Robotic Retromuscular eTEP Repair of Ventral Incisional Hernias and Diastasis
Transcription
CHAPTER 1
My name is Eric Pauli. I'm a hernia surgeon at Penn State Hershey Medical Center in Hershey, Pennsylvania. We're gonna see an eTEP hernia repair today, eTEP stands for extended total extraperitoneal repair. And our goal is to do it as a retromuscular operation and stay directly behind the rectus. The patient is a 52-year-old female, and she has a history of pregnancy, and she's had two cesarean sections. As a consequence of that, she has a diastasis in the M2 and M3 zones, and she subsequently had a cholecystectomy. And as a result of the diastasis plus the surgical incisions near the umbilicus, she has some hernias there in the M3 zones. She has a native umbilical hernia and she has an incisional hernia as well. So our plan is to access the left retrorectus space laparoscopically and then open that space up. We'll then place three robot ports along the left semilunar line and dock a surgical robot. We'll do a crossover maneuver. We'll reduce the hernia content and we'll do a right-sided retrorectus dissection. We'll place mesh. I secure mesh in that operation only with some fibrin sealant, and then we'll close our fascial defects as well. This is our patient. She's a 52-year-old female who has a history of previous abdominal surgery. She's had cesarean section. She's had two pregnancies, and then she had a laparoscopic gallbladder operation. So as we approach the mid-abdomen here, we begin to see some diastasis. Here's the right rectus abdominis muscle. Here's some widened midline. European Hernia Society recommends that distance of greater than two centimeters is a diastasis, and she's three centimeters here. So she's got a bit of a diastasis in the midline. As we approach the umbilicus, she has what is likely a primary umbilical hernia here, again occurring in the setting of a diastasis. And then she has a secondary incisional hernia right here, which is an incision from her cholecystectomy. Her abdominal wall is then, for the most part back together, a little bit diastatic immediately in the infraumbilical region. There's a small subcutaneous, I'm gonna call it a ditzel here, which I'm not concerned about at all. It's a granulation, it's an old suture site problem. She has no history of infection, and I'm unconcerned that this represents an abscess or anything that requires us to be concerned about contamination during the case. In the low midline, the abdominal wall is, for the most part, back together here. As we come down all the way through the low abdomen, we don't see any obvious hernia defects here as we get down low into the M5 zone. One of the things we found during the surgery was that in addition to this umbilical hernia here, this diastasis here, and the incisional hernias, as we were working to get inferior overlap, it became apparent that this is actually a hernia. And this is a special kind of hernia that happens after cesarean sections. On this scan, the rectus abdominis is intact and joined by an anterior rectus fascia. So the linea alba is completely intact all the way up and all the way down. But here is a good example of how you actually have some fat coming between the rectus muscles, because during the cesarean section, the posterior sheath was opened and then not closed. When I looked at this prior to the operation and when I met the patient in clinic, this did not appear to me to be a hernia. And on exam, it doesn't bulge very much. But as you saw in the operating room, this area is actually peritonealized, and when the abdomen is under pressure with insufflation pressure, this area actually herniates up, and we saw content extending up under the fascia and then around and kind of that little mushroom shape that we see with hernias. This is not apparent on the scan, because she is laying down, she is relaxing her abdomen and there's no pressure here. But if we had done a Valsalva CT scan or had looked at this under ultrasound, we would've seen this bowing up and we would've seen a peritonealized layer coming up. So again, it's content extending through what would've been a closed posterior sheath and lifting the anterior fascia up off of the rectus abdominis. This is a variant of an intraparietal hernia that we see after C-sections. Fortunately for us, our planned retromuscular repair, allowed us to not only address the actual hernias in the diastasis up top, but to reapproximate the rectus muscles back together. And even though it's not a true hernia, we did allow our mesh to be reinforced below this area here. So, that allowed us, you know, the robotic technology and our choice of approach of an eTEP operation allowed us to fix this partial-thickness abdominal wall defect as well.
CHAPTER 2
You like there? I like it. This would be an eight port. Take the optical access, get through that. Beautiful, take a Ray-Tec, take the room lights down please. Overheads too. Lots of twisting, a little bit of pushing. One hand's the gas, one hand's the brake. That's Scarpa's. Yeah, ignore for now. Just watch, let's just, we'll just get in. Gas is over here. That's Scarpa's, subcu fat. Subcu fat, anterior muscle showing up there. There's anterior rectus sheath right at the tip. There's some rectus abdominis muscle there. Hopefully, rectus, some muscle layer there. Let the weight of the blade do the work. There's rectus, there's rectus, there's rectus. Still muscle at the tip. Still muscle at the tip. That's posterior sheath there. I agree. Now flatten a hand out. Let's put the camera up. Muscle up, posterior sheath down, it looks like. Agree. Advancing in, hold the camera there. Keep it flat, yep. Let's hook the gas up, gas on, please. High flow, it's gonna alarm. Nobody needs to worry about that. Keep up, up and down, down, great. It's not alarming, and it should be. What insufflator is that? It's the air seals. Got it. Well that's a shame. Yes. 'Cause if it can't insufflate when I'm in the plane that I need under some pressure, then that's not helpful. Let's take it out and see if it'll stay. Go ahead, Cameron. Nice. Looks okay. Yeah, agreed. Beautiful. Again, it's important to just confirm before you start, you know, before you start dissecting. And this view with a zero, like without seeing the muscle, you're making a tunnel and what you're doing is you're making a tunnel, you're lifting the subcu fat up off of the rectus. And that's a, you can... SCOLA. Yeah, it's a SCOLA. And it's shocking how easily you can actually do that. I mean, the connective tissue planes will let you do some of that dissection. Yeah. So, okay. You can put the gas on high flow. You like to, want to switch to 30? Or you want to... Thanks. Well, we'll do a little bit of scope dissection here, the blunt tip here, the straightforward tip is a little bit easier to do some of this dissection. We got anything marked here in the retromuscular space, just that guy up top. So the rest of those should be... And then this bottom. And that guy down there. Again, we probably won't even see that. Agree. I guess it depends on what the angle the port was placed at. All right there, Hildegard, what are we worried about here? We're in the retromuscular space. You've seen us do some retromuscular operations before. So we're worried about getting into the peritoneum. We don't wanna get into the peritoneum. We've kind of already passed that hurdle at the moment. I mean, at some point, as we're crossing over, in the midline, we may get intraperitoneal. Right. Okay, what else? What else can we do? What can we do damage to in the posterior sheath there as we're working? What lives here, what lives in the posterior sheath? Well, so on... You just have a spinal needle at some point that we can use? Not that gigantic one either, like a normal-size one. Well, I mean, so the rectus muscle lives in the posterior sheath. The rectus muscle is... Yeah, it's got a sheath there, but what else? I mean, there's other things that live in this plane, right? You've seen us do the dissection. What are we looking for? On the lateral aspect of the posterior rectus sheath, we're looking for? We're looking for those little nerve bundles. Yeah, there's a neurovascular bundle right there. That's an intercostal nerve. Yeah. That runs in an intramuscular plane between the internal oblique and the transverses laterally. And as it comes closer to the midline, they run in between the plane and they go into the back of the rectus. So you know, you're talking about maybe getting a port somewhere in here. I might do a little bit more kind of in here, but we're kind of over that spot. You know, it's not terrible. We can also, if we have a plane to get the next port, we should switch out to the 30. Yeah. So there's some vessels, there's some neurovascular bundles, lateral, there's another neurovascular bundle right there. So we wanna make sure we're under that and lifting that up. And then at the bottom of this plane are the epigastrics, right? Yes. Straight down the middle are the epigastrics, so... Okay, we'll be much more efficient if we can get another port in and then change. Let's go to the 30-degree lens. Hang on to that for one moment there, Ben. Let's just unspin that guy. We're insufflating just in the abdominal wall. We're not intra-abdominal yet. At some point as we're crossing over, we could get intra-abdominal. So as soon as that camera's up on the field and we're starting to put it up, put that warmer on, because when it goes in, it's cold going in, you got gas going in and then it fogs up. So as soon as you can make that kind of body temperature, the easier it is for everybody. Let's back this port out now, it's gonna be an okay spot, yep. You're pretty close to where we need you to be. And again, we can do some of the dissection if we need to get a little more room. Her rectus muscles are not crazy wide. Yeah. They're not nine centimeters wide. So if we need to, we can make a little more room. So mindful of that perforator going in there. Hold on, yeah, you're gonna be okay there. You'll be able to go a little farther lateral actually. Can you come a micron higher and maybe a little more lateral, go right in between those, yep. Come higher up. Yeah, should be okay. All right, I'll take the camera clean. He's gonna need a knife. Needle back to you, then a knife for me. Don't migrate anymore medial. Lots of twisting, a little bit of pushing. Yep, let the blade do the work. Yep, now drop your hand, wonderful. That's great. Okay, give him a, what do you want? A bullet, a Maryland, a scissor? Think I'll take scissors. Back that out a little bit. Get your remote center right there. Get some lap scissors then. Lap scissors to Ben. Unless you like the pick and pull. Yeah, you can put the gas down here for now. That'll help with the fog. Yep, just sweep. Sweepy, sweepy. Beautiful. Yep. Yep, ignore that for now. Come a little more medial. Do the medial stuff here. Sweep, sweep, sweep, yep. Work up toward me, sweep, sweep, sweep. Yep, sweep, sweep, sweep, sweep up. Lift up to the head. If you wanna cut those guys, you can, back to support out a little bit. That can all be cut. A little bit of energy. Cut it, good. Sweep, sweep, sweep. Sweep up, yep. Cut it. Yep, cut it. Yep, sweep up. Go to the midline, go there. Work your way back down. Yep, sweep up to the rectus, there you go. Let's give that a little bit of energy. Ready? One second. Yep. Sweep, yep, sweep it up. There's a little vessel right there, let's get that vessel. See that right there, just buzz the vessel. It's that little perforator that usually comes from the epigastrics and goes near the umbilicus. Nope, you're grounding out up there. So it's not gonna work. Open one jaw and just touch it with one jaw. That'll keep you off the vessel itself. Yep. Yep. Cut. Cut. You guys have a hook? We'll take a hook cautery. I would not have cut that while it was still not cauterized. Get a Maryland, please. Obturator, please, for the port. Obturator for the port, please. Find your way back through. Yep, Maryland, please. Yeah, put the hook on, but give him the Maryland first. Maryland for me. And then you can put the hook on. Yeah, he just... One second. Grab the vessel. I'm gonna park on the... Grab it. Pull off the abdominal wall. Stay right there. All right, grab this vessel here. Scoot up a little bit if you can. Yep, pull down gently. All right, great, we'll take the L-hook now. Come on in. Yep. Yep, little bit of energy. A little bit of hook, little bit of pull, good. Yep, little bit of energy in that little thing right there. A little vessel or something. A little bit of muscle or something right there. See the muscle on the floor? Yeah, get that stuff, yep. Hook it and pull, there you go. Hook, pull back into the port. That's your counter tension. Good, yep, sweep, sweep, sweep. Beautiful, sweep up, straight up, there you go. Keep working your way back this way now, keep going. Keep going, yep, sweep, sweep, sweep. Lift up, lift up, lift up. Sweep, up to the ceiling. There you go, okay. That you can hook those guys. Yep. Yep, sweep up, beautiful. See if I can give you a better view of this stuff here. Let me back this port out some, at some point, we gotta upsize this as well. Yep, hook that, hook and pull, little vessel in it. Hook it, pull it, get it. Beautiful. Yep, okay, fine. You're gonna be out of room here, that's fine. Okay, let's go down. So for those of you watching along at home, I do a fair bit of this laparoscopically. This dissection is not particularly complex. You're basically just making a pocket in the retromuscular space. The most complex it's gonna be is if somebody's got some old scar on this side of the dissection. And I probably wouldn't have started it here if she had a big scar on her left side, or right side, excuse me. Yep, I would hook those little guys and pull 'em into the port. Hook, pull toward yourself right into the port. Straight back, there you go. I'll change the lens view, we'll look over that way. On her right-hand side, she's got an old appendectomy incision there. And so it crosses, it's like a Rockey-Davis style incision. It kind of crosses, so that's your epigastrics right there, okay? So this little branch right here goes from the epigastrics up to the midline. And then so I would get under that and lift it up and I would intentionally buzz that little vessel. And I'd get it, yeah, right about there. Lift it up, lots of energy on it. Yep, lift it up. Yep, get under it, take it. Yep, keep lifting up. Yep, lots of energy, keep going. You're good. All right, good, now pull back into the port and go through it. Great, one more little buzz right there. I think we'll get it. I would then clean your device. Let's clean that guy. And then it looks like your epigastric fat pad is all that stuff right there. So that clear plane down below is where you wanna be. You'll lift that clear plane up, and we should be close to being able to get down enough to get our third hand in. We can then upsize this and then dock a robot. There you go. Yep, just sweep up toward the epigastrics. There you go up, yep, and then hook that stuff there. Hook under the clear stuff and pull straight into the port. Straight toward yourself. Yep, do it. Yep, yep, lift it up. Pull to yourself, go buzz, good. Be careful when you're buzzing that stuff on the floor, because we don't know what's below us, yeah. Lift up, up to the ceiling. Yep, good, keep going, lift up, good. Okay, good, let's get this stuff medial now. Yep, okay, let's get this stuff in here. So I started to say, I do a lot of this stuff just straight stick laparoscopic. You know, it's not particularly difficult. Yep, sweep back, sweep up to the rectus. There you go, that's the plane. Come back here a little bit, sweep up. There you go, there's the edge you wanna get, that's gonna be stuck right there. Yep, hook in there, get those little adhesions. And you can be pretty fast and efficient and you can port hop left and right if you need to. Hook there, wiggle in between those two. Yep, yep, pull back to yourself. Good, take it, okay, let's go up here. Let's get this band of stuff right here. So there's a vessel, that's a neurovascular bundle right there. So you wanna hook this on this near side of it here. I would hook under and up. I would get that up, yep. And then I would sweep that all up. There you go. Yep, stay off that nerve. Right there, sweep that, lift it. Lift up, good, sweep, in and up. Yep, in and up. Okay, something bleeding. Something bleeding right there. Something off the epigastrics, just touch it. Just swipe it once to see what's oozing. It's nothing, it's just a dollop. Okay, where's your next port gonna go? Somewhere in this range is gonna be okay. Seeker needle. You're a hand, you know, you're a hands breadth down. Yeah. So there's your epigastrics there. Little branch right there. How far apart are you? Can probably come up a centimeter. Yeah, I think so long as you, yeah, I mean I would just make the incision above that and I would angle the port in a little bit, and you'll be fine right there. Once this port is in, we're gonna upsize my upper hand here. Lots of twisting, a little bit of pushing. Lots of twisting there. Yep. Just watch your angle. Don't go too high toward the head, yep. Great. Okay. Let's look up here. See what we can do here. Take a Maryland. Get ready to buzz me. Buzz me, great, buzz me there. Nice, come on up here, and buzz me there. Nice, okay, I'll take the hook and we'll upsize, and we should be able to dock, I think. And again, I'm gonna say it for those watching at home, you don't need to do this much work laparoscopically to be able to dock. It's just, it's fast and efficient for the most part. It gives you a little more room so that when you do dock, you're pretty much ready to do the crossover a lot of the time, maybe with a little bit more. And again, I think you have a little more flexibility to reach above your ports, to port hop, to work below your ports, you know, without having to have the robot camera in and docked. You're definitely a little more flexible in terms of, you know, motion here when you're just pure straight stick lap. Even the upper crossover on a lot of these folks, because there's so much preperitoneal fat in that plane is pretty straightforward lap. I think where the robot really shines and is probably, I'm not gonna say mandatory, but certainly extremely helpful. Let's go way up here. Is, yeah, put the buttons the other way, is where you're doing the deconstruction and the reconstruction and you need to sew on the ceiling or the floor. Certainly those maneuvers can be done lap, but they're certainly a little bit challenging. And so being able to sew on the ceiling robotically and on the floor, very, very helpful. Okay, that's a fair bit of overlap now that we got. It's pretty close, that's a nerve there. Looks like a nerve there, looks like a nerve in here. And there's a nerve just behind my port here. So none of those are coming down. We're gonna leave most of that there. I can probably free a little bit of this up here. We wanna get a little bit of coverage here on this port if we can. And so maybe I can free these guys up here on the floor without going after the nerve itself and leaving those intact. You wanna come from the middle port towards? Yeah, maybe, it's the old proverb. What is the sound of one hand operating, you know? Okay, let's upsize this port here. Okay. Take a robot eight, five port back at you. Okay, let's dock a robot.
CHAPTER 3
We're gonna hand this laparoscopic camera back to you. Is she doing all right? Yep. Awesome. Ah, beautiful, let's do it, that looks great. You wanna burp the arms up or no? Yeah, now you can burp 'em up a little bit. Wonderful.
CHAPTER 4
All right there, team. Let's see what we can do here. We're gonna do an upper crossover. We're almost all the way to the midline here anyway. She does not have a lot of space here. It's good that we did most of this lap. Yeah, okay. It's pretty narrow. Yeah. All right, so we'll cross over here. Fat goes down, the linea alba should be up. It's a linea alba there. We will swim, swim, swim in the preperitoneal space. Drop it all down. We're gonna find a couple little branching vessels. Those guys, we will do a little bipolar action. So the goal here is not to injure the linea alba on the crossover, but obviously not to have many or any holes in the flap that we're making as well. And there's a balance. Sometimes holes are unavoidable at areas where there's old surgical scar, which is why we marked 'em out at the beginning of the case. And sometimes they are avoidable if you just go a little slower and take your time. Swim, swim, swim. Now at her very tippy top here in the preperitoneal space, she does not have a diastasis. It's just in the M2 zone. Her top of her M1 is back to a normal size. And so we don't need to worry about taking all that down with us. This arm up top is gonna need to be adjusted. It's not, I can't reach, I'm colliding with something. Move your arm for elbow out. Okay, thank you. Very nice, Hilde. It's one of our third year, third year, right? Yeah. Third year Penn State medical students, Hildegard, doing the bedside assist here. Ben, are you at the console there? I am. Okay, good. I actually think you're colliding again. Mind if I move the camera? If you can move the camera a little bit, go for it. We gotta go a little higher here. I'll back up so you got some room to do things. Okay, here, I'm moving four again. Yep, you're good, leave it there. We're gonna need to do something with that arm, 'cause we need to get up here to suture. Yeah. Elbow the other way around. Okay. Let us know when you're ready for that. Go for it. Yeah, it's good. And we're also, I mean, if you look here, I think we're also approaching, I mean, there's rectus right here. So this is a normal linea alba. So we're at the apex of where we need to be to operate to suture. And we just need a little, you know, we don't need to suture up there. So if we can get this down in terms of our dissection, then we're in pretty good shape. We gotta be close to the xiphoid there. Yep, we're above the diastasis there. So we're in okay shape. Swim, swim, swim, swim, swim, swim. Look at that, if she got a port right there, This would be upper midline. That's a port site, right? Do we mark a port out there guys on the skin? I don't think so. Well, it's a laparoscopic trocar site in the right just to the midline of the rectus, okay? No, no, we did. Yep, and on the scan, actually if you look at the scan at this spot, you will also see that there is something there on the scan. Now this is gonna be a nice cheat. I could see the rectus muscle through there. That's a hole in the posterior rectus sheath. And so by cheating, I can now see that actually the rectus is actually up there. So this is the actual, that's gonna be the edge of the posterior rectus on the opposite side, on the right-hand side up there, okay? So that's the rectus. Probably from her epigastric lap chole. Very likely. So again, there's no diastasis here. This is the right rectus, this is the left rectus. This is a normal linea alba here. Got a beautiful linea up there. Yeah, it's nice. It's not particularly diastatic at all. And then all of this can come down, and now we're behind the right posterior rectus sheath as well. Let's come back to here now. Again, I'm putting tension on this, and I can feel that as I, up here is easy. Down here, a little bit of tension, so we're gonna come back to this edge here and we'll start working here. Now most of her hernia is peri, I mean, her hernias, the two hernias that she has in addition to the diastasis are both periumbilical. So we need to get those down. And then we also need to remember that she has had a C-section. And so even though there's a low transverse incision, they have divided the posterior sheath up/down. And so we're gonna have some element of scarring in the lower crossover. So this is not a person in whom you can say, well, let's avoid the hernia entirely and let's just go do the crossover above and below and it'll be easy. Just because there's no scar there doesn't mean there's not scar there. It just means that you gotta remember how they do the C-section. Yeah, that's all the diastasis. And again, I mean, that's mostly just the CO2. There's the edge of the rectus right there. So it's probably about as far as we need to go. So edge of rectus, you can see it's there and it comes down this direction, okay? Let the gas do the work. It is starting to come up on our feed. Could be. We gotta be relatively close, right? We docked the camera port, you know, camera port straight in is here. So it's gotta be close to the, you know, close to the location. Having that camera slightly above or at where the hernias are is helpful, 'cause, you know, you can start to look around the corners in the area of the hernia as you go. Again, I think that my impression of her abdominal wall here is that she has favorable amounts of preperitoneal fat to do a lot of the dissection here without, you know, without having to do the circle, the wagon maneuver that you need to do when there's a really complex hernia in the midline and you're worried about how much preperitoneal fat there is. And you know, we know from the scan that the hernias primarily have fat in them. There's not truly bowel in the immediate adjacent area. You always gotta be suspicious about it. But it's not like we've got a picture, and there's a little vessel right there trying to get in trouble. This is gonna be the hernia right here. See, we're actually intra-abdominal right there. See it? So our floor is gonna start to bulge up at us because we have a tiny little hole intraperitoneal. And so if that's happening, what I'm gonna do is just go across to the far side. I mean, you could always sew that close, I guess, if you wanted to and let the gas go away. But I'm gonna continue to work across and open up the retromuscular pocket. You can see the floor bulging at us because of the air going intra-abdominal. So we'll go across, we'll get retrorectus, and we'll just keep opening the space. And by making our retromuscular pocket the bigger space, a lot of that gas should no longer be problematic. If you were the rectus, where would you be? Right there. So again, floor's bulging. So we'll work somewhere where it's a little easier, and we'll extend all the way across. I have an oriented question. You have a what question? An I'm orienting myself question. Yes. Right now you're cutting through the lateral posterior sheath. The right-sided posterior sheath. We're doing the crossover. We initially crossed over from the left posterior rectus space into the preperitoneal space of the midline. But we wanna go farther, and so we're jumping back up into the contralateral rectus plane. You can do any surgery that you want, any hernia repair that we have, you can stay just preperitoneal. But to do that, you gotta be pretty good. The peritoneum is very thin, okay? You don't have to plane hop, you don't have to do release of posterior rectus sheaths. You don't have to do TAR, you don't have to. But the reason we do them is because jumping into those planes means that the layers you're taking down are a bit more robust, they have a bit more connective tissue to 'em. You have a little bit ability to be a little more rough with it. If you get holes, it's just substantially easier to fix and repair. So there are reasons why jumping retromuscular becomes the way to go, okay? You know, in that last case that we did when we didn't have good peritoneum, the next question we asked ourselves was, ah, should we just jump into the posterior rectus space and do it? I mean, there are some consequences to doing that. It was a smaller hernia and doing a posterior component separation for a smaller hernia, you gotta ask, is that the right answer as well? But then we looked down below and because of the previous midline laparotomy, her posterior sheaths weren't together in the midline either. So even doing that would not have worked there. Now we don't know what her posterior sheaths are gonna be like here when we get down. So we gotta be mindful of that as well. It's possible that her posterior sheaths, because of her C-section, are actually apart down below. So the crossover down below may not be super-duper straightforward either, okay? So there's the midline, that's the diastasis, that's all diastasis, that's all diastasis, that's all diastasis. And then back up there, it's normal. Can somebody stick a finger and just push at her belly button? I think we're approaching that area right now. One finger in the belly button, please. There we go, so that's the hernia coming up. Okay, you can stop now. That was very good pushing whoever did that. Congratulations. So we're gonna start then going into the posterior rectus space here as well, okay? And so, you know, this is similar to how we started the operation on the other side, and you saw we did most of it with a hook cautery and with the blunt tip of the camera. And you know, there are some little vessels that traverse this area, but for the most part, once you get it going, you can do a lot of blunt dissection. You kind of sweep and back hand up and get things moving out of the way. When there are vessels, we can cauterize them. And then what are we looking for? How do we know to stop there, Hilde? We have the semilunaris neurovascular bundle. Neurovascular bundles of the linea semilunaris are gonna be our stopping point. Now we also know that down in her kind of right lower abdomen, after we do what may be a very difficult crossover, she has that old Rockey-Davis incision there that we gotta be on the lookout for. See that little partial hole right there? See that, guys? Is that another port site? It's kind of mid-abdomen, mid-rectus on the right. Yeah, yep. Yep. So that's a posterior sheath defect there, but it's not a hole, the peritoneum covers it. I thought it was a blood vessel at first, but it's just a hole in the posterior sheath. You know, those posterior sheath defects from laparoscopic trocar sites are probably, I mean, much, much more common than we think. And their of no consequence, you know, sometimes there's a little bit of fat plug in 'em, like a little partial-thickness hernia, but it's no big deal. That's gonna be a little neurovascular bundle right there probably, maybe, we'll see. Look like the muscle started to move a little bit. And I was not apparent if I was just near the muscle with my cautery or if I was doing something wrong. So again, the floor is still bulging up a little bit. Remember that I'm 30 up and this is the view that we have. We gotta make this pocket bigger, bigger, bigger. And at some point, the pressures will equalize, and this space will be kind of the dominant space, and we'll be in a little bit better shape in terms of our ability to visualize. But also, nothing we're doing is unsafe. If we had any problems with that floor coming up, what would we do, Hildegard? There's gas in the abdomen, and I can't continue. So you would put in another site to prevent it. You got it, I just put a trocar on the other side. Would you make sure she's fully paralyzed as well, please? I see her rectus is starting to contract here. So that is the semilunar line. See it right there? Yep. So if we were to accidentally cut here, we'd be making an injury not only to the neurovascular bundles that run along that direction if we continued, but also it'd be a full-thickness fascial injury and we would then have a iatrogenic hernia of the lateral abdominal wall. And it's a problem you see when people are learning how to do component separations, they're concerned that if they cut down and do a TAR that way it's too thin and they go, that looks thicker and they go that way. It is a lot thicker, they're not wrong. It is the wrong plane, however, and it causes some very real problems. So we wanna always be mindful about where that semilunar line is and how are we working around it. Up here, we kind of want the planes to be symmetrical. We've released it to there. This is just stuck, because this is this trocar site right here. So we'll just take that down with us and then you know, that should all be fine. You can see the edge of the transversus abdominis right there. The posterior lamella of the internal oblique is covering it, but you can see through that, right to the transversus muscle itself. Up top here, the question is always gonna be, you know, where are we gonna stop our suturing? Where's the rectus kind of normal? I mean, this is probably the top of the diastasis right here. This is the top of where we need to sew, right about here. That's gonna be our mesh overlap. I don't like to sew right to the edge and then have zero mesh overlap. Because theoretically, when you're suturing through thin tissue like a diastasis, if you don't have a little bit of superior overlap, you risk that those sutures pull through and you get a hernia above your mesh where you were just trying to fix a diastasis that wasn't even a hernia there the first time around. So that's all fine, we'll leave that. We'll sew to about here. And we should be fine in terms of our, you know, our distance of superior mesh overlap, okay? And again, lateral mesh overlap. If you've got a stitch here, I mean, this is plenty far out in terms of the distance, okay? You know, the thing is once you open up this plane, I think most people feel you're sort of obligated to open up the whole posterior sheath. But if you're thinking about, like, how would we normally do this hernia if we just needed overlap, if we were doing an IPOM, we'd just say five above, five below. Yeah. But here we are doing a lot more. We're trying to get a lot more distance on stuff just because we're doing sort of a different technique here. Coming back, coming back, coming back. Okay, let's go after our hernia here now. So now we're right at it. Let's see what we can do. So we're separating the posterior sheath there with the scissor blade from the peritoneum first. That's all the posterior sheath release kind of around the hernia. And again now below the hernia here, this is gonna go back more toward the midline. And then all we gotta worry about is the crossover where she had the C-section. So I'm going slow, not 'cause I'm concerned there's bowel in here, but because I'm trying to not tear a gigantic hole that we then have to close again, it may tear anyway. I think this is okay to take here. That little band has to go. Now because this is the hernia and you know you're gonna close the fascia, if you were to accidentally injure the linea alba here or kind of burn the abdominal wall, you're gonna be a lot less concerned about that than if you were to do that, say, in the upper midline where it's kind of normal tissue and you don't really wanna damage, you know, the actual abdominal wall, okay? This appears to be some incarcerated hernia content. Here's a true fascial defect there. Incarcerated content here, sort of round ligament and preperitoneal fat stuff, we have a portion of the round ligament there. See if we can get this fat coming out. Come to me.
CHAPTER 5
Okay, this is not coming down, this is clearly very thin. So we're gonna get into the hernia sac here, okay? We can see the hernia there. We can see the edge we're working around, and again, we're gonna have to close, but we already had one little hole there anyway. So it's time to just say, look, this is the hole and we're gonna work with it. 'Cause now that we can do this, now we'll be able to easier see the edge. It's obviously a cribriform hernia. There's gonna be multiple little fascial defects there. And then we'll get back into the preperitoneal space right here near the edge of the defect. So at some point, you just gotta say, look, we're gonna intentionally make the hole bigger so we can just get around this. It's not saving you time to try and preserve it, 'cause at that point, you're going so slow that any time savings is gonna be offset by the fact that you're gonna have a bunch of holes anyway, so... Now shortly after her umbo here though, after the umbo hernia, the abdominal wall comes right back together. So the linea alba is gonna be very, very narrow at that area, okay? This is all preperitoneal dissection here. That's all preperitoneal, preperitoneal, this is nonsense. The other thing is now that we've got a hand and a camera on the inside, we can see that there's no content incarcerated in this. And so like, you know, you can work with a little bit more gusto and not fear that, you know, that, like, there's bowel right here you're gonna suddenly, you know, run into. 'Cause there's not. All these little suture site hernias here. All that little hernia right there. They're so cute. My favorite. Even then hernias are cute. Oh, my goodness, it's the best thing ever. See if we can get a little quick peek here. You know, so I mean, there's a little bit of scarring from the C-section, but mostly, it looks like the posterior, certainly the peritoneum and the stuff that leads to the bladder flap are gonna be intact here, okay? And we've got a nice view, we're sort of looking straight down the middle. The midline is roughly, you know, here to here. So this is kind of your view of the upper pant leg. And so your crossover here is really kind of a top-down crossover, right? We're sort of looking, this is the right-sided, I'm sorry, the left-sided posterior rectus release here. I mean, my hand is almost going straight down. We'll have a little bit of transversal fascia in there, but then we should be able to kind of say, hey, like, where do we wanna go here? Can I just jump straight preperitoneal? Probably, pull it down, lift it up, cross it over. It's gonna be stuck though. And we may wind up having to close that hole kind of this direction from the bottom up. But if I feel like there's a fair amount of tissue here for us to utilize, you know, for this purpose. Yeah, that midline is going to be trouble staying preperitoneal. Yeah, maybe. We can jump pretransversalis though. I think again, here, my main concern, as I'm doing this, is because she doesn't have a hernia defect down below here. Right, there's no hernia past the umbilicus, okay? As I'm taking this plane down, yeah, I don't wanna have any holes in the floor, but unlike when I'm working at the hernia, I can't really buzz and damage the linea alba. You know, you gotta be mindful that you can't injure the linea alba here, 'cause if you do and you don't cover it with mesh, especially low down, you're gonna have, you know, potentially a hernia form, okay? All right, guys. So for posterior closure, Dr. Fung is gonna need a 2-0 V-Loc. Six inch will do. For ceiling closure, he's gonna need a number one, Stratafix, probably just one. I mean, here's the intact linea alba here. That's the midline of the bottom of your defect. You've got one, two, three. There's gonna be a fourth hernia defect there, and you'll run it. You might need two, to be honest with you. It's a reasonable distance of diastasis you're covering. If we say you're coming up to, let's say, you're coming up to about here, okay, we can stick the ruler in and measure. But you know, that's most of the diastasis to there. Yeah. Okay? So he might need two of the Stratafixes. We have one of the V-Loc's, but it's a 9 inch, is that okay? If you have a six-inch, I'd prefer it. Nine is gonna be just a little too long unless I tear this hole open. So I guess here's what I'm gonna say. Have one available. Cut it? No, no, don't cut it. Okay. Thank you for asking though. Then I'll be suturing till tomorrow. Getting a little thin there, huh? I'm gonna tear it open just so that you... Exactly, yeah, so you get to use the entire nine inches of the... That's probably a deep layer. That's right, you hardly ever waste any suture in the OR, that's true. If they open it, I use it, it's my rule. Sometimes I don't even need it. I think this is muscle right here. And so I think that if I can kind of, yeah, see? Agree. Yep. That's in the posterior sheath there. That's still in posterior sheath. Yep, there's some rectus there. So I've done a little, you gotta get a Vicryl on that right there, okay? Yeah. We'll need a six-inch 2-0 Vicryl as well. Okay. Sweepy, sweepy, sweepy, sweepy, sweepy, sweepy. Sweep, sweep, sweep, sweep, sweep, sweep. I don't feel obligated to cover the entire C-section incision. I don't feel obligated to reach the preperitoneal bladder flap and see the pubis. We have a hernia that is of a defined length and that length is there. This is plenty of inferior coverage for what we're trying to do, okay? Which is odd because I wouldn't say the same thing about the lateral coverage. We're definitely gonna dissect out to the semilunar line. You were saying that once you open this space... I mean, you've opened it, you've incurred the price of opening it, you know? Doing the extra dissection and getting the lateral overlap, I mean, we do it, right? I mean, it makes it easier, I think, to size and position of the mesh, because to do this properly, we had to open up the entire left side. Yeah. So then you're putting in a mesh that's like not really symmetrical. And I think that there are just some thought problems that come along with not doing it as well. Maybe. Is our bipolar working okay? It sure seems kind of anemic today. Can somebody please push on the patient's right lower abdomen where this, the appendectomy scar is? So it's down there. Okay, that's good. You can actually see maybe a little bit of disruption there in the sheath. So we'll avoid it for now. We'll come up here, we'll take this down first.
CHAPTER 6
All right Dr. Fung, go for it. Go find the semilunar line all the way across, okay? You got it. I'd work where you're currently working, okay? Here, then I'd go all the way up. So go here, go all the way across, go all the way up, and then I'd come back to where that anticipated scar is gonna be, okay? Avoid the hard spot. Yep, buzz, buzz, sweep. Yep, I love it. Keep going. Yep, this connective tissue plane that he's opening here does not really, it doesn't have a name anatomically. Everybody's amount of connective tissue here is a little bit different. When we do this open, a lot of times, you can just take a peanut or a kitner and just kind of sweep and you're done. On some people, it's really, really thick and you have to do formal surgical dissection with scissors or electrosurgical energy to make it happen. Yep, buzz all those guys, you're good, yep. Yep, buzz it. Good, go straight in. Scissor over dissector. Push down, pull up. Cut, buzz, go, keep doing it, you're doing great. Yep, so hey, your epigastrics are right there. Nope, no, no, look back, they're right above you. That's gonna be very likely epigastrics, okay? You got a fat pad surrounding them. You're lateral enough now and you're inferior enough that you should start to see 'em. They're almost even with your lower hand port where we found 'em before, and they're anastomosing with one of the vessels of the linea semilunaris, right? There's a big branch going over there and that's what they do. So you got that landmark, and so then everything just goes up from there, okay? Now that epigastric may be stuck to the posterior sheath if they divided the posterior layer through, near, around it. Just like when we talk about, like that parastomal case we did yesterday, the old stoma site. You know, the epigastrics can be stuck directly to those lateral defects, and sometimes even though they pushed it out of the way, it's now stuck to the edge of the suture closure. Sometimes they're out, sometimes they're not. Like, there's a vessel, that epigastric continues right through there. That's your epigastric right there. Yep, you got it. So there's little branches coming down. So just stay low, everything goes up, yep. Beautiful. You know, it's a little more prominent that vessel on this side. It's possible that the epigastric actually was taken out, and so you've got a little more prominent, superior epigastric elements here because of that, okay? You can see neurovascular bundles starting to show up there in the distance. There's one above you, that's a nerve artery vein complex right there. So you're approaching semilunar line. I like what you're doing. Everything off the floor, push up. Yep, sweep it. Beautiful, keep going. Yep, wonderful, keep going. It'll eventually stop and you'll say, that's it, we're stuck, we're stopped. Yep, you got good downward tension. Scissors above retractor hand. Yep, buzz, buzz, sweep. Good, you're there, that's stopped, keep going. Work your way up. Yep, right there, do it. Yep, you'd see the nerve above you that you're gonna preserve, that guy right there. Yep, sweep, sweep, sweep. Buzz, buzz, buzz, go, go, go, yep. So you know, so that nerve comes in here and then it runs here and goes up, right? So you wanna sweep way low here if at all, okay? I would sweep right there, I wasn't gonna do anything. We're losing insufflation, guys. Our gas is not hooked up. Okay, hook it back up. Yep, just not the camera arm. Honestly, Ben, I would just ignore that. 'Cause if you look, there's semilunar line there and there. Just ignore that, keep going up. A little bit of downward tension there. Push down, yep, sweep those guys up. Now there's gonna be a little bit bigger vessel right there that's actually starting to ooze a little bit. I would get your bipolar on that thing. That's not a neurovascular bundle. It's just a perforator that goes into the back of the transversus. Yep, good, fine. Yep, sweep, sweep, that's a nerve. That's a nerve right there though. So hang onto to that and save that. Yep, beautiful, yep, fine. So get low, there's a layer below you. See all this flim-flam here? Get this flim-flam on, yeah, that's where you wanna be. Yep, that's the right spot. So that fascia of les larrons needs to go up. Yep, beautiful. Yep, you can see the posterior lamella of the internal oblique below you and then the transversus abdominis is just below that. Not quite yet. Not quite. There's a nerve, save that, yep. Okay, so look, you got one that branches here. It goes into the rectus here and then it comes down into the transverses here, okay? This little branch right here goes into the transversus. So that's nonsense and that can go. I'd get under it, I'd wiggle around it. Yep, lots of energy, great. Now lift that whole fat pad up. Okay, so that edge goes up. There you go, fine, take that stuff. That's nonsense. Yep, do it, yep. All right, so same thing here. There's a branch, there's a branch right there. And that probably goes down to the transversus. So I would work my way up to it. Again, also ask yourself, I mean, I would pause for one minute and I would back up and ask like, "Do I need to do that to get mesh overlap or coverage or to have the mesh sit symmetrical, or are we reasonably close?" So ask yourself what the top edge looks like in terms of symmetry. I think it would be nice to get this so that this lip isn't so much there. Fine, I'm okay with it. So yeah, so it's okay. If you're taking it for a reason, then do it, okay? But obviously, leave this stuff up on the abdominal wall, so you know, that's all nonsense. You can buzz that little edge, but then... So buzz there. Yep, and then get up to the little branch vessel. And I would just get the bipolar on the branch vessel too. Yep, get that. Why don't you wiggle your scissors around it, go behind it. Wiggle around, wiggle, wiggle, wiggle. Slide, slide, slide, great. Okay, bipolar it, kill it. All right, great. Coag through it. Good. All that's gonna go up, yep. Yep, cut it, that's fine. There's your rib. Is that a rib right there, straight ahead? Boom, yep, that's a rib, okay. You're where you need to be. Great, okay. Leave that? I think that's okay. Back up, back up, that looks good. Apex is good. Okay, let's go back down. So you just need to continue to dissect lateral at the inferior portion here. And the good news is you already found the dangerous stuff which is the epigastrics, okay? So I would just, yep, lift all that up. Yep, do it, sweepy, sweepy. Yep, buzz, buzz, cut, sweep, push. Yep, sweep it up. Good, keep working your way down. Cut it, sweep it, go, yep, keep coming down. There's zero need to move your retracting hand. None, look at how much tension you have along that entire plane. If you wanna change the camera view to put it back in field of view, that's fine. But you can reach your hand over the top here. Like, don't reset it, it's perfect. Keep working, get all that. All right, got a little vessel coming up there now. There's your epigastrics above you. Epigastrics are right here. So you got a little vessel out here, you're gonna have to manage, okay? So now I would probably reset my camera and reset my hands. Yep, do it, okay. Yep, so look, it's very thin over there, right? It looks like it's mostly just peritoneum. So I would come down here a little bit and I would open up this first, right here. Yeah, yeah. Before I went over that, I would also briefly ask myself like, how much more of this do I need to do to be symmetrical, okay? That's your, you're stuck - here you're stuck on the, it's the pant leg. It's the posterior sheath insertion point right there. Yeah, I mean, you're about as far down there as you need to be in the midline. But this edge right here has got to come down a little bit more. Let me play for a minute. You know, you can see this is transversalis fascia stuff here. It's getting very cobwebby and thin, but it's not the peritoneum. There's actually an intact layer of stuff, you know, below us. So just like doing an inguinal, when you need to plane hop, you can certainly plane hop between those layers. Again, this muscle's a little scarred because of the C-section. It's the main thing that's going on there. Got another little hole right there, see it? Does she have a hernia there? Yeah. It might be a fake out. On the scan, she's got a gap in the posterior sheath. We'll see what it looks like. Yeah, so this is that very classic C-section style hernia. There's a gap in the posterior sheath here, okay? And there's content that can push up above the level of the rectus, but this is the anterior fascia and it is completely intact, okay? So there's this kind of intraparietal deal going on here, which again, we can come down, now that we see it, we can come down and cover it with mesh, okay? And we'll need to close that hole up there that I'm making as well. Little scrap of muscle right there. So it's a pretty classic C-section hernia at AHS this year. Who presented that? Who presented their classification scheme for it? I forget, I liked it. I've got it on my phone somewhere, 'cause I liked it a lot, I took a picture of it. So the question is, are we gonna put those rectus back together or are we just gonna cover it with mesh? A big gap. You can run two suture lines. Yeah. You run one, you run the other, you close both of the defects, and then your mesh just covers everything. But if we're gonna do that, we gotta get our mesh now down. Much lower. Much lower, probably into the retropubic space. Should get a crack in the rectus there, look at that. Dissection. There's the arcuate line, way down there. Yeah. It's kind of peritoneum coming out of the abdominal wall here. That's the intact external oblique up there. Anterior, I'm sorry, intact anterior fascia, intact linea alba, but just disrupted posterior sheath. And again, this is a pretty common pattern of hernia for people who've had a C-section before. So we'll just make this hole. We'll use the nine-inch hole to close down here, 'cause you gotta go all the way down to there. They use a six inch, we'll need a six-inch one as well, guys, okay? So we'll need a nine-inch 2-0 V-Loc and a six-inch 2-0 V-Loc. We're doing a little more hernia surgery than I wanted to today, but why not? We're here. Does this make sense to everybody? We're on the same page? That's posterior sheath released there, transversalis fascia there. Gotta be close to the end of the arcuate line here somewhere. So you can actually see the peritoneum rolls up and out and on top of the muscles there. And so this is how you get bowel kind of trapped. You know, in between the posterior anterior fascia and the rectus itself. You know, these folks will present with a bulge, but you can't feel anything when you examine 'em, because the fascia's intact. You know, it's only a partial-thickness defect. We also need to be mindful now, because the urinary bladder is gonna be in here somewhere. And it can be stuck to C-section scar. That's what's left of the posterior sheath. All right. Well, that's exciting. Yeah, demonstration. It's gonna make our hernia we're fixing seem gigantic if we report that as a partial-thickness hernia, here's your epigastrics right there. So the fat pad just goes up. All the fat goes up. Guys, what time is it? 12:36. Say again? 12:36. 12:36, thank you. I thought I heard 12:30 and 12:06 and I was like, somebody's estimating the wrong way. All right, so we're at the semilunar line right there. Nerve right there, so we're at the semilunar line here. Nerve there, coming down, nerve there. You know, here's the end of the posterior sheath. The arcuate line is right here. So I've kind of jumped into the preperitoneal space here. And again, if this plane narrows down, if we do this right, we should be able to jump preperitoneal here and then, you know, have a nice little plane to make sure we have enough lateral coverage from this hernia that we're looking at. The lower midline hernia that is. Yeah. Fat pad goes up. You can actually see the transversalis fascia now covering the vessels 'cause we jumped preperitoneal, okay? Okay. Wonderful. Pubis. Yes, I'm just gonna cut it transversely here, 'cause that's the view it's given me, and now I'm back preperitoneal. Now our epigastrics are right there pumping away. Transversalis fascia up, peritoneum down. How bloody is the urine? Urine isn't bloody at all. Oh, that's perfect. That's the correct answer, thank you. That's bone. So we're there, there's the bladder. Again, this is where you get in trouble with the bladder being stuck. You just wanna make sure that it's definitely on the floor as you do the dissection, okay? I've injured one or two bladders in my life doing, you know, difficult pelvic dissection like this where it just didn't seem like the bladder was up against the abdominal wall. You thought it was down, and it may have been somebody who I thought had a lot more preperitoneal fat than they did, and I was, you know, I was just kind in the wrong planes, that's the pubis there, pubis. Yep, and again, this is direct midline here. So this is the partial-thickness, you know, the Spigelian-type hernia you're gonna close with one running suture there. I mean, again, it's longer than it looks, man, okay? I mean, again, we have an X-ray. We've got a CT that shows that the linea alba is intact, and you can see an intact linea alba right there, okay? It's just the rectus are kind of apart, and so we can suture these back together, you know? This is kind of peritonealized muscle, so we'll take a little bite of the peritonealized muscle. Maybe a little bit of bite of the fascia. You don't have to though. But I think you're obligated to cover this with mesh. But you have an intact fascial layer, right? We're gonna put a piece of mesh down here. It's gonna cover, but I think we can suture it. So you'll run one suture line there to there, and then we'll run one suture line up top, 'cause they're separated by a fair bit, right? So we're gonna need two of the six-inch, I'm sorry, two of the nine-inch Stratafixes. 9-inch, 12-inch. Okay, there's midline pubis there. You're pretty far down. I need two Stratafixes, nine inches. I'll need one 6-inch V-Loc and I'll need one 9-inch V-Loc, 2-0. I think our dissection is for the most part done here. We'll take a look around, we'll hide the body, see if there's any bleeding. Then I'm gonna have you guys stuff in a ruler. And the two V-Locs, the two 2-0 V-Locs will go in at the same time. So a ruler and two V-Locs will go in. We'll take out the scissor arm, and you'll give him a mega cut needle driver. So I'm gonna have you give him the six-inch V-Loc, the nine-inch V-Loc and a six-inch 2-0 Vicryl. We'll put three stitches in and a ruler. We're gonna hide the bodies here. First, we wanna make sure our dissection is as complete as we want it to be. Bone, bone. MPO. Yeah. Okay. That's all closable there. That's your nine-inch runner there to there. You'll run it top-bottom. This is your six-inch runner. Sorry, when you say top, you mean this way to this way, right? Yeah, this one you'll kind of run obliquely maybe. Yeah. Okay. You're all the way down. You're all the way down, you're all the way down. No torrential bleeding, looks pretty good. Flap is mostly intact. That all looks pretty good. I'm okay with that, 'cause we're not really going up there to do anything. Yeah. Where was that little hole that we had? It was teeny tiny. In the corner, like, over here. I'm actually wondering if it was here where I started to get into this. Very well could have been. I'm not really seeing anything else. Guys, hold off on putting in the SH, okay? The Vicryl SH. Actually while you were looking, was it back there? Oh, I see it, I just saw it. You did? There it is, nope, I lied, we'll take all three. Okay, so now it's time to put in three sutures. All right, go for it, monopolar, scissors out. Give me three stitches and a ruler. So you're waiting for stuff then? Yep. Waiting for stuff then. Guys, we got sutures coming at me, what's happening? Let's go for it. Okay, coming in. Come on in. Twizzle a little bit, now pull back some. Give us a mega cut needle driver. We should close that tiny little defect first so we can find it first. We haven't found it yet, so I don't know. Good, okay, go for it, Ben. We're gonna write some numbers down, do the hernia first. Three. Three. Two and a half. Two and a half. Would you write three by two and a half, hernia, M3. Great, move your camera up. All right, and you write 12 by 4 diastasis, M2-3. We're gonna give you C-section hernia. Seven by one and a half, M4-5, six centimeters between hernias. Those are all the writing downs for now. Do your bottom one first. That's the nine inch, so it's the blue one. Make sure your sutures are apart before you start sliding that down. Like, make sure they're not tangled together, 'cause you don't wanna drag the needle somewhere unanticipated. Great, okay, you're free and in the clear, start sewing.
CHAPTER 7
Yep. Just make sure you get some peritoneum with the bite and you're in good shape. Yep, take it. A little more than we bargained for. Our pressure is zero, we have no gas flow, guys. Is one of the ports open? Is the gas still connected? I just took it off and put it back on. Is it disconnected from the machine? Can someone... Let the pressure come back up to 15. You gotta make sure that ports, the abdominal wall slides back onto the ports, right? The abdominal wall falls off the ports. The robot holds 'em in space. No, you're good, camera clean, just clean the camera. We've exchanged it numerous times. You gotta angle a little - no, no, no, you gotta angle a little to the head. Yeah, keep going that way. Keep moving the port. Okay, advance it in. Great, thank you. We were just supposed to be doing an eTEP on an umbilical hernia with a diastasis, but she actually has, can you show Dr. Soderman the C-section hernia here? The anterior fascia's intact over the whole thing, but the rectus are apart, so we're just gonna zip 'em together, and... Oh yeah. And tuck it. I mean, it wasn't a true hernia, it's just a peritonealized gap under the external oblique, so we're gonna fix that as well. But it's not obvious on the scan or on exam that it's there. Okay, start sewing. Bigger than you think they are too. But we didn't think it was there at all, so it was much bigger than we thought. Oh, that's fair. Be a two-handed doctor, pick up the flap, put the flap on the needle, keep sewing. Again, if you're gonna do that, you need to pull it all through, and you're holding a needle and you're not helping yourself. I'd put the needle down and I would pull from the end. Pull it from the end. From your last bite, pull. With your other hand, push down. Great, one more. With a V-Loc on the floor, yes, okay? When you're sewing on the ceiling, you don't really need to do that. You can put a couple throws in and then pull it up tight. There's no tension here. And you don't need to do any tension alleviation maneuvers like we do when we're closing on the ceiling. Pick up the flap, put the flap on the needle, roll through. I would do a third bite and then I'd pull through. Yep, pull it through, pull, pull, pull. Be a two-handed puller, 6:30. Well, I will hang around. Appreciate it, thank you. Be careful pulling in the crotch like that where the scissors are. Got it. Great, okay. One more bite. Finish it up and then back stitch it. Run it back. Yep. No, no, no, you gotta get the other side. You only got one side. Did you get both sides there? I got both sides. Okay. If you're happy you got it, pull it tight and then run it back. Once these two are closed, what we'll do is I'll have you measure for the mesh. We'll take the ruler out and these needles out and we'll put in the two Stratafix sutures. Take a look down below, see what's bleeding. Nothing, it's done. I'm pretty happy with that. Fine, park the needle somewhere safe. Great, let's clean the camera. Are you gonna take over? Yep, I'm gonna do this one. Okay. You're doing great, back in. Okay, I think it's closed. That should do. I am not seeing it, Ben. I think we're good. We have plenty of time. If it pops up and we see it, then fine. I would get these three needles out. Actually, let's do your mesh measurement, okay? Do your mesh measurement. Get your three needles and your ruler out and we'll put two other needles back in. He's gonna give you a top-bottom measurement on the mesh. So we'll give you a length and we're gonna give you a top-middle-bottom for the width, okay? Do your top, we will do the bottom first. Show me the whole thing, go all the way across. Keep going, show me the bottom corner on the left, 12. Yep, do middle, come directly under your port in the center. Yeah, let me drive for a second. So probably the easiest way to do it is to take it on this side and make sure you're looking down. I'm just tucking it underneath the port, straight in. Yeah. You're 13 to here. 13 plus 8, 21. So the mid, you can list it as 20, so it's 12 to there plus 7. 12, 8. Oh yeah, yeah, yeah. It'd be about 20 there, that's fine. It can be 20 there. I mean, even if we just look 15, it's gonna be at least 5. Yeah, we'll call it 20. We'll make it a little shorter, make it 19. Top, call it 18, middle is 20. 36 for the length. Yep. 18, 20 and 12. You got it. We're gonna take two Stratafix now. What size do you want those? What are my options? Those and number one. Oh, number one, I want a number one Stratafix. Okay. You have an 0 then as well. I do. You wanna do an 0 down below where the muscle's intact? Yeah, let's do it. So we'll do one 0 and one number one. Someone can take a bullet. Put it in the port, open and then push. Okay. Take the next stitch, got it. Yep, just leave it there. Give 'em the suturing arm back. I forgot to do that. No, no, no, no, they did it on purpose. They just made a bigger loop for you so you have a bigger target. You don't wanna go 30 up as well. Right. Again, I wouldn't try to get too much muscle. Just try to get the peritonealized stuff there, yep. Maybe a little bite of the anterior stuff, yep. And then the peritonealized stuff there, yep. Come down on that side. Fine. Yep, okay, loop it up. This would be a great place to use robotic mesh suture, 'cause you get a big bite of that fascia and not really worry too much about it, or the muscle and not worry too much about it. Yep, get a real bite, get a bite. There you go, yep. Yep, roll through that stuff right there, take it, yep. Yep, keep going. Nice. That hand is not doing anything important, let it go. You don't need to hold back tension, it's a barbed suture. Make some progress. You're in the same spot as the last stitch. Yep, right there, good, roll through. Got a good bite, yep, roll through. Yep, take it. Now your hand is not helping. Push the muscle out of the way, just push, just push. There's your edge, take it, right there. Boom. Yep, that's plenty of slack out, good. I would just get here and then I would get all of that as one bite on the other side and I think you're good. Yeah, roll through right there. You don't want a ton of muscle. There you go, that's fine. Yeah, you can't burn your suture. Be careful. Good. Yep. Your other hand is just digging into the muscle. Just push the edge right from there. There you go, that's the bite, do it, yep. Uh-huh, nice. All right, I'd go back and pull some slack now. Let the needle dangle, let it dangle. One, two, one, two, one, two, one, two. Could we drop the insufflation pressure, please, down to 10? 10, please. A little too much distance there, back that out. Go a little closer. Yep, come through all that stuff there. Good, there's your other edge right there. Perfect, take it. Get yourself reloaded. Probably last forward bite here, yep. Get that little tough to stuff right there. Good, all right, leave the needle. Go to the very first one. Yep, pull. Yep, good. Like a machine, pull, pull, pull, pull. Hand over hand, pull, pull, pull, pull, pull, pull, pull. Great, keep going. Good. Nope, there's one in between. Yep, pull, pull, pull, beautiful. All right, pull the last one. Great, pull, pull, pull. Yep, torque your needle through. Don't get that muscle, don't do that. You can be better than that. There you go, beautiful, good. All right, pull it up, run it back, okay? Okay, I'm gonna scrub in in a minute. Once we're suturing the upper stuff, and I'm gonna cut the mesh. We'll need a 30 by 30 Bard Soft Mesh. It's in the lime green box over there. Bard Soft Mesh in the lime green box. Ask your doctor about Bard Soft Mesh today. When I had a hernia, my doctor said I needed Bard Soft Mesh. I said, Doctor, is it soft? He said, it's the softest. We're gonna want to 20 of Tisseel. Okay. On a lap sprayer. We can do the regular lap sprayer, not the robot one. We don't need the flexi tip, just a regular one. Okay. Ben, do you want a drain for this lady or no? I don't think so. I don't think so either, it's pretty dry. She is, yeah, I would make her... So we do not wanna drain, I'll need a Vicryl, a blue Vicryl 2-0 so I can mark the top and the bottom of that mesh. We'll roll it up, we'll put it in with two bullets. We'll unfurl it, we'll spray it. And then for the ports, we'll need 4-0 Monocryl, Dermabond, then a binder. Okay, you want that 2-0 six inches again? No, the 2-0 can be long, 'cause I'm gonna just tie some little air knots on the end. So we got some markers for the apex. Let me put the first one in so I can show you how I like to back stitch it. And then you wanna do a little camera clean there as well. Yeah, do the camera clean now? Can you do camera clean? Yep. Okay. This is the bottom of the defect right here. Is that an Ethibond or is that an, that's a vessel. Old vessel right there. Old muscle vessel. All right, so pass the defect. Okay, your tab is set, okay? We wanna back stitch over the top of it. Got it. Past it, boom. And now when we pull, that's all gonna be locked. Okay, it's gonna basically lock on itself in that one spot. And now it can't pull through. That tab, while it does have some strength, it really can't, it can't prevent it from pulling all the way through, okay? I also don't quite understand why this Stratafix has a different mechanism compared to the, you know, the other V-Loc's mechanism. Is it just a company issue? Yeah, they're just different ways to begin and end. Okay, it's alright, it's alright. Okay, so we'll do some suturing here. We'll be thoughtful about how we do it. I'm gonna get it going here. Well, you know, we're not gonna go all the way up. So, edge of defect there. We're gonna placate this diastasis a little bit here as well. So I'm gonna go a little bit wider here. Out to about there. And we'll run a little bit into the abdominal wall there. Run a little bit in, run a little bit in. Run a little bit in. Just make sure our loops are okay. Here's my suture here, come to me. That's all free. Am I locked? I shouldn't be. Yep, we're good. Take a little more of the loop out and kind of put it up like that-ish. Got it, here now we're only at 10 in our pressure. And so as you're running this, eventually you're gonna wanna drop it maybe even down as low as eight, okay? And on some of these folks, you can get it way down. That's the edge right there of the fascia. So we're now gonna run, basically yes, we're closing the defect, but most of what we're doing is plicating the diastasis. We'll take a third bite there. That's the mid-bite through the hernia itself. We'll pull, next bite there. That's the proximal edge of the fascia right there. Roll through. What time we start this case? Two and a half hours. Have a ruler and some snaps in the scissors, please. So this is 30 by 30, it's 46 on the angle. What did we say our length was? 36, got it. Should be able to make it work, I'll take a snap. Got a scissor for me? You want a little more light? We can put some light on if it's easier for you. We'll take off five there and we'll snap it. That is now 36 long. Got a snap, top width? Take a snap, that's nine. What's the middle? That's 10, what's the bottom? You can leave, cut that one short. Flip it around, let's do the same thing up top. How's it looking? Good, I think we're almost at the point... Yeah, it looks like it. You're almost even with that upper robot port, which is roughly where we wanted you to stop. And I think when I get to the point where, I can take the diatsasis in one bite, instead of two, I think that will help me. Yeah. With air, which I think is good. Same thing, leave one a little longer than the other. Could we drop the insufflation pressure to eight, please? Go back to the very first one there. We're gonna drop the pressure way low for you. There you go, that guy right there in front of you is fine. Yep, pull it out and down. Good, you don't need two hands on it, and it's not gonna slide back. There you go, good. Pull, pull, pull, like that, beautiful. Keep going, we gotta roll it. This way you get the bottom, I get the top, okay? We're gonna roll it like a scroll. Keep it reasonably tight. You're gonna stop directly in the midline more or less if you can. Yeah, keep coming. Pinch it there, yeah, pinch and hold. So I'm gonna put it from the top port down. We wanna put the bottom end in first, okay? I'm gonna angle it forward. That's the bottom end going in. We'll lock it down and we'll take this guy here. Yep, got it. Okay, ready to rock. I'd leave it a little bit loose. Maybe try to get one more bite in up top, then I'd back stitch. Yep, one across, looks great. I don't see any sutures through the skin. Pull it tight and then back stitch a few. Then we're gonna get ready to take out those two needles that he has in. That's all he is got in, right? Just two needles, ruler's already out. Perfect, that should be plenty. Yep, all right, give it a snip. I would just get one at a time. They're gonna be hard to get out of the port, 'cause especially that one's not skied. Yeah. You got a bullet? I don't have a bullet, my next best is a Maryland. Nope, nope, nope, nope, too close to the needle. Good, close it real tight. Help flip it into the port, there you go. It's in the port, yeah, yeah. Pull, pull, pull, lots of tension on it, good. Needle out. Needle out. Camera clean and mesh after that. We're at home stretch here. Perfect. We're gonna put some mesh in. We're gonna glue it in place. We're gonna close our ports. All right, let's look down to the feet. Give him control, he'll take it, take the camera. All right, man, mesh coming at you. I'm gonna give you the bottom end first, okay? Grab that there. Got it. I'm gonna let go. I'm gonna push the top end coming in. Great. Suture, mega suture cut.
CHAPTER 8
All right, man, unroll it like a Torah. Thank you. Did you say unroll it like a Torah? It's a Torah, we roll it like a scroll. And it's the end of the year, we're gonna roll it back up. Is that what we do at the end of the year? Yeah, you should stretch all the way around the whole temple and then it gets rolled back up. We're learning things. Yep, put your top top and your bottom bottom. Beautiful. Yep, tuck it down. Beautiful, all right, hold the near side, roll the far side. Just push down on the floor and unroll. Just hold the near side and push the far side. Just push down in the middle. Yep, good, work your way all the way up. Keep going up, hold down, push across. Hold down, push across. Gotta pull it out a little bit like that. Yep, keep on rolling. Keep on rolling. All right, good, now hold the far side, unroll the near side. So there's your stitch. You can see the stitch up there in the middle. It needs to go in the middle. I can't, I'll move the middle. Yep, unroll and tuck underneath yourself. Yep, put your camera straight down to the floor. Keep on rolling, tuck it underneath your camera. Yep, good, work your way down. Yep, keep on rolling, keep going, go that direction. Yep, that's gotta go under your camera. Beautiful. Are you 30 up or 30 down? 30 down. 30 down. Put our pressure back up to 15 now, please. There's your midline right there. There's your suture in the midline. Pressure's 15. Thank you. Make sure your midline stitches in the midline. Yep, mesh has to go down a little bit, it looks like. Good, all right, tuck it there. Push down, make sure it's flat all the way around. All right, we're gonna have fix that lap if you can't get it out, robot. Okay. Uh-huh. Go around. Go all the way around, unfurl. Go all the way up. Go to the top. Good, make sure your top is situated in the midline. Yep, okay, that part you gotta get unrolled. All right, we're gonna fix that lap. Pretty good to me, otherwise. Yeah, we could have made it bigger. But I think we have good coverage. It covers everything. I mean, again, it doesn't fill the pocket, but it covers everything that was hernia and that is sutured. Yeah. Remember that the low midline is not a hernia, it's just a partial, It's a posterior sheath defect, which we fixed and now covered with mesh. Yeah. So I think we're good.
CHAPTER 9
Let's undock, we'll fix the rest, lap and we'll glue it in, okay? Arm coming at you. Bring your other arm in. No, no, you're good. Yep, bring it in, let's keep our camera warm here. Camera cleaner, spin the boom and back the robot out please. We'll need the camera eventually and then two bullets, okay? We'll need our laparoscopic monitors back please. Actually, if you can grab that one. Probably the easiest one, yep. I'll take a bullet, that's perfect, yep, thank you.
CHAPTER 10
Got some glue, we have 20, is that correct? We do, yep. Someone hit the foot pedal for us. Yes. Okay, good. Stop spraying. All right, hit the pedal there. Thank you. Okay. Let's come back down to the corner. We're gonna look here. Hit the pedal. Okay, go to the bottom port now. Yep, hit the pedal. All right, that's now all unfurled there. Beautiful, I'll take the next 10 please. Let's go back up top with the camera. We'll start down below and we'll work our way up. This port is once again out somehow. Hit the pedal. I'll take a new spray tip, please. I think that because we're using the air seal, it's actually able to, I think it's able to compensate. If you, you know, if it kind of sits or you pause too long, yeah. Hit the pedal. This port is once again out. Okay.
CHAPTER 11
Gas off, camera off, anesthesia off. We'll need the room lights, overheads, please. I can do this, I can do this. 4-0 Monocryl. Thank you. See you for the next one, yep, take your time. We'll need a for 4-0 Monocryl after this as well, okay? I'm sorry, a Dermabond. Procedure, eTEP repair of ventral incisional hernias. No specimen, no complication. So we'll close our little ports up here. Our mesh covered them very nicely actually at the end of the day. Again, that mesh is a little undersized left right, but as the gas came down, your measurements were spot on. I think it's a much bigger problem when you cheat and it's way oversized, 'cause it just bunches up in the corner pockets. I think the glue really helps. As much as I like, I was like, I'm not sure if I was gonna use it in the future, but it really, really helps with... You're not, 'cause they don't even have it in Canada yet. Is Tisseel available? There is. Oh, nice. There's Tisseel available. The Cleveland Clinic Group has done studies that say after we had all moved on from doing any fixation, they actually did a randomized trial of fixation versus zero fixation. Like no fixation at all, nothing to help hold the mesh. And they said, "Hey, you don't need anything to fixate the mesh." If you're looking at pain and discomfort and stuff like that, there's not really a major difference. But if you're looking at hernia recurrence, there's also not a major difference. From their perspective, they don't do anything. I don't think that the glue, I don't think that it's really a hernia deterrent. I mean, where's the mesh gonna go? It can't really go anywhere. So I don't think it's really helpful in that regard. But I do think that in a difficult posterior sheath closure, having the mesh directly affixed to the posterior layer very likely... Yeah. Gives you some element of, you know, security. It's a hemostatic agent, needle on your pink. I think it's gotta, it's just too hard to study, but it's gotta improve posterior sheath dehiscence, you know? Like, that just makes sense to me. I don't know if I'll routinely do it for my inguinals, but like I feel like an eTEP like this, a big eTEP like this, I would do it. Well again, the rationale and the inguinal is that that bottom edge of the mesh is all the stuff you can't, you know, secure. It's an expensive way to make sure that your mesh sits flat down there. In the US, we don't have cyanoacrylate approved for internal use for many years, we now do. And so, you know, you can use cyanoacrylate to fixate your mesh as well. And the nice part is in an inguinal, it's like a spot weld. You kind of put one little dollop here, one little dollop there, and you can actually close the flap with it as well. You'll hold the flap up and kind of spot weld it in place. Here's your camera back guys, can we turn the robot camera off? We're all done.
CHAPTER 12
So as you saw, we had a little bit of a surprise there in the operating room, which is that in the lower midline, in the M4 and kind of M5 zone, she actually had a variant of a partial-thickness, or what you might call an intraparietal hernia, in the low midline. When people have a cesarean section and the posterior sheath is opened bluntly, oftentimes people have content that herniates between the rectus muscles. In this particular case, not only was it a coming between the rectus muscles, but it was actually slightly lifting up the anterior rectus sheath off of the rectus muscles and it was a peritonealized space. And so to me, that represents a hernia and so we repaired it. We extended our eTEP dissection a little bit lower, going all the way down to the pubis. We closed the rectus muscles back together. There's no fascia to close because the anterior fascia is intact and we made sure that our mesh covered that area. I don't like surprises in the operating room, but that's not a thing that you can see on the CAT scan, because it requires a Valsalva maneuver, and I certainly didn't appreciate it on her exam in clinic. I think that that highlights though the ability of the eTEP operation to really address hernias that extend all the way from the M1 zone all the way down through the M5 zone. So we therefore fix the diastasis in the M2 zone, the hernias in the M3 zone and the partial-thickness posterior sheath defect and hernia from the C-section in the M4 and M5 zones. Other problems we had during the operation, you saw we had some problems with our initial eTEP access. You know, learning how to easily access the retromuscular space and stay in it can be a little bit challenging. I'm not, you know, as good a robot surgeon as many other people out there, eTEP is one method that we use, and I would say it's not an operation that I do on a daily basis, and so certainly, I could be better at that. We had a lot of problems in the room with our staff as well. And I think that that's just a fact of life and surgery. We had trainees learning how to drive the robot and dock it. We had trainees, surgical scrub assistants who are a little slow to turn some things over. You know, part of my job here at the medical center is to not only train surgeons but also help train faculty and staff. And that's just the price of doing business. But obviously, it didn't disrupt us or how we did the operation.
