Good evening everyone. I'm Stephen Kovach and I'd like to welcome you to this evening's webinar on behalf of ASPS and Beckton Dickinson. It's my great pleasure to be part of this this evening and introduce a colleague and partner who's going to give the webinar today and that's Dr. John Fisher. Tonight's webinar really is a look at abdominal wall reconstruction and an integrated approach to abdominal wall reconstruction. Dr. Fisher really has been instrumental in looking at outcomes and prehabilitation and abdominal wall reconstruction and also I think a new appreciation for the dynamic nature of abdominal wall reconstruction. He'll give his insights based on his own experience and the published data and I hope afterwards we'll have a chance to have a lively question and answer session as well. So during the talk if you have some questions please feel free to put your questions in the chat box. We'll either answer them at the end of the talk when Dr. Fisher is done with this lecture this evening or some of them we'll answer during the talk if at all possible. So again it's a great pleasure to have everyone on board tonight for this virtual webinar and with that I'll cede the microphone to Dr. Fisher. Dr. Fisher. Well thanks Dr. Kovach and welcome everyone. Particular thanks to the ASPS and BD for arranging this and putting this together. It's my privilege to be able to present and share some perspectives on abdominal wall reconstruction with you. Now that my screen is advancing, the title of this talk, as Dr. Kovac mentioned, is It's More Than Just a Hernia, an Integrated Approach to Abdominal Wall Reconstruction. So a couple quick disclosures. These are my individual disclosures. And with that, let's talk about the topic of incisional hernia, and if we look at some of the epidemiologic data on incisional hernia, I think we'll come to appreciate that it's a very common surgical health condition that is associated with a significant amount of cost, both for the healthcare system and our patients in many different ways. So it really is a significant problem, and we talk about complex hernia. The reconstructive surgeon and plastic surgery plays a significant role, and we're going to really focus on techniques and approaches tonight to improve outcomes for these challenging and complex patients. And I think the word abdominal wall reconstruction gets tossed around a lot, and we refer to this as AWR, and I would say AWR really represents a situation in which a traditional hernia approach would not get the desired result for the patient. And as you can see in this before and after screenshot, this gentleman has a large, full-thickness abdominal wall defect with skin graft on visceral block, and he also has a G-tube, a fistula, and an ostomy. And through a multidisciplinary approach and through approaches, I think, embodied by abdominal wall reconstruction, again, we'll talk about these, but primarily closing the fascia, managing the soft tissue, reinforcing the abdominal wall with mesh, we were able to achieve, I think, a very good functional result for this patient and significantly improve his quality of life. And these patients are numerous, and I think for those that are interested in tackling this problem and integrating this into their practice, these patients, they're very complex in nature, and they have frequently multiple challenging characteristics, both the size of the defect, the location, the number of defects, the soft tissue envelope, all can contribute to the challenges that we encounter when reconstructing these patients. So we'll kind of go through some of the principles that we leverage in order to get optimal results in these patients. When we talk about complex hernia and situations where we use abdominal wall reconstruction, I think this is a terrific article that operationalizes some of these concepts and creates criteria for defining what a complex abdominal wall hernia is. And they break this down into really four main groups, the size and location of the defect, the quality of soft tissue and the degree of contamination, patient level risk factors, i.e. risk factors for wound complication, and also the clinical situation. So when we stratify patients into high risk groups, we talk about patients with large defects, patients with contamination, patients who have known risk factors for postoperative wound healing events, including large hernias, atypical hernias, wounds where there's been prior infection or prior mesh infection, and different other scenarios in which previous repairs have been done. I think these complex hernia scenarios necessitate a principled approach and abdominal wall reconstruction. And so I would kind of consider AWR an important discipline in which we're operating on a range of surgical patients who have different types of presentations and levels of expectations, but there's a simple yet common goal, that is to improve quality of life for these patients. And as you can see in the different scenarios listed here, we have patients with recurrent defects, loss of domain, different anatomic location of defect, including Spigelian hernias and Plank hernias, and also patients who have small umbilical hernias, but significant diastasis, or patients who have Peristomal hernias. These are the different types of patients in whom we can apply this principled type approach. So when we encounter a patient who has a large midline defect like the one summarized here, we're really trying to improve abdominal wall function, prevent morbidity from the hernia, and also improve appearance. And this gentleman, you can see in his cross-sectional imaging, a wide midline defect. He's had a previous attempt at repair and he has recurred. And so we're going to do component separations and do a tar or a transversus abdominis release, creating a pre-peritoneal plane to place mesh, and we use resorbable synthetic phasics mesh in this patient. And you can see a two-year post-operative video of the improved abdominal wall function in this gentleman. Really, really good outcome for this patient. Two years follow-up and good improvement in function and appearance. So when we talk about how do you approach these patients, and I think that I like to break it into the preoperative phase, the intraoperative phase, and the post-operative phase, and the directionality of this, I think, points to improving outcomes in abdominal wall reconstruction. And I think a lot of this has to do with before surgery. So the more time spent before surgery improving a patient health condition, I think will lead to better outcomes. So this includes weight reduction in obese patients, smoking cessation, and optimization of other comorbid conditions like diabetes. Intraoperatively, I think the principled approach does require trying to get the myofascial layers of the abdominal wall back together. So getting primary fascial closure, as we've learned, really does reduce the long-term incidence of recurrence. We're working the optimal plane for mesh, and we'll talk about some of the data that support a retromuscular sublate position, optimal mesh selection, and, of course, soft tissue healing is critical to the long-term durability of the repair. And I also think that post-operatively, good follow-up and data and the measurement of quality of life and health-related quality of life is critically important to improve outcomes for patients. I think data is always coming out in abdominal wall reconstruction. This is a recent article published in JAX that looks at patients undergoing ventral hernia and is a prospective randomized multi-center study. And just when you think you know everything, this article, I think, kind of contradicts many of the things that we thought we knew about anatomic location and type of mesh. And these authors show that onlay actually resulted in very reasonable outcomes for patients undergoing complex repair, and I think it really does underscore, I think, the fundamental benefit of getting the fascia closed, good mesh inset, good soft tissue management. I think you can achieve that really with all different planes, and I think this article, I think, is a great example that highlights how important technique is independent of what mesh you choose or what plane you put it in. So here's an example, I think, of a complex defect. This is a six-time recurrent ventral hernia defect, several attempts at intraperitoneal synthetic mesh placement, loss of domain type defect, and in this case, we did bilateral anterior external oblique release and onlay resorbable synthetic mesh placement. This is her early postoperative result, and I think an example of how a principled approach, getting the fascia closed, supporting it with a piece of mesh, wide mesh overlap, in this case, was able to get us, I think, a very reasonable early result in this complex patient. Another example that I think presents a challenging situation that was referenced in the previous slide is an atypical defect, and these flank defects, either between the ribs or in the lateral abdominal wall, are very challenging to reconstruct, and I frequently like to do wide mesh overlap, and in this particular patient, we did a large piece of preperitoneal polypropylene, and then did an onlay with resorbable phasics, almost like a sandwich repair to reconstruct and stabilize this gentleman's abdominal wall, and this is a two-year follow-up. Very good result for this patient, big improvement in quality of life, and I think, again, leveraging which planes you have available, so we accessed the preperitoneal plane, were able to put a piece of uncoated polypropylene, and to provide additional support, we did an onlay, very much like a sandwich-type repair to achieve this result for this particular patient. A very challenging defect here, again, that I think highlights just how complex these patients can get with previous failure. This patient does not have an angular hernia. She has a severe suprapubic defect from previous tram flap harvest. She's had four attempts at previous repair, an intraperitoneal synthetic mesh, has an open draining wound, and I think that this presents multiple factors that will lead to a high risk of complication, not just the fact that she's had four prior repairs, there's an open wound, but she also has a very large defect and some tenuous soft tissue, and her goal was to be able to wear jeans, and I think that by managing soft tissue, getting the fascia closed, reinforcing with mesh, we were able to achieve a very reasonable result for this particular patient. Another scenario that I think also presents a significant challenge that we have to be aware of is patients who have large puniculus. This gentleman who was seen in the office then subsequently lost approximately 100 pounds prior to surgery to optimize his health, underwent a puniculectomy and a hernia repair. You can see a couple of the strategies that we've implemented to optimize his result that I think nicely embody that principled approach, preoperative weight loss, aggressive soft tissue and meticulous soft tissue management in the form of puniculectomy, incisional negative pressure wound therapy, multiple surgical drains, and this patient, despite his multiple risk factors, I think a very nice result, no evidence of recurrence, again, a two-year postoperative result, but a challenging patient both from a defect standpoint and from a soft tissue standpoint. Another example that I think kind of exemplifies how complex these defects can get, this is a Spigelian defect, once repaired and now recurrent, enlarging within just a few months leading up to surgery, and this particular patient, we again used a preperitoneal type repair with a placement of preperitoneal polypropylene and also did an onlay with resorbable synthetic phasics. I think a very nice early result, only two months post-op, but I think, again, exemplifying this principled approach for these off-midline defects, I do find that adopting a preperitoneal plane and accessing the tar plane on the right side, we did a reverse tar dissected in a pre-transversalis plane, entered the rectus complex, and then transitioned to an anti-gray tar on the left side to create significant overlap and allow for a wide placement of polypropylene mesh, and then did an onlay creating a sandwich-type repair. So as we talk about these different releases, I think it's important to recognize the goals of doing a component separation and why would you divide the tendinous insertion of a muscle, and I think having a specific reason and goal is critically important. So the two main reasons that I think I do component separations are to aid in achieving primary fascial closure, and we've seen from several articles in the published literature, perhaps most notably from MD Anderson and Dr. Butler's group, that achieving primary peritologous fascial closure is perhaps the most important determinant of success of a complex hernia reconstruction. I think other reasons include to access privileged anatomic planes, and as you can see in this video that's on repeat, this is an example of someone who has undergone a transversus abdominis release on the left side, accessing a preperitoneal plane to place a piece of retromuscular sublay mesh for abdominal wall reconstruction. So the two reasons that I think are most useful are to advance and close the fascia and to access these privileged anatomic planes for protecting the mesh from the visceral cavity and also placing the mesh up against the abdominal wall and achieving wide overlap. So as we talk about these approaches, I think it's worth just referencing the important anatomic considerations. As we talk about the lamella of the abdominal wall, I think it's important to recognize where the mixed motor sensory nerves run. They of course run between the internal oblique and the transversus abdominis muscle, providing segmental innervation into the rectus complex. So you can think about the layers and you can release on top of this nerve layer or beneath this nerve layer. Releasing on top of it would put you between the external oblique and the internal oblique and you would be doing an external oblique release. You can do a posterior release first by accessing the retromuscular plane, incising the posterior sheath, dissecting towards the linea semilunaris, and then you can extend that release by dissecting through the internal oblique, that is the posterior lamella of the internal oblique, and then the transversus abdominis and entering a pre-transversalis plane, which I'll show you in a video here in a moment. I think it's also great to look at the literature. There is an article from the University of Rochester, Dr. Howard Langstein and his group highlighting the anatomy of the rectus complex and the posterior sheath as you head from the superior portion of the abdominal wall to the inferior most portion. And you'll note that this dotted line that you can see bilaterally represents the medial insertion of the transversus abdominis. So they redefine the posterior sheath. And of course, we recognize that the contributions to the posterior sheath vary depending upon where you are along the cranial caudal axis of the rectus complex. That is, the most cranial portion actually includes an insertion from the posterior leaf of the internal oblique, as well as the transversus abdominis muscle. As you can see, the superior most extent of it, where the transversus is most medial. And as you head inferiorly, of course, the transversus abdominis muscle moves laterally and the posterior sheath is really only comprised of peritoneum and transversalis fascia. So recognizing the regional anatomy of the posterior sheath, I think, will be useful as we think about how we're going to start these releases intraoperatively. And so when we compare these two releases, an anterior external oblique release to a posterior transversus abdominis release, I think they're different in many ways, but useful on their own for different reasons. This patient, again, who we showed has a large midline defect, we extended our release onto the chest wall. And as you can see, we released just lateral to the linea semilunaris, dividing the external oblique aponeurosis, extending this onto the check and getting primary fascial closure. Again, perhaps the most important determinant of success. This patient had an onlay repair with resorbable synthetic mesh. Just as a disclaimer, no mesh is indicated for use in contaminated or infected fields. This was a clinical decision made by me. Good soft tissue closure and good healing in this particular case. And we compare that to a posterior sheath release where this patient has a lower abdominal wall defect after a colectomy, and we develop that posterior plane. So comparing and contrasting this, we develop that posterior plane. We close it. You can see the very thin transversalis fascia layer. We don't raise skin flaps. We're able to place wide mesh overlap. In this particular case, we did some percutaneous suture fixation using a Ribery kinetoplaster, and then we closed the fascia and we achieved the same result. That is, we achieve a stable, durable fascial closure and a stable soft tissue envelope. So both of these repairs can get us to the same place. It's really about the decision making around when to use which repair. So I think that this article helps shed some light on this. I think, as you might guess, releasing the external oblique and also mobilizing a skin flap is going to tend to more significantly advance the anterior fascia. I think, by contrast, doing a posterior sheath release and subsequently a posterior component or a transversus abdominis release is going to selectively advance the posterior layers of the abdominal wall and secondarily advance the anterior fascia. So if I had to summarize this to you, I would say that the maximal way, based upon this data and my own clinical experience, to advance the anterior fascia for large defects is to do an anterior release, that is, mobilize a skin flap or do perforator sparing, release the external oblique aponeurosis, then separate the external oblique from the internal oblique, and you'll maximize anterior fascial advancement. If you want to do wide mesh overlap and advance the posterior sheath significantly to close it, I think that doing a transversus abdominis release or a posterior based approach is very, very useful. And so some of the underlying, I think, physiology that explains why this works, a terrific article published in the Annals of Surgery by Greg Dumanian out of Northwestern that I think exemplifies exactly why we do these types of releases. And this shows in a pictorial format how the volumetric measurements based upon CAT scan change before and after component separation. You can see, comparing C to D, when we do an external oblique release, we actually expand the intra-abdominal volume to allow for and accommodate the viscera back into the peritoneal cavity. And this also changes, I think, in a favorable way, the compliance of the abdominal wall, permitting reconstruction of the largest defects. And here's an example. This patient, an older woman, very active. She's actually an octogenarian in her 80s. I just saw her back. She's back playing golf. Very, very, very large defect. Interestingly enough, we preoperatively did some chemo denervation on her to relax her lateral abdominal wall muscles, a technique that I've adopted in my particular practice. This, I think, helped in allowing us to close her fascia primarily. This is a defect that measures approximately 30 centimeters wide. We did a bilateral external oblique release and were able to get her primarily closed and a very good early result for this patient. I think that can be a very useful technique. So just to go through some of the tips and tricks, I think, as I mentioned, the benefits can certainly be anterior fascial advancement. Mesh can be placed in any plane. I think it's relatively easy to perform, although there's some important tips and tricks. The downside is for the typical open release, you're going to increase the risk of wound morbidity. So the key step is to identify the linea semilunaris, which we're marking here. That's the lateral edge of the rectus complex. Two centimeters laterally make an aponeurotomy and we confirm we're in the right plane. You should see a layer of fat and some adventitia. I typically just check that I'm in the right plane before I complete the release. And as we head cephalically, we actually encounter the muscle belly inserting on the lateral chest wall and the rib cage. And we head inferiorly towards the external angular ring. And this is a very nice avascular plane. So this should release pretty easily. And you should be visualizing the vertically oriented internal oblique fibers. And this is a technique that I think can be used for large defects, for epigastric defects. I think a technique that's very useful is to divide the muscle belly of the external oblique in the chest wall. And that is going to be able to give you maximal rotation of the rectus complex for closure of large defects, particularly subxiphoid epigastric type defects. And the release is not complete until you separate the parts. That is releasing and separating the external oblique from the internal oblique, as can be demonstrated here. Here's an example of a perforator going through the external oblique that we typically try to preserve. And this is the advancement, even in a very fibrous abdominal wall patient, demonstrating how much advancement you can get. A similar technique is performed on the right side. Again, just highlighting the precision required to just establish this plane. And once that plane is established, I think it confirmed this is autopilot here, just ensuring that we're in the right plane and that we're lateral to the linea semilunaris. It can be very devastating if you release too deeply at the level of the linea semilunaris. You can destabilize the rectus complex and potentially create niatrogenic spaghetti and hernia. And the same principle shown here, just releasing that aponeurotic layer and then extending the dissection out of the chest wall to really maximally release and advance the rectus complex towards the midline. And getting fascia closed is always super important as we did here. So let's talk now about the transversus abdominis release, kind of a newer release I think popularized for the purposes of creating extra peritoneal mesh planes for placement, very useful for closing the posterior sheath. And these photographs and intraoperative photos from the Rosen Atlas I think highlight the benefits. So what you want to do is release the posterior sheath in front of the intercostal nerves without disrupting the linea semilunaris. You can drop into a pre-transversalis or pre-peritoneal plane and then create a peritoneal flap and a large submuscular plane for placement of mesh while both preserving the neurovascular blood supply to direct this complex and also I think secondarily advancing the midline anterior fascia. So we saw this video previously, but the benefits of TAR in my opinion are maximal advancement of the posterior sheath, a large anatomic plane for mesh placement. And you can I think use this approach for basically any defect on the abdominal wall which I think is very useful. I think some of the cons are it's technically a little bit challenging, it gives you modest anterior fascial advancement in my personal opinion, and typically we're limited in terms of anatomic planes of placement for mesh to the pre-peritoneal retromuscular sublate position which would be on top of this peritoneal surface and underneath the entirety of the abdominal wall. So as we go through just a quick video that I think highlights first the posterior sheath mobilization and the separation of the rectus complex from the posterior sheath and then shows the sequential extension of the TAR as you can see here we're doing a left-sided release and you can directly visualize that posterior lamella of the internal oblique that's that fascial condensation that muscle belly was the transversus abdominis and we just stopped short of the transversalis fascia and as we head from head to toe we are in a pre-transversalis plane peeling the peritoneal surface off of the undersurface of the transversus abdominis muscle. And you can see that shown here you can see the raw undersurface of the transversus abdominis muscle we made a small hole here which we'll just repair with a vicryl. And as you can see this really does liberate in my opinion the posterior sheath and again it's going to create quite a large plane for placement of mesh and I think that the advantages you can put uncoated mesh in this plane. So just to recap again we're going in front of those nerves and you can really nicely visualize a nerve right behind that deep retractor you can see the release of that posterior lamella of the internal oblique and now complete release of the transversus abdominis muscle and now establishing a pre-transversalis plane and then releasing the aponeurotic portion of the transversus abdominis which disappears as you head inferiorly. This will take you beneath the chest wall and you'll see interdigitation of the transversus abdominis muscle with more inferiorly vertically oriented fibers of the diaphragm this will give you good space vertically to place your mesh. Inferiorly you can connect these spaces very easily with the space of bogros and the space of retzius and then you can get posterior sheath closure and you can place really I think as much mesh as you want. One more quick case that I think will hopefully solidify this approach in this technique this patient complex patient recurrent defect serotic patient subcostal incision large defect complicated soft tissue has all the risk factors that we kind of previously identified that necessitate a non-traditional hernia approach he needs abdominal wall reconstruction we initiate this after complete lysis with our general surgery colleagues separating the posterior sheath from the rectus complex in this very nice avascular plane the posterior sheath won't close but the anterior fascia will so we want to do a retromuscular sublase so we initiate a tar we're dividing again those key layers the posterior lamella of the internal oblique the transversus abdominis muscle typically using a right angle here to just establish a pre transversalis plane right in front of our intercostal nerves using good tension and good counter tension really making sure that posterior sheath is nice and taut and flat so that we don't buttonhole through the peritoneum which which can't happen and you can see those nerves are really maintaining our plane we're staying right in front of them so that we don't disrupt any of those important segmental nerves and get a rectus complex innervation bulge so as we head from head to toe you notice the disappearance of the muscle and just the aponeurotic portion again we're using some sharp dissection here just separating that transversus abdominis muscle from the peritoneum and the transversalis fascia dissecting far enough laterally to really liberate that posterior sheath and a plane that's adequate for mesh overlap. This is pretty pretty easy to do once you're past the midline and you can use a sponge And so, after the release is done bilaterally, and this patient who had a previous subcost that we had to kind of reconstruct the posterior sheath, which made it a little bit more complicated, you can see that there is peritoneal continuity. We've excluded the intraperitoneal content, which is great because we can put a piece of uncoated mesh, and in this particular case, we elected to place a piece of resorbable synthetic phasics mesh. And what I think is terrific is that the mesh is actually peritoneal. It's up against a nice muscular surface. We got posterior sheath closed. We knew we could get anterior fascia closed, so our intraoperative component separation progression made sense. This is a 10 by 12 inch piece. And what's great about this is that, for the most part, a limited mesh tailoring is needed. We just typically just trim a little portion of the corner, and the mesh should just fit hand and glove beneath the costal margin laterally into the retroperitoneal region, and inferiorly into the space of retzius. And you can see this will fit hand and glove. We'll put a couple of transfascial sutures to secure it, and I also spray some fiber and glue here to just kind of hemostase the plane. Also a couple of Blake drains that'll come out within a few days. And you can see, with that space that we created, we really do get great mesh overlap, extraperitoneal mesh, good reinforcement. We closed the anterior fascia, didn't raise any skin flaps in this patient who has multiple risk factors for wound healing. That's his on-table closure with a few Blake drains, and you can see a subcostal scar. I think we may have a photograph of him back in the office here in just one second. This is him back in the office, obviously a very early photo. I think it's important to follow these patients for at least two years post-op. This guy is still in his early phase of follow-up, but you can see a reasonable amount of dynamic abdominal wall function, no recurrence, no soft tissue, healing issues in a relatively complicated patient with a principled type approach. And in this case, we use absorbable synthetic Phoenix mesh. So just some parting thoughts as we kind of wrap this up on component separation. I think it's always important to have a purpose when you divide a muscle. And again, we outlined a couple, achieving primary fascial coaptation and accessing privileged anatomic planes. In my hands, if you need skin to close the soft tissue, then I think you've got to mobilize the skin. If you need the anterior fascia, external oblique or anterior release is the key maneuver, in my opinion. If you need posterior fascia, data supports this. The transverse abdominus release is going to give you incremental posterior sheet advancement with some secondary anterior advancement. I typically have a rule, never release the external oblique and the transverse abdominus on the same side. You can potentially destabilize the abdominal wall, and you really only have one layer between the releases. And like most things, there's many ways to achieve great results. So I think that you have to just respect that. The technique, I think, is really potentially the most important factor, as we've seen from recent published studies that highlight that various anatomic planes work great just depending upon technique. And I think that technique is often influenced to a large degree based upon how wounds heal, particularly the soft tissue. And to a group of plastic surgeons, like the group that we have on this webinar tonight, we don't need to emphasize this too much because we're soft tissue masters. And I think that some of the principles that I've adopted is to, when you can avoid skin flaps, avoid them. Typically try to do a marginal skin resection just to freshen up the edges and reduce either venous congestion or marginal necrosis from arterioschemia, a layered closure, a tension-free closure. I really have found negative pressure wound therapy to be incredibly useful. And I have a basic philosophy. If you dissect it, you probably should drain it or alternatively quilt it. And again, I think that in the end, soft tissue isn't just what you're closing. And for the purposes of AWR, it's the packaging-free repair. And I think it oftentimes defines its success. So the last thing I want to touch on is really thinking out of the box and thinking about how we can measure, at least for our AWR patients, not just clinical outcomes, but thinking about quality of care delivery and also the improvement in quality of life that patients derive from these rather involved reconstructions. And some of these outcomes have to do with return to work and activities of daily living, pain, appearance, and satisfaction. And we've tried to integrate this into an instrument that our group has developed very much a la breast Q called the abdominal herniate Q, a disease-specific validated measure of quality of life that has a pre- and post-operative form. It's eight questions before and 16 questions after surgery. Fortunately, published this in the Annals of Surgery. And I think that it's a very, very useful tool and an article that we integrated this into our evaluation of patients as shown here. We published our experience with poly-4-hydroxybutyrate, which is phasics for complex hernia, 70 patients with two years of follow-up and a 5.7% incidence of recurrence. This was published in PRS just this past year. And a closer look at the data, I think, underscores how important disease-specific quality of life measure can be. These are complex patients, high BMI, a lot of obesity, a lot of diabetes, prior infection, prior smoking, large defects on the order of 300 square centimeters. There was some contamination, pretty complex patients, suffice it to say. 5.7% recurrence, a fair number of surgical site occurrences, no mesh removal, but a significant and substantial improvement in quality of life as measured by the abdominal herniate So I think very important to have that as part of our multidimensional pre- and post-operative measurement of outcomes. And I think it's good to have this in our mindset and in our back pocket to communicate with patients before and after surgery. Just a couple of quick case examples, large midline defect, loss of domain. This was an active smoker that we got to quit. Did a retromuscular release, posterior sheath dissection and anterior oblique release. A kind of a classic Ramirez repair with retromuscular resorbable synthetic mesh. Got the fascia closed. This is a two-year photo, but I have five years of follow-up on this gentleman. He has not recurred. It's an 894 square centimeter defect. Very, very nice result. For a young gentleman like himself, who was 38 at the time of surgery, having a resorbable synthetic mesh repair, I think makes a lot of sense. So I guess one of the questions might be is, so what happens when resorbable synthetic mesh goes away? I think the idea is it really doesn't. It leaves a footprint of collagen scaffold in the abdominal wall, creating a load sharing type abdominal wall reconstruction. And this patient is a kidney transplant who you can appreciate a right lower quadrant defect. We did a repair that's shown here, a primary closure and a nice onlay. And he came back to me because he wasn't happy with his contour. Although just in my own defense, I did tell him I thought he would benefit from a paneculectomy. He came back about seven months later wanting a paneculectomy. So we scheduled him for some soft tissue recontouring. And I had an opportunity to visualize what this repair looked like. And as you can see here, these two intraoperative photos, you can see the mesh repair on 2-17-17. Then the subsequent look at this on 9-14-17. I think this gives you an appreciation for just the quality of tissue formed in and around this resorbable synthetic scaffold. Good healthy ingrowth, almost looking as if it's fascia. The H&E shows good, well-organized collagen. And the biopsy, frankly, because I wanted to just understand what this looked like, looked just like good, healthy, organized fascia and collagen. I had the pleasure of seeing him back at about two years post-op. And this is a photo of him in the office with a 15-pound weight gain, asking kind of why things felt painful and did he have a recurrence. Fortunately, he did not have a recurrence. I explained that the 15-pound weight gain potentially could be stretching the abdominal wall out. But I think an example of just how we can leverage tools that we have, including our mesh technologies to, I think, tailor our approaches to complex and challenging patients like this patient, who's a transplant patient who has multiple risk factors. And I think it reliable results in the long term for these folks. Again, a two-year kind of photograph and outcome. We saw this case example. We saw this case example. And again, I think that respecting the soft tissue is critically important. And this, again, an example of a complex patient with a large pantus and a retromuscular repair. So to kind of conclude and go back to our original case, it's not just a hernia, particularly when we have complexities like summarized here, large segmental defects, contamination. And I think that we don't do a typical repair as reconstructive surgeons. We have to adopt an abdominal wall reconstructive approach in order to achieve improvements in health with the quality of life and impact our patients in a significant and major way. So just to conclude, it's not just a hernia. Hasn't really gotten as far. Principles and reconstructive approaches, however, have by thinking about the different elements of a hernia defect, thinking about the fascia, the anatomic planes and layers, thinking about managing the soft tissue has gotten us, I think, great results for patients. Success in abdominal reconstruction, I think, really fundamentally hinges upon optimizing health for your patients before surgery, good technique, a principled approach, and the use of biomaterials to support your repair. I think also knowing your data is important. All the advanced techniques that we've gone through are useful and complex abdominal wall reconstruction. And I think just from a fundamental standpoint, leverage the laminar structure of the abdominal wall that's very well conserved across patients. And by understanding the neurovascular and myofascial anatomy of the abdominal wall, we can really take the abdominal wall apart very effectively as plastic surgeons in order to put it together. And our component separations are really primarily used for getting the fascia closed and co-opting our defects and also accessing these privileged anatomic planes, which we think improve outcomes for patients. And so, at least in my practice, biosynthetic mesh, and in these cases, and in many of the data you've seen, resorbable synthetic phasics has offered a very nice solution in higher risk cases. I've, of course, used it in contaminated cases. There's no mesh that's indicated for contaminated cases, but certainly in my practice, I have used resorbable phasics in these very challenging and difficult cases. It works in any plane. And it's been a really good answer to some of the long-term concerns about permanent synthetic mesh and the complications from that. So with that, I will thank you all for your attention this evening. And I will conclude. Thank you. Great, John. Thank you so much for that talk. That was an incredible overview of abdominal wall reconstruction. And there's so many important principles that you had in that talk that it truly was a mini course in abdominal wall reconstruction. And really, as your lecturer pointed out, abdominal wall reconstruction really is leveraging the anatomy of the abdominal wall in a laminar way. And I think, importantly, appreciating that the living myofascial abdominal wall and getting it closed is vitally important, and then reinforcing it with a piece of mesh. So I think, just as you stated in your lecture, I think as reconstructive surgeons, we really understand the power of living tissue to heal, and then something along the lines of biosynthetic mesh like phasics really being able to reinforce it during the healing period. So I wanted you just to comment on sort of how your mesh selection has changed in terms of the availability of biosynthetic mesh and your mesh choice in your abdominal wall patients. Yeah, that's a really insightful comment. And I think important to understand that I think it really has a lot to do with getting the fascia closed, which plane you select. I think tailoring your mesh selection to the individual case, I think that biosynthetic mesh, I think, has opened up the onlay plane a little bit. I think not a lot of meshes work that well as an onlay. I think that biosynthetic mesh, when coupled with a good repair and a durable myofascial closure, is getting me results that are as good as synthetic repairs, at least based on the data that I've seen. So I've had an anatomic plane shift. I used to do a lot of intraperitoneal repairs with Biologic, and I think that I've replaced a lot of those with preperitoneal retromuscular sublay type repairs using tar. And in cases where that's not possible, I think an onlay has really kind of become my kind of secondary go to repair. And I think biosynthetic just works really well in that plane. It handles like synthetic, but has many of those kind of healing principles and many of those, I think, biologic principles that you'd kind of want to have for a patient. Yeah, I think really the importance of mesh and why biosynthetic mesh really makes sense in a lot of these abdominal wall patients is that you're really kind of harnessing the ability of the autologous vascularized myofascial abdominal wall to heal, and you're sort of offloading it in that healing period to allow the native abdominal wall to heal. And obviously, the poly4-hydroxybutyrate biosynthetic mesh is going to go away in a very predictable manner over time. So the other thing I wanted to talk to you about is plane selection in terms of mesh placement, because there's a lot of different planes. And when you sort of go from outside in, you mentioned intraperitoneal placement, there's preperitoneal, there's retromuscular sublay, and there's onlay. So, you know, each of those ideally would equate to a different risk profile in terms of hernia recurrence. So why don't you just talk to us briefly about your ideal plane placement, all of the things being equal, and access to all those privileged anatomic planes in the abdominal wall? Yeah, I think that's a great question. I don't do a lot of intraperitoneal repairs anymore, I think, for a few different reasons. I think that it's a very labor-intensive repair to do transfascial fixation for intraperitoneal open repair. And I think that just the potential issues related to intraperitoneal mesh, fistula, adhesional issues, I think, just make it, I think, a less favorable anatomic plane for me, personally. Now, that being said, if it was a question of intraperitoneal reinforcement versus no mesh, I would favor an intraperitoneal repair. I think the gold standard for me would be a retromuscular sublay, as you described, where you either do a standard reef stopa-type repair, release the posterior sheath, close it, put mesh in that sublay position, and close the anterior fascia. I think that an onlay, surprisingly, in my hands has worked really good. And I think I tried to underscore with some of that recent data that I think that we've seen a lot of recent articles that may contradict kind of traditional thinking that retromuscular repair is the only way to get good repair. I think that it has a lot to do with, I think, technique, mesh fixation, soft tissue management. There's so many different dimensions and variables that I think contribute. So they're hard to capture. But I think that if you can fundamentally get the myofascial abdominal wall closed and get healthy vascularized tissue approximated with mesh, I think you're going to get very good results. I think that carries the day most of the time. Yeah, I think the important thing also is that mesh provides reinforcement. So mesh is a vital part of abdominal wall reconstruction. And I think, ideally, close the fascia and reinforce with mesh. I think none of this really happens without the ability to reinforce these defects with mesh because the recurrence rates would really be prohibitively high. We'd be back to the days of primary closure. So really, mesh is essential in these patients who have complex defects, either primary or recurrent defects. I think mesh has been a boon for abdominal wall reconstruction and reducing the risk of recurrence. So I wanted to go back to one of the questions from one of our attendees. And the question relates to damage control abdomen and the placement of skin graft, essentially, on viscera. And the question is, what do you do with the skin graft during your abdominal wall reconstruction? Do you use it in some meaningful way? Or do you just get rid of it during the lysis of adhesions and then discard it? Yeah, that's a great question. I think, typically, and maybe you can comment on this, too, I typically just get rid of the skin graft. I think the fundamental question, though, I think gets at something that's maybe even more important is not discarding potential vascularized tissue until you know you have your desired plant. I'll give you an example is that if you have hernia sac available and that's attached to the abdominal wall, you can kind of use that as part of your posterior sheath closure. Or you can use omentum to help get the posterior sheath closed in cases where you're having trouble. So I think that not getting rid of anything, I think, is very useful. I think that's probably where the question is going. But I think mobilizing skin flaps has been probably the most useful thing for me for these damage controls to get them closed. But yeah, I'd love to hear your thoughts, too. Yeah, I typically discard it. I think the lysis of adhesions, I typically will take all the skin graft off the viscera. I sometimes will use it as the neo-posterior sheath just to shield the retromuscular sublayer preperitoneal mesh from contact with the viscera. But I typically will discard it. And some of those patients who have a damage control abdomen, they have a massive ventral defect with skin graft on a visceral block, the lysis can be challenging, number one. And number two, it's relatively dysvascular when you're done with the lysis of adhesions anyway. So I typically discard it. And then just, I think, as you do, I'll advance skin flaps off the abdominal wall to get primary closure of the soft tissue in the midline. Yeah, so I think you showed a number of different planes of mesh placement and you showed a number of defects that are off midline defects as well, the flank hernias. So the hernias from kidney transplant, from nephrectomy, from, you know, potentially very laterally based subcostal incisions. I want you to talk a little bit about just your different approach. And you mentioned a sandwich repair as well. When are you choosing to reinforce some of these more challenging off midline paramedian defects with more than one piece of mesh? Yeah, that's a great question. I would say a lot of this personally has become somewhat anecdotal, although I think that I've been getting great results with these folks. I think that a couple kind of key principles, if someone has an existing incision and they have a flank hernia, I tend to use that existing incision. Wide exposure, I don't tend to go midline. I think it's just easier to get into the peritoneal cavity or get into the pre-peritoneal plane if you want by going over the incision. So I tend to go right where the money is, so to say. And I think that that helps a lot. I think the favorite plane is to get into a pre-peritoneal plane out there and create wide mesh overlap. I think that that is the stabilizing force. And as you said, I think so eloquently is get a good myofascial plane, maintain perfusion of the abdominal wall and reinforce that with a piece of mesh. That's key. I think the situations in which I'm doing a sandwich type repair are very specific. I think that those are for patients where there's significant attenuation of the myofascial layers. And you know it when you see it. It's not just where the hernia sac is and the defect is, it's but all the surrounding segmentally denervated abdominal wall from the previous surgical approach. I think those are the cases when I'm thinking more and more about an onlay. And again, I think that this I think goes back to that conversation about which mesh and which plane. I think that the pre-peritoneal plane gives you the liberty of putting in basically whenever mesh you want. So if I'm gonna put synthetic mesh in someone permanent synthetic mesh, it's gonna be in a privileged anatomic plane in a retro muscular type plane. And that's kind of where I'll typically put it for these off midline defects. Wide overlap, typically a 30 by 30 piece of mid-weight macroporous polypropylene. And then again, the scenario is where there's attenuated abdominal wall and you wanna get additional buttressing. I think it's very useful to do an adjunct to do an onlay. I think that again, resorbable synthetic P4HP or phasics has worked great for this purpose. Yeah, I think what you had embedded in your talk and what you just mentioned is probably the take home point tonight. And that is if you could sort of establish three principles of success in abdominal wall reconstruction it's closed fascia, reinforced with mesh and respect the soft tissue. And I think regardless of your plane choice of mesh, if you follow those principles, you're setting yourself up for success really. There's another question from one of the attendees and that question is, how do you approach a more challenging hernia which is a peristomal hernia? And do you have anything special that you do in terms of plane of approach, mesh choice or how you approach a peristomal defect? Yeah, I think the answer is maybe don't fix it because the recurrence rate is so high but I have fixed my fair share of peristomals. It's a tough problem. And I think that to be totally honest, I've had recurrences from my peristomals and I've had people in whom we've made the mesh hole and the orifice for the peristomal too tight, for the stoma too tight and they've had to go back for not an urgent release but the ostomy is not working because there's mechanical obstruction either at the level of the mesh or at the level of the anterior fascia. So my approach for peristomals are make sure there's a good reason why you're doing it. I think it's really important to just tailor the mesh and kind of how you cut it and reinforce the ostomy I think very carefully. I like to do like a little cruciate so there's little flaps of mesh kind of up against the ostomy as it goes through the abdominal wall. I prefer a keyhole type repair. I typically do a retromuscular dissection and then frequently with a tar we'll pull through the peritoneal layer, we'll lay the mesh down, find the right spot to pull the ostomy through the mesh and then subsequently pull the ostomy separately through the anterior abdominal wall. Now there's good thing that supports an intraperitoneal type repair with like a sugar baker approach. Again, there's so many ways to do it. I think that oftentimes we recite these folks. I think doing an insight to repair, at least in my hands hasn't been very successful. But again, I think the same approach, a tailored approach. I typically will not use permanent synthetic in these patients because of the contamination. I typically gravitate towards biosynthetic. I again, favor a retromuscular plane. I typically just do like a cruciate type incision, the mesh and very, very carefully try to just make sure it's just big enough to fit the stoma through the ostomy through. Yeah, I think the off midline defects can be the more challenging ones. And I think what I tell my patients is probably what you tell your own patients. And that is when the ventral defect goes off midline, their occurrence rate goes up. That's not because it's a lesser operation. It just means that anatomically, the tensile strength of the abdominal wall, once you really go through a ventral defect, lateral to the semilateral line, the tensile strength of the abdominal wall is not as great. So your anchoring mesh to something that's not as strong. So you really need a much, in my opinion, a wider mesh overlap, regardless of your anatomic plane and mesh placement. So I think the recurrence rate, just by virtue of human anatomy is gonna be a little bit higher for off midline paramedian defects, including peristomals or big plank or subcostal hernias as well. I think- Yeah, that's a great point. Yeah, and I think a lot of us who've fixed an awful lot of hernias have really transitioned, I think, our practices to a large percentage of using biosynthetic mesh. And you've certainly published your data with phasics in PRS. And Scott Roth has published some very good data. And there's some very good longer term data now for polypore hydroxybutyrate phasics mesh that compares very favorable to synthetic. So I guess one of my questions I have for you is when are you using a synthetic versus a biosynthetic, or you have transitioned mostly to biosynthetic at this point, even you showed some very complex challenging cases, but what about your 50 year old patient who comes in with a hernia after getting an elective colon resection two years ago, who's a clean case, relatively low comorbid patient? Yeah, I think that that's a good patient for a synthetic to be totally honest with you. I mean, I guess the situations in which I'm less likely to use permanent synthetic are when there's contamination, either known or a change in CDC wound clots that happens interoperatively because of an aneurotomy or something that's unforeseen. Sometimes you can see that there's an old piece of mesh that may have fluid on it or may be infected. I think those situations I think are fluid and you gotta kind of adjust your plan accordingly. But I think permanent synthetic for those types of lower risk clean cases make sense, especially if you can get a retromuscular plane. I personally think for older patients, I tend to put in more synthetic mesh, more permanent synthetic mesh. I think in patients who have less quality abdominal wall, and that's kind of a very subjective thing to say, you can look at CAT scan and you can look at the patient's abdominal wall interoperatively and get a good sense as to kind of how good of a quality is their abdominal wall. And I think those people are oftentimes the people that need wide prosthetic and permanent prosthetic support. So I would say contamination, I wouldn't, I don't typically put permanent synthetic. I typically don't put permanent synthetic in the subcutaneous plan because I think that the frequency that these patients have wound healing complications and the number of times these wounds can open back up, I just don't wanna be looking at permanent synthetic in my office and I know my patients don't wanna either. Yeah, I think one of the most important conversations that I have with my patients is actually the preoperative visit. And we discuss mesh very carefully and the different kinds of mesh. And many times all things being equal, I'll give them the choice and I'd share with them the published data, both my own and other people's data. And many, I would say almost always patients will choose biosynthetic mesh when I give them the option and show them the data. They'd much rather have reinforced their abdominal wall in the short term than deal with any type of longer term synthetic mesh complication. So in the last few minutes, I would just wanted to ask you about sort of jump back to the pre-op patient and sort of what are your criteria for saying, you know what, I'm not gonna do this. I'm sorry, I can't offer you this operation. What are your hard and fast criteria for saying no, that you're not a candidate for abdominal wall reconstruction? Yeah, that's a great question. And I'm gonna kind of just tell you this just off the top of my head. I think that unrealistic expectations, I think just like any operation, I think you're gonna know it when you see it. I think patients that have prohibitive health conditions that is not gonna tolerate a big operation if they need it. Someone who has a high likelihood of not surviving surgery. I think that sounds crazy, but there's big defects in sick patients. I said, you can really have one of the two kind of bad things. You can be really, really sick and have a small hernia. You can be really healthy and have a big hernia, but you can't have both. And I think that like, those are the scenarios in which we see kind of, I think, catastrophic issues happen. I think people that are actively smoking, I really try to persuade to not smoke. I think people that have BMIs in that supra 40 range. So anything above 40, I really try to avoid electively operating unless there's a pressing need, whether it's obstructions or issues or severe pain or major disability. I think that we try to optimize these patients from a smoking and obesity standpoint before surgery. But I think the main one is that, a prohibitive health condition that's gonna put them at risk for a major medical issue or really, I think, unrealistic expectations. Or I think that I can't improve their quality of life or I don't think I can close them. I think are really kind of the key things. Yeah, so we have another question from one of the attendees. And the question relates to really one of the important issues that you highlighted in your talk. And that is the importance of soft tissue. And if you look at the soft tissue complications in the published data, soft tissue complications really beget hernia recurrence in many ways, which is why you really have to pay very careful attention to the soft tissue. So the question relates to augmentation of the soft tissue of the abdominal wall. And do you ever see the need to do TFL flaps, tensor fasciae latae flaps, rectus femoris flaps, or other soft tissue augmentation procedures to help with the soft tissue of the abdominal wall? Yeah, it's a great question. I think for the biggest of big defects, we talk about doing regional flaps or microsurgical tissue transfers to get the abdominal wall covered and closed. I think that it's pretty unusual to have that happen. You really need a big, big defect to necessitate that. When you think about the laminar structure of the abdominal wall and the amount of advancement and closure you can achieve with skin flap mobilization, a full external oblique release, you can close massive defects. And I think that getting the abdominal wall closed rather than replacing it with regional tissue, whether it's TFL or otherwise, I think is gonna give you a more dynamic, functional abdominal wall and a bigger improvement in health-related quality of life. So I would say is if you can get the abdominal wall closed using these kind of principle type component separations, I think you're gonna give your patients a greater quality of life benefit. That being said, I think that there's definitely scenarios in which you have large composite abdominal wall defects and loss of domain. You can't get soft tissue closed. I think regional flaps become the option, pedicle ALT, free ALT, TFL, I think are definitely some to consider, but that's a very rare situation. I know, Steve, you've definitely published on this and maybe could comment on it as well. Yeah, I think we've done actually a fair number of microvascular free tissue transfer for abdominal wall reconstruction. And when I say a fair number, I've been doing this for 14 years and I think we've done 10 free flaps for the abdominal wall, maybe 11 or 12 at most. And I think, you know, in terms of regional flaps, we don't really do TFL or rectus femoris flaps. You know, the regional flap ends up being a pedicle to anterolateral thigh flap or a free anterolateral thigh flap to achieve soft tissue coverage. And it's really not fascial reconstruction. Your fascial reconstruction, as you said, is leveraging the laminar structure of the abdominal wall to get primary fascial closure, then mesh reinforcement. And then you're using your flap really for soft tissue closure because you have inadequate soft tissue. The thought that you're gonna take a regional or free flap and reconstruct the fascia with it is just not reality because it doesn't have the tensile strength to reestablish the fascial domain of the abdominal wall. If you can't get fascial continuity with primary closure, even with your external or post your component separation, then you're really, you're bridging the abdominal wall with a piece of mesh and then you're augmenting the soft tissue with a microvascular free flap. There are some cases of dynamic abdominal wall reconstruction where you can use a neurotized free tissue transfer, but I think those are cases are few and far between. And even those flaps are going on top of a piece of mesh to reestablish fascial continuity. So we call those patients really soft tissue cripples, but they're really soft tissue cripples. Fascial cripples are reconstructed with a large piece of mesh and the soft tissue, the regional flap is used for soft tissue, not to regain fascial continuity. I agree with that. So let me see if we have any other questions from the attendees. We don't, and I'm gonna ask you one last question as well. And that relates to, you know, I think the idea of mesh being load sharing and really allowing the abdominal wall to heal as the mesh reinforces it, sort of you're gaining tense, especially with the biosynthetic mesh products, you're really gaining tensile strength as the strength of the mesh goes away over the course of 12 to 18 months. So just in the last comments, why don't you tell us what your postoperative regimen is to protect the abdominal wall while it's gaining tensile strength? Yeah, that's a great question. And I think that a lot of that, I think it's just a function of how good of a repair you do. And I think that I liberate patients pretty significantly for activities after surgery. I think, you know, I let people start lifting above 10 to 20 pounds within a month and a half after surgery. So at six weeks, I kind of liberate people for, I think, incremental pain guided lifting and exercises. I encourage patients immediately after surgery to do as much walking and light cardiovascular as possible. And I think that, you know, a lot of times, I think that the abdominal wall closure has good strength and I think the mesh kind of, as you kind of nicely said, I think kind of load shares as the autologous tissue heals. And I think that that's a very plastic surgery way of thinking about it. I think it makes a lot of sense. And so I think the transferring that load makes sense, but I also think that, as you know, activation of that tissue, I think is gonna help remodel the myofascial closure. So I think that, you know, we know from tendon healing, I think that's beneficial. So I think that using the abdominal wall in the postoperative recovery, I think is very important. So I typically liberate people for progressive incremental activities after six weeks, guided by pain and comfort. And then frequently for patients who are having trouble getting back to activity, I'll refer them to physical therapy for kind of core strength of the exercises and stretching. And I found that very useful. Yeah, you know, I agree. And, you know, I think it's all about really a graduated return to full functional activity, these patients. So they're not stressing their abdominal wall closure in the short term when they don't have enough tensile strength and they're not protected enough to go back to unrestricted physical activity. I follow a very similar regimen as you do. And let me just check our question box here for a minute. The question is, do either of us use Gore-Tex mesh? And I'll just, I'll start with my own personal opinion that is no, I don't use Gore-Tex mesh. Gore-Tex doesn't integrate well. It's, in my opinion, challenging to heal. And remember what you heard from Dr. Fisher and myself, you really want the mesh to be an adjunct to the abdominal wall. And you really think about reestablishing the dynamic nature of the abdominal wall and mesh allowing the autologous fascia to heal, which is a vital part of the postoperative course. You know, Gore-Tex is just, it's not a mesh that integrates well into the abdominal wall. It never integrates, as a matter of fact. So I personally have never used it, nor will I ever use it. And John, I don't know what your opinion is. Yeah, I think a lot of people have used it for peristomals and sugar bakers. I haven't used a lot of it. I think the benefit, as you said, is nothing really integrates into it. So the idea is that the bowel is not gonna stick to it. But yeah, I think that, you know, Gore-Tex is PTFE. I've used some PTFE products for abdominal wall reconstruction and gotten some pretty good results, but certainly not laminar PTFE. It wouldn't be my choice for abdominal wall reconstruction. Although I think historically it has kind of been one of the important tools for intraperitoneal sugar baker type repairs for peristomals. It's been pretty successful, but I haven't used a lot of laminar Gore-Tex, frankly. Yeah, no, I agree with you. You know, and I think, you know, the answer is really not always more mesh. It's really the right mesh that, you know, that's really the appeal of the biosynthetic constructs and phasics is that it really allows the abdominal wall to heal in a load-bearing way and reinforces it as the autologous fascia is healing. So, you know, I think with that, I will see if there are any more questions, which there are not. And I will thank you, Dr. Fisher, for a great talk this evening. And special thanks to ASPS for having us and special thanks to Becton Dickinson for having us do this seminar on abdominal wall reconstruction. And if no one else has any questions, I will bid everyone good night and thanks for attending. All right, thanks everybody. Have a good night. Good night, everybody.

abdominal wall reconstruction

AWR techniques

hernia repair

transverse abdominis release

external oblique release

mesh reinforcement

biosynthetic mesh

multidisciplinary approach

patient outcomes

postoperative management