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Learn more about Transorb, self-gripping resorbable mesh, MaxTac, motorized fixation device, and the rest of their portfolio on Medtronic.com. Okay, and we're here with Behind the Knife's ab site review. So the topic today is hernia. So let's just go over some basic principles. So John, when we talk about the basic principles that we always ask medical students, what is a basic principle of a good hernia repair? What do we always talk about?
Yeah, the obvious answer to that is a tension-free repair. Exactly. We're always going for the tension-free repair. We're going to talk about a few tactics we use to get that tension-free repair. But when it comes to recurrences, Kevin, so what's the most common cause of a recurrence of any type of hernia? I believe that's wound infection. Yeah, yeah, that's an easy answer on that side if they ask you what's the most common condition that leads to a hernia recurrence. It's wound infection.
So, we all know hernias lead to bowel obstructions. It's the second most common cause in the United States, of course, next to adhesions, because we have a lot of people that have surgery in the United States. Worldwide, however... Hernias are the number one cause of small bowel obstructions.
So let's get a little bit into anatomy. So, John, when we talk about hernias, especially abdominal wall hernias, it's important for us to understand the different layers of the abdominal wall. So can you just walk us through the body, starting from the outside? superficial and going deep, the layers of the abdominal wall, and let's say just right off the midline.
Yeah, there's a great picture in our book regarding this, but if you're going to go from skin to deep, it would be skin, sub-Q fat or campers fascia, scarpus fascia, anterior rectus sheath. rectus muscle, posterior rectus sheath, preperitoneal fat, and finally peritoneum. Yeah. So again, yeah, great reference to the image in the book. It has all those layers.
That's going to be really important to really intimately understand that anatomy and how we can exploit those different layers when it comes to hernia repair. And that's a lot of questions actually on the outside is which layer do you divide when you're doing this? component separation versus that component separation, so make sure you have that down cold.
Going out a little bit laterally, so John walked us through going through the rectus sheath. Kevin, how about if we're lateral to the rectus sheath, what are the layers there? Yeah, it starts the same, but it changes a little bit. And you start with the skin, and then you go through the subcutaneous spad or camperspacia.
then you go through scarpus fascia, then you go through the external oblique, then the internal oblique, then the transversus abdominis, then the transversalis fascia, then the preperitoneal fat.
than the peritoneum. Yeah, that's good. So again, you ought to know these layers down cold and be really familiar with abdominal wall anatomy because those different layers are going to be very important when we talk about our different types of abdominal wall reconstructions as to which layers that we can exploit.
So back medially, John, you walked us through the layers. Where did that transition? So you were walking us through the rectus sheath, probably a little bit higher up on the abdomen. Where does that posterior rectus sheath end? Yeah, and it's a good landmark. So I always use the umbilicus and you go about the third of the distance.
Between the umbilicus and the pubic symphysis, which is known as the arcuate line. Yeah, so at that arcuate line, all layers of the rectus sheath pass anterior to the rectus sheath. And that becomes important when we start talking about our... extra peritoneal repairs, our taps, we exploit that space and our minimally invasive hernia repairs, as well as it's important to know when we talk about doing our posterior component separations and our tars.
In reality, it's a little bit more complicated than that. You're below that arcuate line. You'll read some different things, whether that's you're just in that pre-peritoneal space. There's your transversalis fascia, which actually has two layers, a parietal and visceral layer that you can exploit and sometimes split those layers. But just to keep it simple, below the arcuate line, all layers of the rectus sheath pass anterior to the rectus muscle.
Kevin, so what's the blood supply to the rectus? You're a vascular surgeon. What are the vessels that supply the rectus muscle? Well, you know I love a good blood vessel. And so the blood supply to the rectus is the inferior and superior epigastric vessels. So we encounter the inferior epigastric a lot in vascular surgery when we're exposing the common femoral artery. It differentiates the external iliac.
from the common thermal artery. You'll see that the superior extent of the common thermal artery And then the superior epigastric arteries are the continuation of inferior mammary coming off of the subclavian arteries. All right. Well, it turns out you did learn something at fellowship. So, John, a favorite question we like to ask medical school students is about Hasselbach's triangle.
What are the borders and what's the anatomy of the Hasselbach's triangle? Yeah, it's almost impossible to really visualize this. And so unless you have a picture in front of you and somebody who's experienced with hernia repairs. you know explaining it to you but from a test point the medial border is the rectus abdominis The inferior border is the inguinal ligament. The lateral border are the epigastric vessels.
And what all this means is that if you have a hernia within Hasselbeck's triangle, that's a direct. space hernia. Okay. Now, so you mentioned that inferior border being the inguinal ligament. Tell me a little bit more about the inguinal ligament. What anatomic structure is it contiguous with? What abdominal wide layer is it formed out of?
Yeah, clinically, it's usually the ligament you can feel the easiest in that space, and it's an extension of the external oblique fascia. Yeah, great. So your external oblique fascia comes on, and it's got its insertion sites down on the symphysis and the ASIS. So it's an extension of that external oblique fascia that's kind of rolled over there inferiorly. And as Kevin mentioned, it's a very good anatomic landmark for your femoral artery as well in a clinical situation.
So let's talk a little bit, let's switch from the groin and talk a little bit more about the umbilicus, another favorite spot for hernias. So... Our umbilicus is a natural weak spot where we can form hernias, and the reason for that is because there used to be a lot of embryologic structures that pass through the umbilicus.
So let's go through some of those, and what we're going to do is I'm going to tell you the structure that goes through the umbilicus, and then you're going to tell us what its clinical significant is as adults. So first, let's go for the John, omphalic mesenteric duct, or the vitalin duct. What is the clinical significance in adults? Yeah, that becomes the Meckel's diverticulum, where you can then develop Meckel's diverticulitis.
Yeah, so if you have an unobliterated on palomesecteric duct, you can have a little meccles, which is very common, can cause lots of problems. Well, it can be asymptomatic most commonly, but it can cause problems, bleeding, obstruction, diverticulitis, as you mentioned, all those things. Kevin, what about the median umbilical ligament?
This becomes a Eurekis. Well, yeah, it can become a Eurekis or a Peyton Eurekis. Moving back to John, now the medial with an L, umbilical ligament. What is that? Yep, those are your obliterated umbilical arteries. Okay. And what about the, what is the round ligament of the liver, the ligamentum teres, and what is that a remnant of?
It's a remnant of the obliterated umbilical vein. Okay, so as I mentioned, all the stuff at one point traveled through your umbilicus, leaving that natural space where you could either congenitally or acquire a defect in a hernia there. When do all those structures, or the mid-gut rather, herniate through that umbilicus during development, and when does it return, John? Yeah, this really takes you back. But the mid-gut herniates at six weeks in developmental period.
and then it returns at 10 weeks. Okay, right. So the mid-gut, during embryologic developments, I know everybody loves embryology, is it herniates through six weeks and then returns typically at 10 weeks. What if that fails, that process? There's some abdominal wall defects. What are those, Kevin? And how do you differentiate those?
Yeah, I'm going to take this one. So the emphalocele, the way you kind of determine the difference between the two, and this is what for test-taking purposes, the emphalocele is a defect within the umbilical stock within the umbilical ring. so it herniates through the umbilical stalk. A gaseous schesis is to the inferior or to the right of the umbilicus. And Kevin, which one of those is more associated with birth defects? Yeah, that's the valid seal. Great.
Okay, so let's go on to some different types of meshes. It's really important to be familiar with meshes. It's something you don't often think about as a resident, but I tell you what, the first day of staff, you're fixing a hernia on yourself. You'll be happy if you spend some time reviewing what types of meshes to use in different situations.
The thing to remember is there really is no one size fits all. So the mesh has to be tailored based on what anatomic location you're wanting to put it in, what layer of that abdominal walls that we talked about, what type of repair you're needed, how big is the hernia, some different patient factors.
there are some general there's a lot of different brands out there it's honestly hard to get information on meshes because a lot of the data is proprietary so it can be very confusing it's helpful to break it down as some general categories of mesh so kevin What are the big main categories of mesh, and how do you distinguish between them?
Yeah, so you can think of it really as synthetic and biologic. And then there's a whole bunch of variations of synthetic. And so you have the absorbable and the partially absorbable. So first you have your non-absorbable synthetic. So this is your polypropylene or polyester kind of permanent mesh. Then you have your non-absorbable synthetic with a barrier. So it's the same thing, but with a polyester mesh with a collagen barrier. So this has the extra barrier to prevent adhesion.
Then you have your partially absorbable synthetic. So this is polypropylene with PDS polymer matrix. And then you have your biosynthetic, which is a biodegradable polymer. And then you have your full biologic, which is an acellular porcinedermin. Yeah, so depending on what type of repair, how long you want the mesh to be there, how long you want to stick around, if you want it to be permanent, where you're putting it, how much tensile strength you need.
Those are your big categories, and you can really, again, tailor it to your individual patient and individual situation. So the mesh material, the pore size, whether it's macroporous versus microporous, the weight. This is all going to affect its bioreactivity and how it behaves in the body, so it's really important to understand those characteristics when you're choosing a mesh for a hernia.
So for all comers, really your go-to mesh is going to be your light and medium weight, macroporous, polypropylene, or polyester mesh. So a synthetic, permanent, light to medium weight, macroporous mesh is going to be your go-to for most circumstances. Now, the caveat being, you need to know what layer you're putting in. So if it's extra peritoneal, an uncoated mesh is generally what you're going for. If it's intraperitoneal, you want that barrier to prevent adhesions, as Kevin alluded to.
So, John, let's say you were dealing with a... strangulated bowel in a contaminated field. So a big obese patient comes in, a smoker has a bowel obstruction and dead bowel and a hernia. What are you going to, what kind of mesh are you going to go for there? Yeah, I think this is, you know, talked about a lot and it's been a lot of different studies on this.
It's a relative contraindication for the use of synthetic mesh. Now, with the newer mesh developments, the light weights and macroporous and polypropylene meshes, You could consider it, especially if it's not an extremely contaminated field, but most people would just go to using a biologic method.
I still think that's a safe answer on the boards. You know, there is, as you mentioned too, some recent data, Rosen's data coming out using synthetic mesh in contaminated fields. But there are some nuances to that data, you know, getting that minimally contaminated versus... grossly contaminated be sure to get that mesh outside of the peritoneum you know for the boards i would still stick with the safest answer which is using a biologic mesh in those contaminated fields
Okay, so Kevin, moving back now that we understand our meshes, let's talk about some different types of hernias. So, umbilical hernias. Tell me a little bit about umbilical hernias. Yeah, so these are usually congenital. Most of them in pediatrics go away on their own, but sometimes they can persist or sometimes they can become new hernias later in life.
Well, how do you, so what's usually, most commonly, what's the contents of these small umbilical hernias, and then what are your different repair options?
yeah so for the most part it's just pre-peritoneal fat that's protruding through these umbilical hernias and as far as repair options you have a lot of different repair options but in general you have the open versus laparoscopic and if it's small one less than a centimeter you can consider a primary repair or if it's a pediatric patient they generally do the primary
Yeah, so that's an important thing there. For pediatric patients, generally try and avoid putting mesh in, so usually primary repairs. For these very small umbilical hernias, less than a centimeter, you know, less than your index finger, you can get away with a primary repair.
I think we've seen, especially in the American population, as patients are getting more and more obese, we see these small umbilical hernias becoming problematic and growing and becoming to the point where they even need abdominal wall reconstructions after. pre-habilitation so they can be pretty problematic but this just goes back to you really got to know what the size of the hernia those different layers that you're dealing with and how to best approach those but there's a lot of options
You talked a little bit, Kevin, about pediatric umbilical hernias. So expand on that a little bit. You said most will close spontaneously? Yeah, the vast majority of them. So when do you repair them then? So it's hard to convince parents of this, but you really have to just watch and wait until about five years old because most of them will close.
So, yeah, okay, so you said at least five years old or right about the time they're about to go to school. If they're persistent, you should probably fix those, and I would agree with that. John, a favorite question for boards and a challenging clinical scenario in real life is your cirrhotics with umbilical hernias. So let's talk a little bit about that. So we know that 20% of patients with cirrhosis will develop umbilical hernias, and there's a lot of reasons for that.
then these patients tend to be not the best operative candidates and have poor nutrition. They have a high rate of rapid enlargements and a high rate of complications to include incarceration, evisceration, wound breakdown with ascites drainage. peritonitis. How do you approach these patients? Yeah, this is a clinical question that I didn't think I would be facing as much, but...
It's definitely a hard problem to deal with. But in general, if a patient has advanced cirrhosis and is a transplant candidate and is going to get the transplant soon, you just repair the hernia at the time of the transplant. However, if the transplant is going to be out three to six months, you know, around that time, it should be repaired electively.
The goal in general with dealing with these umbilical hernias is to control the ascites and try to optimize them medically the best you can to make sure that your hernia repair works and also isn't exposed to ascites within the abdomen. Yeah, I would agree with that. I think ideally, even if they're not necessarily going to get a transplant, I think a lot of times these patients are best managed in transplant centers just because they have the infrastructure and the ancillary services.
medically optimize that patient so that The key there, what you mentioned, was getting that ascites under control. So Maxwell Medical Control of Ascites. So how about when you go to repair that hernia? What are some tips and tricks there?
Yeah, it depends on the patient's clinical scenario. So if they are producing lots of ascites, you want to... you know, drain them and do a paracentesis, you know, before and after, and also do them routinely afterwards to try to do the best work of getting, to making sure that hernia repair is not, is being exposed to a significant amount of ascites.
Yeah, so controlling this AIDS post-operatively is very important. You need to make sure that you're closing all layers, including the peritoneum, and really get a good closure to protect that wound. You'll hear some people talk about leaving drains versus not leaving drains. In general, on the boards, I would try not to leave drains and then opt for serial paracentesis postoperatively to control the SIDs.
In addition to all the medical management of the societies that you can do. Now let's say that you're in a situation where you do have that skin breakdown and you have a leaking umbilical wound. That's a little bit different than that electric repair. So how do you approach that? Yeah, this should raise some red flags when you see this on a test question because this isn't just approaching a hernia at this point. You have to know.
kind of switch to like a resuscitation and managing an infection situation so you would start resuscitation you know iv fluids you'd also start antibiotics and then this also now triggers an urgent repair Additionally, the difference is, you know, you could put mesh in a patient who's getting an elective repair.
but you want to avoid mesh in the circumstances due to the infection risk. You have to assume that if they are leaking from the umbilical wound, that ascites inside their abdomen is exposed to the external environment and is infected. This also requires aggressive post-operative ascites management. They are higher risk than even the elective repair. And once again, that includes serial paracentesis and diuretics. And this helps avoid your wound complications and dehiscence.
And unfortunately, just based on this patient being a cirrhotic and having ascites and having now a new infection, this places them a pretty high mortality rate. Yeah, unfortunately, it's not a fun situation. I think we've all probably been in these situations, and they're certainly not fun. And at the end of the day, you're just trying to get that patient out of Dodge so that they can live and fight another day.
So let's move on to something that is more manageable, and that's inguinal hernias. So Kevin, again, we like to ask med students, what's the difference between a direct and an indirect hernia, and how do you distinguish the two? Yeah, to keep it simple, an indirect is lateral to the inferior epigastric vessels, whereas a direct is medial to the inferior epigastric vessels.
Again, yeah, so like we mentioned before, that direct is through that Hasselbach's triangle, a medial to those inferior epigastric vessels. What's the, John, etiology of an indirect hernia? Yeah, most of the time these are congenital. It's also the hernia you'd see typically a younger population. And by congenital, I mean a patent processes for that vaginalis. Okay, how about direct, Kevin? So this is acquired through weakness in the floor of the inguinal canal.
Okay. What predisposes people to form direct or acquired hernias, John? Yeah, it's basically the same stuff. You put your risk for everything. It's obesity, smoking, poor nutrition. ascites, and anything that would increase your abdominal pressure. Yeah, unfortunately, it's also all the things that increase your chance of a recurrence. So it's all the things you don't want your hernia patient to have is the reason why they have hernia in the first place.
It can be pretty challenging, and this is why the concept of prehabilitation has become so important when it comes to hardware repair. Back to the basics, though, Kevin. The spermatic cord. This travels through our inguinal canal, in men at least. So what are the contents of the spermatic cord? Yeah, so you have your cremesteric muscles, your testicular artery, your vas deferens, your pampiform plexus, your ilioingual nerve, and the genital branch of the genital femoral.
So yeah, that's an important, just identify, know those structures, know they go through the Inglot Canal. Again, we're going for that low hanging fruit, those easy answers on the ab sites. You may get lucky with some of those. What about the cremasteric muscles, the cremaster muscles, that is? What abdominal wall layer forms those cremaster muscles?
John. Yeah, that's the extension of your internal oblique muscle fibers. As a reminder for your ingle ligament is formed from the extension of your external oblique. So we need to be careful with these. One of the more common complications of a hernia repair is chronic pain afterwards. So it's important to know the nerve. When we're talking about an open inguinal hernia repair, Kevin, what are the key nerves that we need to have an understanding of where they're at?
Yeah, so there's a couple of them, and that's the ilioinguinal nerve, the genital branch of the genital femoral nerve, the iliohypogeth. And which of those is the most commonly injured during a open inguinal artery repair? Yeah, definitely that ilioinguinal nerve. Yeah, so you need to watch for that. It passes right underneath that external oblique. When you're opening that external oblique, identify that.
Some people will routinely divide it. Some people will selectively divide it. Some people try to preserve it at all costs. But just be aware that it's there and watch for either injury or getting incorporated into the mesh, which can lead to some problems with post-operative pain.
How about laparoscopic or a robotic hernia repair, minimally invasive? What is the nerve situation there, John, and which ones can get injured? Yeah, this is everything lateral to include the lateral femoral contaneous nerve. that's your triangle pane and usually occurs to inappropriately place tack or if you dissect out too laterally during your ingle repairs.
Yeah, absolutely. I'm always harping on the residents there laterally doing those minimally invasive repairs to stay right on the parrot's knee and not dig into that lateral abdominal wall. Avoid putting in any tacks. Avoid thermal, using thermal energy out there just to avoid. injury to those nerves because that can be quite a problem post-operatively.
Switching back to opening one hernia repairs, there's the tried and true, a lot of different named hernia repairs. Let's just quickly go through what those are and what you're sewing to what, because again, we want to pick up those easy points on the app site. So Kevin, you're... Classic Bissini tissue repair. What do you sew into what?
So this is the conjoint tendon, which is a mix of the transversalis and the internal oblique, and you sew that to the inguinal ligament. Great. Conjoint tendon, inguinal ligament. John, the one we don't see often is the shoulder-ice tissue repair. We're seeing less and less of them. Yeah, you don't see them as much. A lot of people, if you're doing tissue repairs, will do some sort of like modified shoulder dice.
but it's similar to the bassini repair but it's closed in four layers so once again sewing the con joint tendon to the ingle ligament Not in two layers, but in four layers. Yeah, yeah. Honestly, don't worry. Don't stress too much about the four layers of a shoulder lash repair. You're not going to get asked on the ab side. Kevin, the Lichtenstein repair.
Okay, yeah, so the Lichtenstein repair, that's the more classic mesh repair. And so you sew to the inguinal ligament, and then the mesh also is sewn to the conjoint tendon slash transversalis. Yeah, so this is our first really kind of tension-free repair. It's kind of interesting, if I could go off on a little bit of a tangent, that... We started using mesh in order to decrease pain in a hernia repair from the tension.
But now all you do when you turn on the TV is you see the lawyers threatening to sue for pain after a mesh repair. In reality, the pain we would be seeing after any lawyer repairs would be a lot more if we were using mesh than if we were. But that's the medical legal system for you. So, John, how about a plugin patch? What does that mean?
yeah the plug and patch is like kind of my favorite term it's a very simple term for you know a very simple procedure but basically you're taking the lictage style repair and doing a normal mesh placement and putting a plug inside the internal ring that would theoretically scar down and prevent anything from coming back up in it.
Yeah, also kind of, it might be your favorite one to say. It's my least favorite one to see. Also kind of falling out of favor. What you'll see sometimes are these plugs turn into these meshomas. I see them a lot in recurrent hernias where I have to go and... dig these plugs out of that internal ring, and it is not fun. It is still done, but also falling out of favor, thankfully. Kevin, how about pediatric repairs? What is some just broad strokes?
basic principle of a pediatric inguinal aria repair. Yeah, this always blew my mind. You just do a high ligation of the sac. Yeah, halogation of sac. And when you think about it, it's congenital from that patent processus vaginalis, so you're just closing that off. The inguinal floor really isn't the issue. And again, as we mentioned, pediatric patients you want to avoid putting mesh in because pediatric patients grow mesh shrinks it's usually not a good combination
John, switching over now to outside of open repairs, back into things that we're probably more familiar with in this day and age, which is the minimally invasive laparoscopic robotic repair. But what are our options for minimally invasive inguilarity repairs?
Yeah, and that's also my preferred way of dealing with inguinal femoral hernias, and I'll tell you why. So there's two different types of repairs. So you have your total extra peritoneal repair, also known as your TEP, and you have your transabdominal preperitoneal repair, known as the TAP.
And now it goes for both laparoscopic and robotic. The benefits of this approach is that it covers not just the indirect and direct space, but it also covers the femoral spaces because you can see everything in place mesh from the inside.
Yeah, me too. It's my favorite because, again, you can look at all those spaces. You cover all those spaces with a nice big piece of mesh overlap. It makes it dummy-proof. I don't have to think about what are the four different layers of the shoulder latch repair. It's the same operation for every little hernia. How about in a laparoscopic repair, we talked a little bit about avoiding laterally. So where do you fixate the mesh?
The main point of fixation is Cooper's ligament, and that's medially. and then you would fixate the mesh if you're there's multiple different ways of doing fixation but if you're using a tacking or you're sewing it in it'd be cooper's ligament and then maybe the abdominal wall yeah there's a lot of options for this now more and more we're going to a minimal fixation so at most
one or two points of fixation there immediately. There's self-fixating meshes, there's fiber and glues that people are using, and the trend is rightfully so to less and less fixation, which I think does have an effect on post-operative pain. You know, I think we mentioned, you mentioned this earlier a little bit, you know, triangle pain, triangle of doom. What and where, let's do the triangle of doom first. What and where is the triangle of doom? Yeah, so this contains the iliac vessels.
and then medially with the apex at the iliopubic tract and is bounded by the vas deferens medially and spermatic vessels laterally. Okay, and how about the jaw of the triangle of pain? Yeah, that's the portion out laterally where it contains all your nerve structures. It's lateral. If you're looking inside, it's lateral to the spermatic vessels below the iliobivac. Okay, let's talk briefly about femoral hernias. We were just talking about hemoral hernias.
Like I said, I'm a minimally invasive surgeon, so it's kind of all the same to me when I go to my minimally invasive repair. But there are some distinctions in regard to the patient and things you have to think about. So, John, who's at the highest risk for femoral hernia? Yeah, the classic test questions for this that you have to...
And I'll look out for the female patients and the elderly. Yeah, so women are more at risk for femoral hernias. Now, be careful because in women, still the most common groin hernia is an inguinal hernia. yet they are higher risk than men in femoral arnea. So a little bit of, can be a little bit confusing there. So just make sure you have that straight. Kevin, where is the actual defect in a femoral arnea?
So this is below the inguinal ligament and medial to the femoral vein. Yeah, so it goes below that inguinal ligament. So that will affect things when you go to do an open repair. So how is that different than your, why won't your Bassini repair work with that, John? And what do you do in an open repair? Yeah, and an open repair, it's also known as the McVeigh repair or Cooper's repair. is that the difference is that you have to open the inguinal floor.
And you have to close the space by suturing the conjoint tendon to Cooper's ligament. Yeah, so don't say, especially if you're in an oral board scenario, be careful. If you have ephemeral hernia, you've got to do that McVeigh-Cooper's repair.
your bascini is not going to cut it because that defect again is below the inguinal ligament. Okay, that's enough about femoral hernias. Something more rare but you still see and it's kind of fun is the obturator hernia. So what is an obturator hernia, Kevin?
So this is a herniation through the weakness in the obturator membrane. And how does it present? What kind of patients do you see this in? So generally this is in thin elderly patients that present with a bowel obstruction. Right, yeah, usually very thin. elderly patients coming with a bowel obstruction. And what kind of things, John, might you see? It's difficult on physical exam, unlike other hernias. So what might you see on physical exam? Yeah, that's the classic Hauschip-Romberg sign.
And this is shown with groin or thigh pain with internal rotation of the hip. And it's present about 50% of the time when patients present with obturator hernias. Yeah, so it's kind of a cool thing, but it's not reliable. As you say, it's present about 50% of the time. I mean, really.
This is the 2020s. Your CT scan is going to be the way you diagnose these. It does have a high morbidity and mortality. Again, that's mostly related to the patient population. As we said, these are often elderly thinned, often malnourished individuals. and they do have a tendency to strangulate.
So how do you approach these, Kevin? What would you do if they called you? I don't know why they'd be calling you as a vascular surgeon, but let's say that they did call you as a little old lady who's got incarcerated. bowel obstruction with an operator hernia on the CT scan. Yeah, so you have to have, you know, take these patients to the OR fast. You need early surgical exploration and reduction is required. Sometimes you need to actually incise the membrane to reduce the incarcerated bowel.
And what are your options for, you know, so let's say you take them, you reduce it, you know, you can do this either open or minimally invasive, but now you're staring at this hole down in the obturator for him and how, what are you going to do with that? So generally you can repair this. primarily with permanent suture, and you can plug the defect with the round ligament or the medial umbilical ligament.
Yeah, so it's difficult. It's a difficult spot to get to. This is, I think, an advantage of that laparoscopic or robotic repair. You can get down there. I'll regularly visualize the obturator canal when I'm doing my minimally invasive inguinal hernias. There's not a lot to sew to, so it can be a little challenging, especially when the tissues are very thin and you obviously have some vessels and nerves that travel through that that you have to be careful not to tag.
So you have to get a little bit creative. Using those structures you mentioned, either the round ligament or the meaty umbilical ligaments to patch are good options. You can cover with mesh, although it can be challenging for mesh fixation in that area, but it's certainly an option.
So you'll see them at some point in your career. They're rare, so it's good to think it through, and you certainly might see it on the app site. So moving on from there, lumbar hernias, another rare but sometimes seen hernia. What are the different types of lumbar hernias, John? Yeah, there's two types, the Grinfelds and the Petite.
hernias the green felt is the landmarks for this is bordered by the 12th rib the paraspinal muscles and the internal oblique regarding the petite this one's bordered by the lat dorsi the iliac crest Okay, great. Kevin, diastasis recti. This is something we see on a daily basis that referred to the general surgery clinic. What is this and how do you approach it?
Yeah, I see lots of influencers on Instagram telling you how to fix this. So this is a weakening and widening of the linea alba, so it's not a true hernia. And there's no risk of incarceration or strangulation, and repair is not required. Plication can be performed, but is mainly cosmetic. Yeah, so we see this a lot. Again, it's just a widening of that lineal elbow. The initial treatment is physical therapy. There are exercise programs that are designed to improve the abdominal wall.
function and improve these. The caveat I would be is if you have a combined diastasis with a ventral or umbilical hernia, there is evidence that there's a higher rate of recurrence of the hernia if you don't placate the diastasis at the time of the repair. And there's a number of options that are becoming more and more available, minimally invasive, ETEP, that type of thing for addressing these diastasis recti. But for the most part,
And what's likely going to be the answer on the outside is patient reassurance, because these aren't true hernias. There's no risk of incarceration or strangulation. Okay, so moving on to ventral and incisional hernias. This is a very broad topic. It's something that's going to be very difficult, but let's just try and hit some high points that might help us out on the upside. So, John.
Risk factors for an incisional hernia. We mentioned some earlier, but let's go over more. Yeah, these are the same as always. It's the wound infections, obesity, COPD, and most commonly what you'll see on tests and in real life is smoking. Yeah, great. So again, it's all the things you definitely do not want your hernia patient to have or be doing, and it sets them up for a recurrence is also what sets them up for having a hernia in the first place.
That's why in recent years, this idea of prehabilitation has become very crucial to having successful hernia outcomes. Number one, you need to get them to stop smoking prior to electric repair. You need them to lose weight. Oftentimes, I'm a bariatric surgeon, so I get a lot of hernia patients, or a lot of bariatric patients, rather, in my hernia clinic where we'll stage them. will do a bariatric procedure, and then after they lose weight,
we will go and do a definitive repair of the hernia. It's that important that they lose weight and stop smoking. So if you get this patient with a BMI of 45 and as a smoker and a diabetic, On the exam, don't just rush to the operating room. You need to work on getting them ready, which sometimes can take up to a year or longer to get them ready for surgery. Kevin, what are your options for placing a mess?
in these patients. Yeah, very simplistically you have the options of an underlay, an inlay, or an onlay. Yeah, inlay used to see more. It's a highest risk of recurrence. Usually inlay meshes are... If you do an inlay mesh, you're in a bad spot where you can't get things together and you're not in a good place to do a component separation, and often those are temporizing procedures.
that will need to be addressed down the road. It's a very high risk of recurrence. But in general, underlay, onlay, as we talked about, there's different layers that you can exploit to get that mesh outside of the peritoneum versus putting it intraperitoneal. What we talked about before, your kind of go-to meshes are your light and medium weight macroporous polypropylene or polyester synthetic meshes for with or without a barrier for most situations.
So John, what if you're in the situation where you have a very large hernia, and let's say that the patient's been optimized, we did a sleeve on them, they got their BMI down to 29. They're not smoking. We've considered them optimized for surgery. But still, you have a large 12-centimeter defect, and you're not going to be able to get that together. What are your options?
Yeah, I hope you figured this out, you know, prior to going to the operating room and, you know, planning purposes. And there's a lot of different criteria you can use to determine if you're going to need to do this or not. But the basis is a component separation. And there's a couple different types of variations.
that regard different types of layers that are sized, where you place your mesh and different approaches. Yeah, so let's just go through those. And again, like you mentioned earlier, refer to that in the companion book. There's a great image that has the different layers and actually has what you incise for these different separations. So let's go through that, because a lot of times this will be the question on the outside, is what layer do you incise?
with an, say, anterior component separation. So, John? In an anterior co-oponus operation, what layer are you incising? Yeah, you're incising the external oblique. Okay, how about a... posterior component separation in a let's say a retrorectus repair. Yep you incise the posterior rectus sheath and then place the mesh in the behind the rectus muscle. Yeah so you're incising that you're developing that retrorectus space.
Again, there's ways to do that minimally invasive versus open, but the principles are the same, and you're laying that mesh in that retroactive space. Now, how about a posterior component separation with a transversus abdominus release? Yep, also known as a TARG. This is where you incise the transversus abdominus.
Yeah, okay, great. So the TARD, you're entering that retroactive space, you're developing that retroactive space, and then laterally, just medial to those neurovascular bundles, you're going to incise that transverse abdominus and release that transverse abdominus muscle and develop that space. give you a nice big mesh overlap, a nice visceral sac to cover your viscera and protect your bowels from that mesh.
you know typically when we're talking about sizing mesh and what area we're going to need to exploit my general rule of thumb and what i use is i take the size of the defect and i add 10 to it So, you know, you have a 10-centimeter defect, you're going to need at least a 20-centimeter mesh. Whether or not you can put that in the retroactive space or need to develop that tar plane is based on the patient's anatomy.
So you're, you know, we know that your transverse synopsis release is able to achieve as much faster release as an anterior component separation. However, the advantage is that you have fewer wound complications because you're not raising those big skin flaps. So the tar has become really the preferred approach, and the anterior component separation has fallen a bit out of favor. but there are still certainly circumstances where you would need to do an anterior component separation.
all right so given a lot of work has gone into figuring out what the optimal suture closure method is different types of suture how big bites. So, and this goes into your primary closure of your laparotomies in addition to your hernia repairs, but what is an optimal suture closure method?
Yeah, so generally you want small bites with an absorbable suture. So five to seven millimeter bites and probably a slowly absorbing suture like PDS. Yeah, great. Slowly absorbing suture, five to seven millimeter bites. You know, we mentioned minimally invasive versus open techniques for all this.
There are good lap or robotic approaches that have been described and they're done pretty routinely at this point with low wound. For a test taking, sometimes you'll get forced to go to the OR for whatever reason in a patient who's obese. Just remember that minimally invasive approaches are preferred in obese populations, and sometimes that's the principle they're getting at with those questions on the ab site.
Okay, so that wraps up our discussion of hernias. As always, we're going to end with some quick hits. Are you guys ready? Let's do it. All right, so John. Quick check, hernia that occurs at the junction of the semilunaris and the arcuate line. That's your Spigelian hernia, or also known as intramuscular hernia. Yeah, so spiegelian hernia, these can be very difficult to diagnose on physical exam because that external oblique is intact.
So the patients usually do not have a bulge. So if you have a patient that presents with classic symptoms, non-contrast CT can be very helpful in identifying these. They are at a relatively high risk for incarceration, so if you do identify them, you should repair them. Okay, so Kevin, appendix... In an inguinal hernia sac, what is that? That's your amyond hernia, and do a primary repair in appendicitis.
Yeah, so amyone hernia, and if you have appendicitis within that appendix that's in the hernia defect, you obviously want to, that's a contaminated field, so you want to be careful with that. John, Meckel's diverticulum in a hernia, what's that called? That's our alliterase hernia. Alliterase hernia. Kevin, let's say your patient has both an indirect and a direct hernia, what's that called? So that's your pantaloon hernia.
John, what's a sliding hernia, and so what's unique about it that you have to consider during a repair? yeah that's your retroperitoneal structure that makes up a portion of the sac so you have to be careful Not to open the sac during the repair of a sliding hernia. Exactly. So an organ is making up some component of that hernia sac. So if you're open to the hernia sac and you're doing an open repair.
you very likely could open that retroperitoneal structure, that organ, so you definitely don't want to do that. Kevin, Richter's hernia, what's the significance of a Richter's hernia? Well, first off, what is it and what's the significance? So part of the bowel wall, typically the anti-mesenteric border of the bowel, is present in the hernia sac. And so this can present as strangulation without. Great. John, we covered this briefly, but what's the most common hernia in females?
The femoral hernias are more common in women than in males, but the indirect hernia still remains the most common for both men and women. Great. Yeah, sometimes that can be tricky, and they'll ask you that. And it's a trick question. It's definitely a trick question. Just don't fall for it. During, okay, so Kevin, so let's say during an inguinal hernia repair and skeletonization of the cord, you can't find a hernia. What do you do?
So in this situation you need to open the floor and look for a femoral hernia. Exactly, exactly. If it's not making sense, you need to look for a femoral hernia. Like we said, that femoral hernia travels under the inguinal ligament. It's not always apparent on physical exam, and you don't always have imaging, and sometimes it's not clear on imaging either. So if you're not seeing that hernia sac, then look for that femoral hernia.
Okay, Kevin, child C-sirotic with massive ascites and umbilical hernia with intermittent obstructive symptoms. What do you do? So you do tips first to control the ascites before considering repair. Excellent. Yeah, we talked about the importance of controlling the ascites. Absolutely essential. John.
Laparoscopic emo heart repair, and you tack the mesh to the Cooper's ligament, and you get pulsatile arterial bleeding. What happened? Oh, I hate this thing. It's the corona mortis. It's the branch between the obturator and the external iliac artery. Yep, you should have been more careful. Kevin. placing a suture during open inguinal hernia repair and you get sudden bleeding.
Those damn veins. The femoral vein injury. What do you do? Pull the suture out and hold pressure. Yep. Femoral vein injury. Just pull the suture out. Don't tie it down. You're just going to rip the vein open. Pull the suture out and hold pressure. It'll be okay. We stick needles into veins all the time and it's fine.
John, groin pain, significant medial thigh pain with internal rotation of the hip. You mentioned this earlier. What is it? Yeah, that's the rare obturator hernia. And it's also the name of the obturator sign or the house ship Romberg sign. Exactly. It's present only about 50% of the time.
Kevin, we have a patient's one-month SASPOS and open inguinal hernia repair with a proline mesh, and now we have a wound infection, and you have purulent fluted around the mesh. What do you do? Yeah, in this situation, you have to explant the mesh.
Yeah, I would say that's getting a little bit controversial. There are, with the newer macroporous polypropylene meshes, there are mesh salvage techniques. But if you have, you know, gross purulent pus coming out of your wounds, yeah, you're probably going to need to explant that. okay john so you have a young female with a minimally symptomatic Umbilical hernia that she noticed during pregnancy.
She does desire future pregnancies. What are you going to recommend? Yeah, I see at least one of these probably every month in clinic. But you want to talk to her and counsel her about deferring her hernia repair. Until after she's completed all planned pregnancies if possible. Yeah, absolutely. Especially if it's minimally symptomatic. You want to defer that until they're done. Okay. Inglomerate repair and you can't reduce the SAT. What do you do?
So, you can ligate the proximal portion and that will reduce it into the abdominal cavity. And then you keep the distal portion open to reduce the chances of a hydroseal. Yeah. So the abandon the sac technique, you can do this minimally invasive event. It has good data that it turns out just fine. Okay, so I think that does it for our hernia abcite review. So hopefully that'll help you guys on the exam. And until next time.
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