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Algotrithm to Repair of Ventral
Hernias
Jin S. Yoo M.D.
Assistant Professor of Surgery
Duke University Medical Center
My
Pre-op considerations…
• The patient contribution
• Overall functional status and medical conditions
of the patient
• The hernia
2
The Patient Contribution
Page 3
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!”
4
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
Page 6
The Hernia
Page 7
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
8
Intra-op considerations…
• Pure lap, hybrid, or open?
• If open, then why and how?
9
Lap, open or both?
Page 10
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
11
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
12
Lap or open?
• You must adhere to all the “Best Practice”
guidelines…
• Avoid compromising “best practice” techniques
because of the approach
13
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
Page 14
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
Page 15
Lap, open, or both?
#1 HYBRID approach
#2 Pure OPEN approach
#3 Pure LAPAROSCOPIC approach
16
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
Page 17
I go back and forth between OPEN and LAP approach to
accomplish each step in the fastest and most effective manner.
Open
Page 18
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
19
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
20
20 x 30cm BIO-A® as an onlay during large
VHR with concurrent panniculectomy
Page 21
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VIDEO – PRE-OP CT SCAN
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VIDEO – POST-OP CT SCAN (4 weeks)