatomy really well, train how to do this operation well because it's a big, big procedure. You're rebuilding the whole abdominal wall and if you don't do it well the first time, basically the patient doesn't have many options afterwards. Optimize the patient as much as possible medically. And then also, you know, be liberal about imaging studies and getting CAT scans and have an operative plan beforehand so that you know what exactly you're getting yourself into.