Jin S. Yoo M.D. Assistant Professor of Surgery Duke University …. Algorithm... · 2017-07-25 ·...

Algotrithm to Repair of Ventral

Hernias

Jin S. Yoo M.D.

Assistant Professor of Surgery

Duke University Medical Center

Jin.Yoo@duke.edu

My

Pre-op considerations…

• The patient contribution

• Overall functional status and medical conditions

of the patient

• The hernia

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The Patient Contribution

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Patient factor

PATIENT A

• PATIENT: “Doc, my hernia really hurts! You gotta

help me! I rather die than live with this!!!”

• SURGEON: “OK, I’ll help you. But first, I need you

to help me, help you. You need to stop….”

• PATIENT: “But I can’t stop smoking…I can’t lose

weight… I can’t eat any healither to control my

sugars… this is the way I’ve always been!”

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My Rx:

No surgery

But if do, just “standard” repair

Patient factor

PATIENT B

• PATIENT: “Doc, my hernia really hurts! You gotta

help me! I rather die than live with this!!!”

• SURGEON: “OK, I’ll help you. But first, I need you

to help me, help you. You need to stop….”

• PATIENT: “OK doc! I understand what you’re

saying… I will STOP smoking…I will LOSE

WEIGHT… I will EAT HEALTHIER to control my

sugars… I will meet you halfway on this!”

5

My Rx:

Surgery

and consider “deluxe”repair.

Patient Functional Status and

Medical Contributions

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The Hernia

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Hernia considerations

• Type of hernia

- first-time incisional hernia (normal abdominal wall)

- recurrent incisional hernia

- swiss-cheese defect (hernia from sutures)

- any hernia (thin abdominal wall)

• Location of the hernia

• Hernia sac : Ab wall defect RATIO

• Quality of adjacent tissues and previous surgeries

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Intra-op considerations…

• Pure lap, hybrid, or open?

• If open, then why and how?

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Lap, open or both?

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Ideal for pure laparoscopic conditions…

• “Small” hernias – where (1) fascia closure not

important or (2) fascia can be closed easily without

CS

• Non-midline hernias – where CS not possible or

helpful

• No need to remove anything (sac, old mesh, etc)

• Avoiding large incision truly advantageous

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Ideal for hybrid and open repairs…

• Any hernias that don’t meet the criteria on the

previous slide

• Larger incision doesn’t necessarily mean more pain

– more pain from laparotomy incisions are from abd

wall retractors

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Lap or open?

• You must adhere to all the “Best Practice”

guidelines…

• Avoid compromising “best practice” techniques

because of the approach

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Lap vs open

OPEN LAPAROSCOPIC

SURGEON PATIENT SURGEON PATIENT

1) Close the fascia defect

* Component separation

2) Wide overlap of mesh

3) Maximize mesh-to-host

tissue coaptation

4) Minimize subcutaneous

dead space

5) Faster surgery

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Lap vs open

OPEN LAPAROSCOPIC

SURGEON PATIENT SURGEON PATIENT

1) Close the fascia defect GOOD BAD BAD BAD

* Component separation GOOD BAD BAD GOOD

2) Wide overlap of mesh GOOD BAD /

GOOD

BAD GOOD

3) Maximize mesh-to-host

tissue coaptation

BAD GOOD GOOD GOOD

4) Minimize subcutaneous

dead space

GOOD BAD BAD GOOD

5) Faster surgery GOOD GOOD BAD BAD

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Lap, open, or both?

#1 HYBRID approach

#2 Pure OPEN approach

#3 Pure LAPAROSCOPIC approach

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Steps in HYBRID ventral hernia repair

• Initial survey

• Adhesiolysis

• Bowel resection/repair (?)

• Component separation (?)

• Removal of FB (?)

• Debridement of skin, subcutaneous tissue, fascia (?)

• Fascia closure

• Mesh placement / fixation

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I go back and forth between OPEN and LAP approach to

accomplish each step in the fastest and most effective manner.

Open

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Ideal for hybrid and open repairs…

• Any hernias that don’t meet the criteria on the

previous slide

• Larger incision doesn’t necessarily mean more pain

– more pain from laparotomy incisions are from abd

wall retractors

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OPEN approach

• For midline hernias, default is Rives-Stoppa’s repair

– rectrorectus placement of mesh

• If Rives-Stoppa’s dissection not enough, then will

consider EXTERNAL and/or POSTERIOR CS,

which depends on

- amount of release needed

- hernia sac : ab wall defect RATIO

- width of rectus muscle

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20 x 30cm BIO-A® as an onlay during large

VHR with concurrent panniculectomy

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VIDEO – PRE-OP CT SCAN

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VIDEO – POST-OP CT SCAN (4 weeks)