Intraperitoneal Mesh Repair for Incisional Hernia

CHAPTER 1

My name is Shabir Abadin. I'm a general surgeon, we're at the World Surgical Foundation Brigade in Honduras. And we're about to perform a procedure, an incisional hernia repair on a woman. She's had numerous laparotomies. It's a 75-year-old woman who's had a perforated colon several years ago and underwent an emergency exploratory laparotomy and had a diverting colostomy. She ended up having this reversed and subsequent to that, developed an incisional hernia along her midline and, quite possibly, her stoma site. So given her symptoms, she has intermittent obstructive symptoms and pain. We have offered her incisional hernia repair with possible mesh and then evaluation for a possible stomal hernia. Key steps are: after incision, exposing, identifying the hernia defects, evaluating the size of the defect, and carefully not dissecting and adhesiolysis of any bowel adjacent to this. If this is maintained, then we're able to place a synthetic mesh into the space and, typically, doing it in underlay fashion with absorbable suture.

CHAPTER 2

So this is a woman. Our patient is a native Honduran, she's had numerous laparotomies and procedures prior. She had perforated intestines, perforated colon, which required emergency surgery where she needed a colostomy. And during that - do you have an Adson with teeth? During that time, after that time, where the colostomy was closed, she developed an incisional hernia through her laparotomy site. Adson. So due to symptoms and pain from that, she's here for repair of that. But she developed a hernia at the midline and then she possibly has one from the colostomy site. And that's not uncommon in patients who have colostomies, that's termed a peristomal hernia. So what we're planning on doing is identifying the hernia that we know of on the midline, and once we are in the peritoneal cavity, feeling for a hernia near the area of the colostomy. So this is just all scar from the numerous operations she's had. And we're going through it kind of delicately so we don't injure any intestines deep. So what we can start to see here is this is the sac, this is what we call the hernia sac, and deep to that we can see there's hernia contents, likely bowel, possibly some fat. Do you have another Allis? I do. It's not necessary, most of the time people will just go through the scar, but I think it just makes it a lot easier. Do you have the other Adson? Our suture removal kit - I don't know if I can get that on film, what I just did. And now this is just scar, there's no point for pathology for this, but it's - you know, this is what the patient sees, but the stuff that's more important is deep to this. So Dr. Yoko and I discussed, kind of our game plan before the surgery, but our plan, typically for these incisional hernias, is to start our dissection in the what we term kind of a virgin area, so an area that we hope has not been affected by surgery previously with scars, so we're going to start here.

CHAPTER 3

Oh, that's all the way down there. Yeah... Okay. No. We can just... Oh, this is all fat. Okay, so we can just do this - just open up. We can just take a… A layer at a time? Yeah, a layer at a time, and then once we get a little deeper, we can just take a knife here. Do you have that 10 blade? In this case, a lot of the times, electrocautery is very useful for us because it helps us maintain hemostasis, but in some cases here, we prefer sharp. In this particular instance, we're using sharp dissection just because if there's intestines that are stuck with adhesions to the underlying site, a sharp injury to the intestines is a lesser evil than a cautery injury. You can just keep taking this superficial here. Barry, can you hold this with your left hand here? Yep. The sharpest knife we have. Yeah. That is all good, yep. Where do you want this, it just popped off. That's fine, don't worry about it. We'll get it, I'm just going to nick it with the belly of the blade. There we go. So we're just cutting through scar tissue. Yeah, so she's got pretty intense adhesions - at least we can see right now. So you can see, this is kind of the interface. This is bowel right here. This is a sheet of scar, and it's almost covering like a layer on top of the bowel. This way - Dom? Let's open the rest of this, here. Okay. Bovie, or...? Bovie all this stuff, yep, mm hmm. So for incisional hernia repairs, the trick with them, I think, is often we'll have a lot of - more scar - sometimes we don't have much scar, but sometimes we have to be prepared for a lot of scar. And also sutures, sometimes mesh, sometimes other foreign materials where surgeons have been before. So it just takes a little bit more cognizance and…

CHAPTER 4

So I think what we can do - so this is fascia edge I think, right here. Okay. You can feel it circumferentially up this way. Okay. On this side - so she's got a decent-sized defect here. I'm going to have you just hold up a little bit like that, yep. Here like that? Straight up. I think - so I agree, this is all sac here. We can come down - this is fascia right there, you can feel underneath here. Yeah. So we're going to tag that. Do you have another Kocher, Sheena? Mm hmm. I'm going to have you - you can hold that, and then we're going to divide the hernia sac like this and kind of bring it around this way and then bring it around that way. Okay. Okay? So basically, you just kind of come through like this. All right. Mm hmm. We'll get some good tension. So, anatomy - So, this is the hernia sac here? Yes, this is all - this shiny surface is basically a hernia sac, basically a lining of peritoneum that's popped through the hernia and the intra-abdominal contents, which Dr. Yoko has below, protecting them below her left hand is what was popping through into the hernia sac. So we're basically now clearing off the sac and getting down to the strong connective tissue of the fascia. We'll use that for our repair. The object is to get the hernia sac away, and clear out the fascia, but not go through the fascia. Her fascia's been closed numerous times and probably is not as healthy as it was before she had all these operations. Now we can just kind of come through like this. Once we start seeing fat, then we know the hernia sac's open. You're just going to follow the hernia sac. The point of taking the hernia sac off is - a lot of it is, since it's slick, if we leave it in place, it doesn't necessarily do anything with the repair, but it can form seromas - fluid after, in the space. Do you have a rake? You can relax on that. We'll just take this off and then we can find fascia while here and then we'll trace it over this way. I'm going to do like this. You hold this down. Uh huh, We want to protect, the fascia's here - you're going to come right here and clear all this stuff down until you start to see normal fat. Again, just stay pretty close here because this is all fat. Yep, nice. Release some fat. Great. So we're peeling the hernia sac away, we're getting down to subcutaneous, kind of golden, normal fat. We're going to do this on this side, and then on the previous side, and then the contralateral side as well. What most patients feel is, typically, the hernia contents and the hernia sac. I know I'm kind of on the edge, I'm going to be giving it the utmost attention. Just even the tip of the cautery is letting it kind of glide through. We're going to go nice and slow, I'm just using my fingers underneath to give tension. There's a bowel right here. So the goal of the surgery is once we get the hernia sac away, we want to identify the defect. The defect is - comprises of the edges of the fascia. Once we connect this here, we'll come down and take the rest of this off. Okay. Key parts of this are just good counter-tension and tension. Otherwise, when the tissues are floppy, everything kind of compresses on each other, itself, and you're more likely to get into the bowel and bowel injuries. Fascia here, let's see. No, it's right here. Okay, see this as a band, this is - feels like something here, It's actually another defect there. Oh. There's the - defect - we'll clear it up and show them a little bit better here, but let's do this, let's clear off the top part here. Okay, underneath. Right here? Yeah. Mm hmm. And lift it up. That looks good. So what I'm holding here is the rectus muscle.The left-sided rectus sheath. And she does have - she indeed does have two hernias. So what we can do is just strip this hernia sac on top of the rectus. Right here? Yeah, it's kind of the slick stuff here. Okay. Go ahead and get a little higher, you know, right here. You can leave a little layer on there because I think we're going to do an underlay for both, you know? Okay. We'll see if we need one big piece of mesh or if we can… Mm hmm, you can just take it all. So she definitely has a hernia here, where the intestines are poking through. This is her rectus sheath, her rectus muscle on the left side and she's got another defect on this side right here. This is where the area where the colostomy was. So she has kind of dual defects, and we're going to have to figure out a creative way to fix both of those, once we clear off all the fascia. So once we do that, we're going to do this side now. You're fine, for now. So we can see the edge right here. This is the edge of peritoneum and our bowel and we want to maintain that. Sometimes we get bowel injuries and they're not full-thickness injuries, but they're called serosal tears. So the serosa is torn from the bowel. We want to make sure that doesn't happen because in this case what it does is, especially in these conditions, we're not able to put a mesh in. The mesh is a prosthetic appliance, and if we have any contamination with bacteria, her defects are not able to get repaired because of the risk of infection. So we're cutting the adhesions now. Yeah, so - here we're cutting the adhesions, we're trying to separate the bowel away from the area of scar, but we're not, you know, this operation's not to take care of somebody with a bowel obstruction. We're not taking every little bit of adhesion that we see. We're only doing enough to be able to safely place the prosthetic. Can I have the other Rich? There's actually - some adhesions are a little dense and kind of really aggressive. Some are a little bit softer, and we always hope for the softer variety. In this area, especially in these dense adhesions, I think the key thing is flapping being between the forefinger, and the thumb - the bowel because then you can see, you can see the edge of bowel. Sometimes when it's loose, you don't see the edge and when you compress it, you see the edge and then you can see where it is from the… So this is our bowel. What we're looking for is this band right here, this is our fascia right here. Can I get the Kocher? So our plane really here, when we talk about our dissection plane, our plane is kind of a couple millimeters, you know? We don't have much give because we're trying to get the bowel away, but we're not trying to strip the fascia because the fascia's the good. The fascia is our layer that we use to sew the mesh to. Okay, that's probably good enough. Let's see, this is fascia. You can take big enough bites - it's all pretty thin still, you know? Yep But I think if we grab it deep enough there… I'm using my left hand with a dry laparotomy pad just for counter tension on the bowel. I'm using that to give us that extra little bit of traction to allow us to lyse these adhesions. That's probably more than we bargained for, yeah. That looks like bowel. So I think - let me just feel here. This area seems like scar, but it's a combination of scar, and I think we're going to have enough space on this side. Okay. So that side looks okay, I'm going to have you do the same thing over here just to clear the bowel away. Okay. The trick here is that it's going to be - there's going to be rectus in between. I think that it may be easier - let me see if it's free completely. Barry, I'll have you come over back this way. Yep, right there, that's perfect. Go ahead - DeBakeys? Got it. And you can snip this stuff too. just enough to get the other one. Looks okay. Nice, nice, nice. Looks good - okay. So we've basically cleared out our midline hernia. Now we're looking at our lateral hernia. So I don't know if this is omentum or preperitoneal fat because it's like in here, and the... Yeah, I think so. I looks kind of - I think what's happened is that it's - I think... That's the omentum? I think it's omentum. It spilled in from here to that one there. Okay, okay. Underneath the rectus. Okay. What we can do is just clean this up on this side, here. Metz. So this is the omentum. Omentum is a portion of fat different than subcutaneous fat, intra-abdominal fat. It - protects the bowel, but for - in these cases, it can often be involved in the hernia and in the scar tissue. So this is omentum here. This is our omentum that we're holding tension with. On this lateral side is edge of peritoneum that we're peeling away. Can I have a sponge stick? You can use cautery because I don't think we're in bowel on this side right here, and you just… Yeah, just stay superficial and you're good. Let's get this business here. Okay then get this cleared out. Are you taking that fat out, or are you just trying to...? We took it back it. No, well it's kind of meandered to a new spot. This is actually the first time seeing that, but if you see it came through one defect and went into another. All right, nice. Okay, so that side's - that's great there, yeah.

CHAPTER 5

So this is our lateral edge. So this is where the previous colostomy was, right here. Sometimes you'll see proline stitches and stuff here. I don't see much of any stitch here, I think they just kind of… They probably used Vicryl. Yeah - oh yeah, totally. Let's see if we can tuck this in. Is it all the way done? Yeah. Yeah, so this is our defect from our colostomy, here. That's the edge. And this is our midline defect from our midline. So what we're trying to do now is incorporate one piece of mesh that incorporates all of that, because if we do two pieces, then we're really going to have to rely on this, and the blood supply of this is - you just don't know over the long period. So, can we have a ruler? We have a - I brought some with Dr. Mary, like the really big one. Okay, yeah. She would do better with a Ventralex, I know that she would. Something that would help prevent adhesions later. We know that she's an adhesion former. Hopefully she's a healer, and her fascia and mesh heal up. But this is good though because I think this is something we can sew to right here. Yeah. Right? Because this is all goodness there. Yeah. Here's your ruler. So right here? Perfect, yeah.

CHAPTER 6

So now we're measuring the defect to understand how much mesh we're actually going to need. So the idea is we need to measure the defect, and then our mesh needs to be bigger because it's going to be an underlay. If this is the hole, the mesh is going to come underneath and it needs to be bigger than the actual defect. It can't just be the same size, otherwise it's going to slip through. It needs to be bigger, so that's why we're measuring this. So 13.5 superior to inferior. Yup. In there. Relax, Barry, on yours. Yep. And then come all the way across this. Only 15. 15? Do you want to do all the way across? So you're not thinking about the - like, which separately, or...? Well, I think we're just going to - yeah, I think two meshes is not going to work with this thing. Okay, so then this is 15. Okay, so - 15, yeah. Okay, so I... I think a little bit more than 15, like maybe… 16, or...? Yeah. Because this is the deep - this is - we could sew to this. Yeah, okay. So our defects - are something like this. So our dimensions across here are 15 cm, and our dimensions cranial-caudal, superior-inferior are 13.5. So we need a mesh that's going to be big enough beyond that to incorporate both the repairs, so… We need like a 20 by 15. Yeah. I think it will work. Yeah, I think it'll be good. It may, you know, curl at the end, but at least we just need a good - a good underlay on this side. I think it will work. I think it'll be good, yeah. All right. 0 proline? This is 2-0, I wonder what they have. 2-0. Well it's - we have to make sure it goes all the way across too, you know. So you can take - you can take a couple bites of this. Okay, okay. You can travel through the… And I'm going to mark that side and then try to come around it. Okay. I need a bigger needle, probably an 0 is better, but we'll do what we can here. Yep. We're going to get at least two from these. Yeah, all right. Suture scissors. And another tag. Suture scissors? It's over there. Needle back. No, it's fine. What's helpful, Yoko, is I just - I leave this here, so then I don't make a loop into myself. You know? Yep. Okay, let me grab this stuff. The Ventralex has a nice bumper that I usually sew to, you know? Mm hmm. Suture scissors. You don't have to pull that hard. Yeah, that's good. Scissors? They're a little bit shorter, but I - I like the surgeon's knot here. Mm hmm. And then I bring it down - before I bring it down, I put my finger underneath, lift up, and the mesh is basically close. Okay. As opposed to - I think one-hand ties are fine, but I think you push away the mesh sometimes. Okay. Whereas this, I know it's… Hemostat? Or you want to cut right now? Yeah, we can cut them, we can cut them. Okay. Okay. Yeah. Tail? Yeah. That's good? Yes, that's great, yeah. So… Bring it down, lift up, then I know there's not a gap. Sometimes on an 0, I can hear, kind of, the knot crinkle a little bit. Uh huh. And I know - I feel good about that, you know? One-handed ties - I feel like you did them okay, but the vector is a different direction, so you're kind of really pushing away the mesh. Okay. So now we are basically - we're putting the mesh in place. This is one edge of it, and now we're going to work around the other ways And put the mesh in. And what's the mesh doing? The mesh is basically sealing the hole. It's like if you have a - you know, if you have a break in the wall - patching the hole. Okay, so it's a patch. It's a patch, yep. And you need that because there's - you don't want to just sew it back together? Yeah, the defect is pretty big. Okay. So it would be under a lot of tension, and the chance of it to come back would be real high. Oh, so it would open up again? Yeah. At least 40-50%. Especially in her, she - you know, her fascia, I mean at this point is pretty… Right here? Yeah, that's great. Yeah. In, you know? And has she had hernia repairs before, is that what it is? Not a hernia repair, but she had a previous colon operation. She had at least two previous surgeries. Okay, it's been under a lot of stress. Yeah, exactly, it's… Thank you. Okay, good. So I think, maybe, easiest working on it for you is going to be doing these here, and then these, and then these last ones we'll just, you know. I'm making huge stitches. Closer - further away - travel some. And kind of right here. Oh, okay. So you want close here? Exactly. And then there's no gap, you know? Okay. The idea is that there's… I'm not going to even care as much about if there's any bowel right through there. So basically what we're trying to do is taking something that's pre-cut and putting it into, or kind of customize it for the defect we have at hand. So here - so this is the thing - so now, we know our lateral part - this is going be our other cardinal point, here. We have to make up this, we have to, you know, march a little more. Okay. Then we use quarter-bites, okay? And you can - so you're going to want, you know, bigger bites here. We want to make sure… It varies? Exactly. Yeah, we're going to take a bite right here. Yep. Okay. So you're going to have to make some progress here. So the last stitch was… Okay, I want you to do this here. Like so, yeah? Oh, I see it now. Hold this, Mary. I got it. Yep, and you have to make a good amount of progress here. Okay. So I'm always feeling like where the fascia is - the strongest part is, possibly. Yeah, yeah, so I mean - ideally you want to take just a layer, but - all this - I mean it's all so lateral, and it's not like midline fascia anymore, you know? It's all like a conglomeration of the three muscle layers, at this point. Yep, so pull the mesh out, control it. Can I have another pickup, another pickup? Yep. Oh, right there? So you're going to kind of keep it concentric with the mesh. Not like this, but just kind of follow it this way. Okay. You have to do one more bite of the tissue. Yep, get me out there. So now, this is kind of near the, you know, the cardinal point. So you're going to be kind of coming like this and like that. Okay. You got it, or no? Yep - empty needle driver? Scissors. Empty needle? You can do it probably on the other side, on the underside of this. Yeah, on the underside. And you're going to be kind of close to this one right here, yeah? Just feeling to make sure that's the right stuff. You know, that's... Probably need to clear that off. Needle back? Sorry if I'm burning you. It's okay, it's okay. I should know better. Now we're putting the last probably three or four stitches in here for the mesh repair. Okay. So now where… And make some progress here. Okay. So, like here, and then you're going to come right there. Needle back. Stitch. So I guess we need to come down here more, right? Yeah, yeah. Exactly. It's a little bit redundant there, but what we'll do is - exactly, we'll come back… Or do you want to cut it? Well, we'll just - I don't think it's going to make a difference really, but I agree. It's like right here, so we'll just march down. Okay. Through this way here. Do you want to fold it this way, or no, you want the scar. Exactly. Scar on this side, and the slick side here. Yeah. I think if we get it on this side, it's going to be fine. Okay, okay. Empty needle. Get the small needle. Do you see that all? You can undo it. Scissors. So we're just cleaning it up some more so that all we get is the fascia. And that's all hernia sac here. Yeah, so this is… Pickup? Anything else? Yeah, hold that side your way, yep. One second, let me see something. Sure. It's kind of folded… No, this is the underlay. Yeah, this is our other side. It's the redundant side anyways, yep. Suture scissors. Okay, so we've sutured circumferentially around the mesh. Now we're basically pulling all the sutures taut and in order. Okay. This looks pretty good. Yep. So now we can see that we basically have coverage. Basically covering it all over, you see this defect? The defect on this side and this side, and basically a mesh that covers all the borders of the fascia. Now we're going to close this down and see what we have for a closure. Yes. Yeah, so this is basically termed an underlay repair because the mesh is kind of parachuted underneath the fascia. So it's actually a good repair in terms of pressure because when people cough, or Valsalva, or anything of that nature, they're pressures coming from the inside out, not the outside in, so if there's any defect it's actually, you know, the redundancy on the mesh on the outside, hopefully, will keep that in place once it scars into place, you know? Bring it down and lift up. Again, you can see the mesh arch into the fascia, and just lay it down. She's slippery as hell. Yeah. This is a monofilament-type non-absorbable suture called proline. It's really good for this repair because it's non-absorbable, it's strong, but it's sometimes a pain to tie because it's so slippery, especially when she has so much subcutaneous tissue. So the first and probably the major stage of the operation is cleaning up the hernia, finding it, finding the defect, seeing what the problem is, basically. We know there's symptoms, we know there's a defect, and we try to find the problem. This stage is the solution, trying to figure out what works to cover over the mesh, repair the defect. And the final part of it is to get a good closure over it. Sometimes we like to get fascia, which is this, these edges here, over the mesh. That's an ideal situation because if we don't - if she develops a wound infection, or anything of that nature, we know that we have coverage over the mesh, and it doesn't necessarily translate into a mesh infection. In this case, we'll see what we're able to put together. Probably not much. Ways to judge whether the knots are done well, you can see - sometimes when you - if you see the suture, then you know the knot's not tight enough. You know, you want to see just the knot basically. There you go. I'm sorry. I'll come up to my side now. Okay, sounds good. And then we'll get the mesh out. What was there? So now we're going to go… So, underneath it. Underneath it, yep, exactly - you're going to end up right here. Give it a feel, kind of close up in there. What we'll do is at the end, we'll kind of just feel our finger around and make sure everything is okay. You know, if our finger can get through, that means that bowel can. Thank you. I don't know how well Exparel is going to work for her. Multiple vials, but… You can give her some local though for sure. We're going to need some local. But we'll do a - you can do a mixture of - how much Bupivacaine? Do you have a lot of vials of Bupivacaine? Yeah. Go ahead, try it. So the repair - so this is an underlay, it's repaired. It's basically tacked all the way underneath, and we're basically - We've tested it, just kind of feeling our finger around, making sure there's no gap, and now we're just closing over this defect where the stoma was previously.

CHAPTER 7

Some of these, I know some people will leave a drain in, but… So for that Exparel and the Bupivacaine, we're going to mix both. Just mix it together, and we'll use that. So one 30 and one 20? 30 - 30 and the 50. No sorry, 20 and 50. 20 Exparel and 50 Bupivacaine. Was it 20, 30? Yes, 20, 30. 20 and 30, perfect, yeah we can mix both those. Yep. Closing the wound. I think it's going to be too much tension to bring it together. Okay. Yeah, unless we do… Basically an incisional hernia repair. She had two hernias from a stoma site and a midline laparotomy, so we put a mesh in there. Now we're closing over the wound. I'm wondering, she's going to have a good amount of dead space. We can just try to close it in layers maybe, you know? Try our best. Here to here, you know? As much as we can? As much as we can. Sometimes transversely closing it works as well. Okay. Okay, you want to try? I don't think it's going to - I think it’s going to be too tense. Yeah, I just don't want any of this to rip or become ischemic either, you know, that's the only problem. So we'll just do the sub-q, you know, maybe use something like Vicryl, bring it together. Okay. And we'll just have to get a good binder and seal on her. Sometimes it'd be nice to have just a drain right here, just to leave it in place on that side. Okay, we could always ask. The repair is done. She has kind of a large space here - dead space. And what happens is the body doesn't like open spaces like this, and fluid will accumulate. What we can often do is put a drain in on the side here, allow for that fluid to seep out while the wound heals and scars into place. That'll be ideal for her and so she won't develop anything - what we call a seroma, which may potentially get infected and cause the mesh to get infected. So what we'll do is we'll bring this to this. Okay, and then tack it down here. This edge is not our strength layer, but it'll be just kind of closing it over. Okay. And then we'll tack that down. Okay. Take that to that. So we are tacking what little tissue we have to cover the mesh as much as we can. You good with that? Yeah, it’s perfect. I think we can just run it. Okay. Let's see, let's see, let me take a look. We're good, that's a good job there. Want me to move down a little bit, or...? Yes, thank you. Uh, I think that's it. That's all we got. Ah, I don't think I can do anymore on… Okay, let's take a look. Without causing too much tension. I think that's fine. Yeah, that's perfect. It's good. Nice. Yep. Scissors. And it won't close, of course. Scissors. Yeah, that's good. That works. We're going to close in layers now. And try and not get the drain. Are you okay with me running it, or do you want me to do it interrupted? Yeah. Scissors. We can throw that out. Oh, question! Yeah. Right here, should I have done the belly button here first, and then… Oh, yeah, you can. What you can do is just - with your running Vicryl, just incorporate, grab a little bit of tissue here on the underside of the umbilicus, then it'll pull it together. Okay. If it doesn't look good, then you can just stop right here, tie with that running, and then put an interrupted. Okay. Yeah.

CHAPTER 8

Our initial inclination was that there was a stomal hernia, and we did identify this during the operation. There was a midline hernia and also a stomal hernia, so the complexity of this case - the complexity of the case was a little bit higher because we had to utilize a mesh that could cover both defects and had a portion of rectus muscle that was bridging in between. So, just to the nature of the hernias, we had to be a little bit creative in terms of repairing it and doing it in a sound, non-tension manner.