23 Hernia- edited

Okay, and we're here with Behind the Knife's Ab Site Review. So the topic today is hernia. So let's just go over some basic principles. So John, when we talk about the basic principles that we always ask medical students, what is a basic principle of a good hernia repair? What do we always talk about?

Yeah, the obvious answer to that is attention free repair. Exactly. We're always going for that tension free repair, and we're going to talk about a few tactics we use to get that tension free repair. But when it comes to recurrences, Kevin, so what's the most common cause of a recurrence of any type of hernia?

I believe it's wound infection. Yeah. Yeah. That's an easy answer on the, on the app side. If they ask you what's the most common condition that leads to a hernia recurrence, it's wound infection. So we'd all know hernias lead to bowel obstructions. It's the second most common cause in the United States, of course, next to adhesions.

Cause we have a lot of people that have surgery in the United States worldwide. However, hernias can lead are the number one cause of small bowel obstructions. So let's get a little

bit into anatomy. So John, When we talk about hernias, especially abdominal wall hernias, it's important for us to understand the different layers of the abdominal wall.

So can you just walk us through the body starting from the outside superficial and going deep, the layers of the abdominal wall, and let's say just right off the midline. Yeah, there's a great picture in our book regarding this, but if you're going to go from skin to deep, it would be skin, sub Q fat or campus fascia, scarpus fascia, anterior rectus sheath.

Rectus muscle, posterior rectus sheath, preperitoneal fat, and finally peritoneum. Yeah, so again, yeah, great reference to the image in the book. It has all those layers. That's going to be really important to really intimately understand that anatomy and how we can exploit those different layers when it comes to hernia repair.

And that's a lot of questions actually on the outside is which layer do you divide when you're doing this component separation versus that component separation. So make sure you have that down cold. Going out a little bit

laterally. So John walked us through going through the rectus sheath. Kevin, how about if we're lateral to the rectus sheath?

Well, what are the, what are the layers there? Yeah, it starts the same but it changes a little bit. You start with the skin and then you go through the subcutaneous fat or camphor's fascia. Then you go through scarpa's fascia. Then you go through the external oblique, then the internal oblique, then the transversus abdominis, then the transversalis fascia.

Then the pre peritoneal fat, then the peritoneum. Yeah, that's good. So again, you got to know these layers down cold. And be really familiar with abdominal wall anatomy because those different layers can be very important when we talk about our different types of abdominal wall reconstructions as to which layers that we can exploit.

So, back medially, John you walked us through the layers. Where does that, that transition? So, you were walking us through the rectus sheath, probably a little bit higher up on the abdomen. Where does that posterior rectus sheath end? Yeah. And that's, it's a good landmark. So I always use the umbilicus and you go about the third of the distance between the umbilicus and

the pubic symphysis which is known as the arcuate line.

Yeah. So at that arcuate line, all layers of the rectus sheath pass anterior to the rectus sheath. And that becomes important when we start talking about our extra peritoneal repairs, our taps, we exploit that space and our minimally invasive hernia repairs, as well as it's important to know when we talk about doing our posterior component separations in our, in our TARS.

In reality, it's a little bit more complicated than that. You're below that arcuate line. You'll read some different things, whether that's you're just in that preperitoneal space. There's your transversalis fascia, which actually has two layers, a parietal and visceral layer that you can exploit and sometimes split those layers.

But just to keep it simple, below the arcuate line, all layers of the rectus sheath pass anterior to the rectus muscle. Kevin, so, What's the blood supply to the rectus? You're a vascular surgeon. How does, what, what are the vessels that supply the rectus muscle? Well, you know, I love a good blood vessel.

And so the blood supply to the rectus is the inferior and superior epigastric vessels. And where do those vessels

come off of? So we encounter the inferior epigastric a lot in vascular surgery when we're exposing the common femoral artery. It, It differentiates the external iliac from the common femoral artery.

You'll see that the superior extent of the common femoral artery and then the superior epigastric arteries are the continuation of inferior mammary coming off of the subclavian arteries. All right. Well, it turns out you did learn something in fellowship. So John, a favorite question we like to ask medical students is about Hasselbalch's triangle.

What are the borders and what's the anatomy of Hasselbalch's triangle? Yeah, it's almost impossible to really visualize this. And so, unless you have a picture in front of you and somebody who's experienced with hernia repairs, you know, explaining it to you. But from a test point, the medial border is the rectus abdominis.

The inferior border is the inguinal ligament. The lateral border are the epigastric vessels. And what all this means is that if you have a hernia within Hasselbalch's triangle, That's a direct space hernia. Okay,

now you, so you mentioned that inferior border being the inguinal ligament. Tell me a little bit more about the inguinal ligament.

Where, what anatomic structure is it contiguous with? What abdominal water layer is it formed out of? Yeah, clinically it's usually the ligament you can feel the easiest in that space. And it's an extension of the external oblique fascia. Yeah, great. So your external oblique fascia comes on and it's got its insertion sites down on the symphysis so it's an extension of that external oblique fascia that's kind of rolled over there inferiorly.

And as Kevin mentioned, it's a very good anatomic landmark for your femoral artery as well. In a clinical situation. So let's talk a little bit, let's switch from the groin and talk a little bit more about the umbilicus, another favorite spot for hernias. So. Our umbilicus is a, as a natural weak spot where we can form hernias.

And the reason for that is because there used to be a lot of embryologic structures that pass through the umbilicus. So let's go through some of those. And what we're going to do is I'm going to tell you the

structure that goes through the umbilicus, and then you're going to tell us what its clinical significance is as adults.

So first let's go for the John umphalic mesenteric duct or the What is the clinical significance in adults? Yeah, that becomes the Meckle's diverticulum where you can then develop Meckle's diverticulitis. Yeah, so if you have a unobliterated omphalomesicteric ducts, you can have a little Meckle's which is very common, can cause lots of problems, can be, well, it can be asymptomatic most commonly, but it can cause problems, bleeding, obstruction, all the diverticulitis as you mentioned, all those things.

Kevin, what about the median? Median umbilical ligament? This becomes reka. Well, yeah. It can become a ureas or Peyton Uuss. Going back to John now, the media o media o with an l umbilical ligament, what is, what is that? Yep, those are your obliterated umbilical arteries. Okay. And what about the, what, what is the round ligaments of

the, the, the liver, the ligament terce?

Kevin, what is, what is that a, a remnants of? It's a remnant of the obliterated umbilical vein. Okay. So as I mentioned, all this stuff at one point traveled through your umbilicus, leaving that natural space where you could either congenitally or or acquire a defect in a hernia there. When do all those structures or the midgut rather herniate through that umbilicus during development and when does it return, John?

Yeah, this really takes you back. But the, the midgut herniates at six weeks in developmental period and then it returns at 10 weeks. Okay. Right. So the midgut during embryologic developments, I know everybody loves embryology. Is it, it herniates through six weeks and then returns typically at 10 weeks.

What if that fails? That process, there's some abdominal wall defects. What are those Kevin and how do you differentiate those? Yeah, I'm going to take this one. So, the infallis

seal, the way you kind of determined the difference between the two, and this is what for test taking purposes, the infallis seal is a defect within the umbilical stock within umbilical ring.

So it herniates through the umbilical stock. A gaseouschisis is to the inferior or to the right of the umbilicus. And Kevin, which one of those is more associated with birth defects? Yeah, that's the fallacy. Oh, great. Okay, so let's go on to some different types of meshes. It's really important to be familiar with meshes.

It's something you don't often think about as a resident, but I tell you what, the first day as staff, you're fixing a hernia on yourself, you'll be happy if you spend some time reviewing what types of meshes to use in different situations. The thing to remember is there really is no one size fits all.

So the mesh has to be tailored based on what anatomic location you're wanting to put it in, what layer of that abdominal wall is that we talked about. What type of repair you're needed? How big is the hernia? Some different patient factors. There are some general, there's a lot of different brands out there.

It's honestly hard to get information on

meshes because a lot of the data is proprietary, so it can be very confusing. It's helpful to break it down into some general categories of mesh. So Kevin, what are the big main categories of mesh and how do you distinguish between them? Yeah, so you can think of it really as synthetic and biologic.

And then there's a whole bunch of variations of synthetic. And so you have the absorbable and the partially absorbable. So first you have your non absorbable synthetic. So this is your polypropylene or polyester kind of permanent mesh. Then you have your non absorbable synthetic with a barrier, so it's the same thing, but with a polyester mesh with a collagen barrier, so this has the extra barrier to prevent adhesions.

Then you have your partially absorbable synthetic, so this is polypropylene with PDS polymer matrix. And then you have your biosynthetic, which is a biodegradable polymer, and then you have your full biologic, which is an acellular porcine dermis. Yeah. So depending on what your, what type of repair, how long you want the mesh to be there, how long you want to stick around, if you want it to be

permanent, what, where you're putting it, how much tensile strength you need, you're going to, those are your big categories and you can really, again, tailor it to your individual patient and individual situation.

So the mesh material, the pore size, whether it's macropores versus micropores, the weight. This is all going to affect its bioreactivity and how it behaves in the body. So it's really important to understand those characteristics when you're choosing a mesh for a hernia. So for all comers, your really your go to mesh is going to be your light and medium weight macroporous polypropylene or polyester mesh.

So a synthetic permanent light to medium weight macroporous mesh is going to be your go to for most circumstances. Now, the caveat being if you're need to know what layer you're putting in. So if it's extra peritoneal, an uncoated mesh is generally what you're going for. If it's intraperitoneal, you want that barrier to prevent adhesions as Kevin alluded to.

So John, let's say you were dealing with a strangulated

bowel in a contaminated field. So big obese patient comes in, A smoker has a bowel obstruction and dead bowel and a hernia. What are you going to what kind of mesh are you going to go for there? Yeah, I think this is you know, talked about a lot and there's been a lot of different studies on this.

So, it's a relative contraindication for the use of synthetic mesh. Now, with the newer mesh developments, the light, weight, and macroporous and polypropylene meshes, you could consider it, especially if it's not an extremely contaminated field, but most people would just go to using a biologic mesh. I still think that's a safe answer on the boards.

You know, there is, as you mentioned too some data, recent data, ROSEN's data coming out, using synthetic mesh in contaminated fields. But there are some nuances to that data, you know, getting that minimally contaminated versus grossly contaminated. Be sure to get that mesh outside of the peritoneum.

You know, for the boards I, I, I would still stick with the safest answer, which is using a biologic mesh in those

contaminated fields. Okay, so Kevin, moving back now that we understand our meshes, let's talk about some different types of hernias. So umbilical hernias tell me a little bit about umbilical hernias.

Yeah, so these are usually congenital. Most of them in pediatrics go away on their own, but sometimes they can persist. or sometimes they can you know, become new hernias later in life. Well, how do you, so what's usually in most commonly, what's the contents of these small umbilical hernias and then what are your different repair options?

Yeah. So for the most part, it's just pre peritoneal fat that's protruding through these umbilical hernias. And as far as repair options, you have a lot of different repair options, but in generally of the open versus laparoscopic and if it's, A small one, less than a centimeter, you can consider a primary repair, or if it's a pediatric patient, they generally do the primary repair.

Yeah. So that's a, that's an important thing there for pediatric patients generally try and avoid putting mesh in. So usually primary repairs for these very small umbilical hernias, less

than a centimeter, you know, less than your index finger, your finger, you can get away with a primary repair. You know, I think we've seen, especially in the American population, as patients are getting more and more obese, we see these small umbilical hernias becoming problematic and growing and becoming to the point where they even need abdominal wall reconstructions after prehabilitation.

So they can be pretty problematic, but this just goes back to, you really got to know what the size of the hernia, those different layers that you're dealing with and how to best approach those. But there's a lot of options. You talked a little bit, Kevin, about pediatric umbilical hernias. So expand on that a little bit.

He said most of them will close spontaneously. Yeah. The vast majority of them. And so when do you, when do you repair them? It's hard to convince parents of this, but you really have to just watch and wait until about five years old because most of them will close. So yeah. Okay. So you said at least five years old or right about their time.

They're about to go to school there. If they're persistent, you should probably fix those. And I would agree with that. You know, John, a

favorite question for boards and a challenging. Clinical scenario in real life is your serotics with umbilical hernias. So let's talk a little bit about that. So we know that 20 percent of patients with cirrhosis will develop umbilical hernias.

And there's a lot of reasons for that. And these patients tend to be not the best operative candidates and have poor nutrition. They have a high rate of rapid enlargements and a high rate of complications to include incarceration, evisceration, wound breakdown with the sides, drainage, peritonitis. How do you approach these patients?

Yeah, this is a clinical question that, you know, I didn't think I would be facing as much. But it's definitely a hard problem to deal with. But in general, if a patient has advanced cirrhosis and is a transplant candidate and is gonna get the transplant soon, you just repair the hernia, the time of the transplant.

However, if the transplant's gonna be out three to six months, you know, around that time, it should be repaired. Electively. The, the goal in general with dealing with these umbilical hernias is to

control the ascites and try to optimize them medically the best you can. to make sure that your hernia repair works and also doesn't, isn't exposed to the sites within the abdomen.

Yeah. So yeah, I would agree with that. So, you know, I think ideally, even if they're not necessarily going to get a transplant, I think a lot of times these patients are best managed in transplant centers just because they have this, the infrastructure and the ancillary services to medically optimize that patient.

So they. The key there, what you mentioned, was getting that ascites under control. So, maximal medical control of the ascites. So, how about when you go to repair that hernia? What are some tips and tricks there? Yeah, it depends on the patient's clinical scenario. So, if they are producing lots of ascites, you want to...

You know, drain them and do a paracentesis, you know, before and after. And also do them routinely afterwards to try to do your, the best work of getting, to making sure that hernia repair is not, is being exposed to a significant amount of site use. Yeah, so controlling the ascites post

operatively is very important.

You need to make sure that you're closing all layers, including the peritoneum, and really get a good closure to protect that wound. You'll hear some people talk about leaving drains versus not leaving drains. In general, on the boards, I would try not to leave drains and then opt for serial paracentesis post operatively to control the ascites.

In addition to all the medical management of the societies that you can do now, let's say that you're in a situation where you do have that skin breakdown and you have a leaking umbilical wound that's a little bit different than that elective repair. So how do you approach that? Yeah, this, this should raise some, you know, red flags when you see this on a test question, because this isn't just approaching a hernia at this point, you have to now kind of switch to like a resuscitation and managing an infection situation.

So you would start resuscitation, you know, IV fluids you'd also start antibiotics. And then this also now triggers an urgent repair. Additionally, the difference is, you know, you could push mesh in a patient who's getting an elective repair, but you

want to avoid mesh in this circumstances due to the infection risk.

You have to assume that if they are leaking from the umbilical wound, that that ascites inside their abdomen is exposed to the external environment and is infected. This also requires aggressive post operative ascites management. They are higher risk than even the elective repair. And once again, that includes serial paracentesis and diuretics and this helps avoid your wound complications and dehiscence.

And unfortunately just based on this patient being a cirrhotic and having ascites and having now a new infection, this places them at a pretty high mortality rate. Yeah, unfortunately, it's not a fun situation. I think we've all probably been in these situations And they're certainly not fun and at the end of the day You're just trying to get that patient out of dodge so that they can live and fight another day So let's move on to something that is more manageable and that's inguinal hernias So Kevin, what is the, we, again, we like to ask med students, what's the difference between a direct and an indirect hernia and how do you distinguish the two?

Yeah, to keep it simple, an indirect is lateral to the inferior epigastric vessels, whereas a direct is medial to the inferior epigastric vessels. Again, yeah, so like we mentioned before, that direct is through that Hasselbalch's triangle medial to those inferior epigastric vessels. What's the, John, etiology of a, of an indirect hernia?

Yeah, most of the time these are congenital. It's also the hernia you'd see typically in a younger population. By congenital I mean a patent processes for that vaginalis. Okay, how about direct, Kevin? So this is acquired through weakness in the floor of the inguinal canal. Okay what predisposes people to, to form direct or acquired hernias John?

Yeah, it's, it's basically the same stuff you put your, put your risk for everything. It's obesity, smoking, poor nutrition. ascites and then anything that would increase your abdominal pressure. Yeah, unfortunately it's also all the things that increase your chance of a recurrence. So it's all the things you don't want your hernia patient to have is the reason why they have a hernia in the first place.

So it can be pretty challenging. And this is why the concept of prehabilitation. Has become so important when it comes to hernia repairs back to the basics though, Kevin the, the spermatic cord, what this travels through our inguinal canal in men at least. So what are the contents of the spermatic cord?

Yeah, so you have your cremasteric muscles, your testicular artery, your vas deferens, your pampiform plexus, your ilioinguinal nerve, and the genital branch of the genitofemoral nerve. So yeah, that's an important, just identify, know those structures, know they go through the inguinal canal. Again, we're going for that low hanging fruit, those easy answers on the app site.

You may get lucky with some of those. What about the the cream master muscles, the cream master muscles? That is what are, what abdominal wall layer forms those cream master muscles, John? Yeah, that's the extension of your internal oblique muscle fibers. As a reminder for your angle, ligament is, is formed from the extension of your external oblique.

So we need to be careful with these. One of the more common complications of a hernia repair is chronic pain afterwards. So it's important to know the nerves. When we're talking about an open inguinal hernia repair, Kevin, what are the key nerves that we need to have an understanding of where they're at?

Yeah. So there's a couple of them and that's the ilioinguinal nerve, the genital branch of the genital femoral nerve. The ilio hypogastric and which of those is the most commonly injured during a open inguinal hernia repair? Yeah, definitely that ilio inguinal nerve. Yeah, so you need to watch for that rise.

It passes right underneath that external oblique when you're opening that external oblique. Identify that. Some people will routinely divide it. Some people will selectively divide it. Some people try to preserve it at all costs. But just be aware that it's there and watch for either injury or it getting incorporated into the mesh.

Which can lead to some problems with post operative pain. How about laparoscopic or robotic hernia repair? Minimally

invasive. What's what is the... nerve situation there, John, and which ones get can get injured. Yeah, this is everything lateral to include the lateral femoral continuous nerve. That's your triangle pain.

And usually it occurs to inappropriately placed tack or if you dissect out too laterally during your angle repairs. Yeah, absolutely. I'm always harping on the residents. They're laterally doing those minimally invasive repairs to stay right on the parents and the not dig into that, that lateral abdominal wall, avoid putting any tax.

Avoid thermal using thermal energy out there just to avoid injury to those nerves. Cause that can be quite a problem postoperatively. Switching back to opening hole hernia repairs there's the tried and true, a lot of different named hernia repairs. Let's just quickly go through what those are and what you're sewing to what.

Cause again, we want to pick up those easy points on the, on the outside. So Kevin, you're Classic Bissini tissue repair. What do you sew into what? So this is the conjoint tendon, which is a mix of the transversalis and the internal oblique. And you sew

that to the inguinal ligament. Great. Conjoint tendon, inguinal ligament.

John one we don't see often is the sholdice tissue repair. We're seeing less and less of them. Yeah, you don't see them as much. A lot of people, if you're doing tissue repairs, will do some sort of, like, modified sholdice. But it's similar to the Bissini repair, but it's closed in four layers. So once again, sewing the conjoined tendon to the inguinal ligament, not in two layers, but in four layers.

Yeah, you know, honestly, don't worry, don't stress too much about the four layers of a shoulder repair. You're not going to get asked on the ab site. Kevin Lichtenstein repair. Okay, yeah, so the Lichtenstein repair, that's the more classic mesh repair. And so you sew to the inguinal ligament. And then the mesh also is sewn to the conjoined tendon slash transversalis.

Yeah. So this is the first, you know, really kind of tension free repair. It's, it's kind of interesting. If I could go off on a little bit of a tangent that. We started using mesh in order to decrease pain in a hernia repair from the tension. And now all you do when you turn on the TV is you see lawyers

threatening to sue for, for pain after a mesh repair.

In reality, the pain we would be seeing after animal hernia repairs would be a lot more if we weren't using mesh than if we were. But that's the medical legal system for you. So, John, how about plug and patch? What's, what does that mean? Yeah, the plug and patch is, like, kind of my favorite. term. It's a very simple term for a, you know, a very simple procedure.

But basically you're taking the Lichtenstein repair and doing your normal mesh placement and putting a plug inside the internal ring that would Theoretically scarred down and prevent anything from coming back up in it. Yeah. Also kind of, it might be your favorite one to say. It's my least favorite one to see.

Also kind of falling out of favor. What you'll, what you'll see sometimes are these plugs turn into these meshomas. And I see them a lot in recurrent hernias where I have to go and dig these plugs out of that internal ring and it is not fun. So it is still done, but also falling out of favor. Thankfully Kevin, how about a pediatric repairs?

What's the, some just, It's broad strokes, basic principle of a pediatric inguinal hernia repair. Yeah,

this always blew my mind. You just do a high ligation of the sac? Yeah, high ligation of the sac. And when you think about it, it's, it's congenital from that patent, you know, processes vaginalis, so you're just closing that off.

The inguinal floor really isn't the issue. So with, and again, as we mentioned, pediatric patients, you want to avoid putting mesh in because pediatric patients grow, mesh shrinks. It's usually not a good combination. John, switching over now to outside of open repairs back into things that we're probably more familiar with in this day and age, which is the minimally invasive laparoscopic robotic repair.

What are our, our options for a minimally invasive inguinal hernia repairs? Yeah. And that's also my preferred way of dealing with inguinal femoral hernias and I'll tell you why. So there's two different types of repairs. So you have your total extra peritoneal repair, also known as your TEP. And you have your transabdominal pre peritoneal repair, known as the TAP.

And that goes for both laparoscopic and robotic. The benefits of this approach is that it covers not just the indirect and direct

space, but it also covers the femoral spaces because you can see everything in place mesh. from the inside. Yeah, me too. It's my favorite because again, you can look at all those spaces.

You cover all those spaces with a nice big piece of mesh overlap. It makes it dummy proof. I don't have to think about what are the four different layers of the shoulder repair. It's the same operation for every little hernia. How about in a laparoscopic repair? We talked a little bit about avoiding laterally.

So where, where do you fixate the mesh? The main point of fixation is Cooper's ligament and that's medially. And then you would fixate the mesh if you're there's multiple different ways of doing fixation, but if you're using attacking or you're sewing it in It'd be Cooper's ligament and then maybe the abdominal wall.

Yeah. There's a lot of options for this now. More and more, we're going to a minimal fixation. So at most one or two points of fixation there immediately there's self fixating meshes, there's fiber and glues that people are using. And the trend is rightfully so to less and less fixation, which I think

postoperative pain.

You know, I think we mentioned, you mentioned this earlier a little bit, you know, triangle pain, triangle of doom. What and where, let's, let's do the Triangle of Doom first. What and where is the Triangle of Doom? Yeah, so this contains the iliac vessels and then medially with the apex at the iliopubic tract and is bounded by the vas vessels laterally.

Okay, and how about the, John, the Triangle of Pain? Yeah, that's that portion out laterally where it contains all your nerve structures. It's lateral, if you're looking inside, it's lateral to the spermatic vessels below the iliopubic tract. Okay. Let's talk briefly about femoral hernias. We were just talking about inguinal hernias.

Like I said, I'm a minimally invasive surgeon, so it's kind of all the same to me when I go to my minimally invasive repair. But there are some distinctions in regard to the patient and things you have to think about. So John, who's at the highest risk for femoral hernias? Yeah. The classic test questions for this, that you have to And I'll look out for our female patients and the elderly.

Yeah, so, so

women are more at risk for femoral hernias. Now, be careful because in women, still the most common groin hernia is an inguinal hernia. Yet, they are higher risk than men to femoral hernia. So, a little bit of It can be a little bit confusing there, so just make sure you have that straight.

Kevin, where is the actual defect in the femoral hernia? So, this is below the inguinal ligament and medial to the femoral vein. Yeah, so it goes below that inguinal ligament. So that will affect things when you go to do an open repair. So, how is that different than your, why won't your bassini repair work with that, John?

And what do you do in an open repair? Yeah, in an open repair it's also known as the McVeigh repair or Cooper's repair is that the difference is that you have to open the inguinal floor and you have to close the space by suturing the conjoined tendon to Cooper's ligament. Yeah. So don't say, especially if you're in an oral board scenario be careful if you have a femoral hernia, you got to do that McVeigh Cooper's repair.

Your basini is not going to cut it because

that defect again is below the inguinal ligament. Okay. That's enough about femoral hernias. Something more rare, but you still see, and it's kind of fun is the obturator hernia. So what is an obturator hernia, Kevin? So this is a herniation through the weakness in the obturator membrane.

And how does it, how does it present? What kind of patients do you see this in? So generally this is in thin elderly patients that present with a bowel obstruction. Right. Yeah. Usually very thin. Elderly patients come in with a bowel obstruction. And what kind of things john might you see it's difficult on physical exam is unlike other hernias.

So what might you see on physical exam? Yeah, that's the classic how ship Romberg sign. And this is shown with groin or thigh pain with internal rotation of the hip. And it's present about 50 percent of the time when patients present with obturator hernias. Yeah, so it's, it's kind of a cool thing, but it's not reliable as you say.

It's present about 50 percent of the time. I mean really. This is the 2020s. Your CT scan is going to be the way you diagnose these. It does have a high morbidity mortality.

Again, that's mostly related to the patient population. As we said, these are often elderly, thin, often malnourished individuals.

And they do have a tendency to strangulate. Okay. So, what did you want to, how do you approach these, Kevin? What, what would you do if they called you? I don't know why they'd be calling you as a vascular surgeon, but let's say that they did call you as a little old lady who's got a incarcerated bowel obstruction with an off rater hernia on the CT scan.

Yeah. So you have to have, you know, take these patients to the OR fast. You need early surgical exploration and reduction is required. Sometimes you need to actually incise the membrane to reduce the incarcerated bowel. And what do you want to, what are your options for, you know, so let's say you take them, you reduce it you know, you can do this either open or minimally invasive but now you're staring at this hole down in the obturator foramen.

How, what are you going to do with that? So generally you can repair this primarily with permanent suture and you can plug the defect with the round ligament or the medial umbilical ligament. Yeah, so it's difficult. It's a difficult

spot to get to. This is I think an advantage of that laparoscopic or robotic repair.

You can get down there. I'll regularly visualize the operator canal when I'm doing my minimally invasive inguinal hernias. There's not a lot to sew to, so it can be a little challenging, especially when the tissues are very thin and you obviously have some vessels and nerves that travel through that, that you have to be careful not to tag.

So you have to get a little bit creative. Yeah. Using those, those, those structures you mentioned, either the round ligaments or the, the meaty umbilical ligaments to patch are good options. You can cover with mesh, although there are, it can be challenging for mesh fix, mesh fixation in that area, but it's certainly an option.

Okay. So, you'll see them at some point in your career. They're rare, so it's, it's good to think it through and you certainly might see it on the app site. So, moving on from there, lumbar hernias. Another rare, but sometimes seen hernia. What are the different types of lumbar hernias, John? Yeah, there's two types.

There's the Grinfeld's and

the Petit's. Hernias, the Grinfeld, the landmarks for this is bordered by the 12th rib, the paraspinal muscles and the internal oblique. Regarding the petite, this one's bordered by the lat dorsi, the iliac crest and the external oblique muscle. Okay, great. Kevin, diastasis recti.

This is something we see on a daily basis referred to the general surgery clinic. What is this and how do you approach it? Yeah, I see lots of influencers on Instagram telling you how to fix this. So this is a weakening and widening of the linea alba, so it's not a true hernia. And there's no risk of incarceration or strangulation, and repair is not required.

Plication can be performed, but is mainly cosmetic. Yeah, so we see this a lot again. It's just a widening of that linear elbow. The initial thing or initial treatment is physical therapy. There are exercise programs that are designed to improve the abdominal wall.

And improve these the caveat I would be is, is if, if you have a combined diastasis with a ventral or umbilical hernia, there is evidence that there's a higher rate of recurrence of the hernia if you don't placate the diastasis at the time of the repair.

And there's a number of options that are becoming more and more available, minimally invasive, ETEP, that type of thing for, for addressing these diastasis recti. But for the most part, And what's likely going to be the answer on the outside is patient reassurance because these aren't true hernias.

There's no risk of incarceration or strangulation. Okay. So moving on to ventral and incisional hernias is a very broad topic. It's something that's going to be very difficult, but let's just try and hit some high points that might help us out on the outside. So, John risk factors for an incisional hernia.

We mentioned some earlier, but let's go over more. Yeah, these are the same as always. It's the wound infections, obesity, COPD, and most commonly. What you'll see on tests and in real life is smoking. Yeah, great. So again, it's all the things you definitely do not want your hernia patient

to have or be doing and it sets them up for a recurrence is also what sets them up for having a hernia in the first place.

That's why in recent years this idea of prehabilitation has become very crucial to having successful hernia outcomes. Number one, you need to get them to stop smoking prior to elective repair. You need them to lose weight. Oftentimes, I'm a bariatric surgeon, so I get a lot of hernia patients or a lot of bariatric patients rather in my hernia clinic where we'll stage them.

We'll do a bariatric procedure. And then after they lose weight, We will go and do a definitive repair of the hernia. It's that important that they lose weight and stop smoking. So if you get this patient with a BMI of 45 and as a smoker and a diabetic on the, on the exam, don't just rush to the operating room.

You need to work on getting them ready, which sometimes can take up to a year or longer to get them ready for surgery. Kevin, what are your options for placing a mesh in these patients? Yeah, very simplistically, you have the options of an underlay. An inlay or an onlay? Yeah, we used to see,

inlay used to see more, it's a highest risk of recurrence.

Usually inlay meshes are, if you do an inlay mesh, you're in a bad spot where you can't get things together and you're not in a good place to do a component separation. And you're often, those are temporizing procedures. That will need to be addressed down the road. It's a very high risk of recurrence, but in general, underlay onlay.

As we talked about, there's, there's different layers that you can exploit to get that mesh outside of the peritoneum versus putting an intraperitoneal. What we talked about before, your, your kind of go to meshes are your light macroporous. polypropylene or polyester synthetic meshes for, for with or without a barrier for most situations.

So John, what if you're in the situation where you have a very large hernia? And let's say that the patient's been optimized. We did a sleeve on them. They've got their BMI down to 29. They're not smoking. We've considered them optimized for surgery, but still you have a large 12 centimeter defect and you're not going to be able to get that together.

What are your options?

Yeah, I hope you figured this out, you know, prior to going to the operating room and, you know, planning purposes. And there's a lot of different criteria you can use to determine if you're going to need to do this or not. But the basis is, is a component separation. And there's a couple different types and variations.

In that regard, different types of layers are incised where you place your mesh and different approaches. Yeah, so let's just go through those. And again, like you mentioned earlier, refer to that in the companion book. There's a, a great image that has the different layers and actually has what you incise for these different separations.

So, so let's go through that because a lot of times this will be the question on the outside is what layer do you incise? With a, you know, say anterior component separation. So John, in an anterior component separation, what layer are you incising? Yeah, you're incising the external oblique. Okay, how about a posterior component separation in a, let's say a retrorectus repair?

Yep, you incise the posterior rectus sheath and then place the mesh in the, behind the rectus muscle. Yeah, so you're incising that, you're developing that retrorectus space.

Again, there's ways to do that minimally invasive versus open, but the principles are the same. And you're playing that mesh in that, in that retro rectus space.

Now, how about a posterior component separation with a transversus abdominus release also known as a tar. This is where you incise the transversus abdominus. Yeah, okay, great. So the tar, you're, you're entering that retroactive space, you're developing that retroactive space, and then laterally just medial to those neurovascular bundles, you're going to incise that transversus abdominis and, and release that transversus abdominis muscle and develop that space.

It gives you a nice big mesh overlap, a nice visceral sac to cover your viscera. And protect your bowels from that mesh. You know, typically when we're talking about sizing mesh and what area we're going to need to exploit my general rule of thumb and what I use is I take the size of the defect and I add 10 to it.

So, you know, you have a 10 centimeter defect. You're going to, you're going to need a 20, at least a 20 centimeter mesh. And, and whether or not you can put that in the retroactive space, we need to develop that tar plane is

based on the patient's anatomy. So you're, you know, we know that your, your transverse abdominal release is able to achieve as much faster release as an anterior component separation.

However, the advantage is that you have fewer wound complications because you're not raising those big skin flaps. So the tar has become really the preferred approach. And the anterior component separation has fallen a bit out of favor. But there are still certainly circumstances where you would need to do an anterior component separation.

All right. So Kevin, a lot of work has gone into figuring out what the optimal suture closure method is, different types of suture, how big of bites. So, and this goes into your primary closure of your laparotomies in addition to your hernia repairs, but what is an optimal suture closure method? Yeah. So generally you want small bites with an absorbable suture.

So five to seven millimeter bites and probably a slowly absorbing suture like PDS. Yeah. Great. A slowly absorbing suture, five to seven millimeter bites. You know, we mentioned minimally invasive versus open techniques for all this. There are good lap or

robotic approaches that have been described and are done pretty routinely at this point with low wound morbidity in for a test taking.

If you're sometimes you'll. Get forced to go to the OR for whatever reason in a patient who's obese. Just remember that minimally invasive approaches are preferred in obese populations. And sometimes that's, that's the principle they're getting at with those questions on, on the ab site. Okay. So that wraps up our discussion of hernias.

As always, we're going to end with some quick hits. Are you guys ready to do it? All right. So John. Quicket, hernia that occurs at the junction of the semilunaris and the arcuate line. That's your spaghelion hernia, or also known as intramuscular hernia. Yeah, so spaghelion hernia, these can be very difficult to diagnose on physical exam because that external oblique is intact.

So the patients usually do not have a bulge. So if you have a patient that presents with classic symptoms non contrast, non contrast CT can be very helpful in identifying these. there are at a relatively high risk for incarceration.

So if you do identify them, you should repair them. Okay. So Kevin appendix in an inguinal hernia sack.

What is that? That's your Ammion hernia and do a primary repair in appendicitis. Yeah. So Ammion hernia. And if you have appendicitis within that appendix that's in the hernia defect, you obviously want to, that's a contaminated field. So you want to be careful with that. John, Meckle's diverticulum in a hernia, what's that called?

That's our Elytra's hernia. Elytra's hernia. Kevin, both, let's say your patient has both an indirect and a direct hernia, what's that called? So that's your pantaloon hernia. John, sliding, what's a sliding hernia? And what's unique what's unique about it that you have to consider during your repair?

Yeah, that's your retroperitoneal structure that makes up a portion of the sac. So you have to be careful. Not to open the sack during the repair of a sliding hernia exactly So an organ is making up some component of that hernia sack So if you're open to the hernia sack and you're doing an open repair You very likely could open

that Retroperitoneal structure that organ so you definitely don't want to do that Kevin Richter's hernia.

What's the significance of a Richter's hernia? Well, first off, what is it and what's the significance? So part of the bowel wall, typically the anti mesenteric border of the bowel is present in the hernia sac. And so this can present as strangulation without obstruction. Great. John, we covered this briefly, but what's the most common hernia in females?

Yep. That's your indirect hernia. The femoral hernias are more common in women than in males. But the indirect hernia still remains the most common for both men and women great Yeah, sometimes that can be tricky and they'll ask you that and it's a trick question. It's definitely a trick question. Just don't fall for it During okay.

So Kevin, so let's say during an inguinal hernia repair And a skeletonization of the cord you can't find a hernia. What do you do? So in this situation you need to open the floor and look for a femoral hernia Exactly. Exactly. If it's not making sense you need to look for a femoral hernia like we said that femoral hernia travels under the

inguinal ligament and It's not always apparent on physical exam and you don't always have imaging and sometimes it's not clear on imaging either.

So if you're, if you're not seeing that hernia sac, then, then, then look for that femoral hernia. Okay, Kevin, child sees cirrhotic with massive ascites and umbilical hernia with intermittent obstructive symptoms. What do you do? So you do tips first to control the ascites before considering a repair.

Excellent. Yeah, we talked about the importance of controlling the ascites, absolutely essential. John. Laparoscopic inguinal hernia repair and you tack the mesh to Cooper's ligament and you get pulsatile arterial bleeding. What happened? Oh, I hate this thing. It's the coronamortis. It's the branch between the obturator and the external iliac artery.

Yeah, we should have been more careful. Kevin, placing a suture during open inguinal hernia repair and you get sudden bleeding. Those damn veins, the femoral vein injury. What do you do? Pull the suture out and hold pressure. Yep. Femoral vein injury. Just pull the suture out. Don't tie it down. You're just going to rip the vein open.

Pull the suture out and hold pressure. It'll be okay. We stick needles into veins all the time and it's fine. John, groin pain,

significant medial thigh pain with internal rotation of the hip. You mentioned this earlier. What is it? Yeah, that's the rare obturator hernia. And that's also the name is the obturator sign or the Halshep Romberg sign.

Exactly. It's present only about 50 percent of the time. Kevin you have a patient's one month staspos and open inguinal hernia repair with a proline mesh. And now we have a wound infection and you have purulent fluted around the mesh. What, what's the, what do you do? Yeah, in this situation, you have to explant the mesh.

Yeah, I would say that's getting a little bit controversial. There are, with the newer macroporous polypropylene meshes, there are mesh salvage techniques. But if you have, you know, gross purulent pus coming out of your wounds yeah, you're probably going to need to explant that. Okay, John, so you have a young female with a minimally symptomatic umbilical hernia that she noticed during pregnancy.

She does desire future pregnancies. What are you going to recommend? Yeah, I see at least one of these probably every month in clinic, but you want to talk to her and counsel her about deferring her hernia repair until after she's completed all planned

pregnancies if possible. Yeah, absolutely. Especially if it's minimally symptomatic, you want to defer that until they're done.

Okay. Kevin, inguinal hernia repair and you can't reduce the sac. What do you do? So you can ligate the proximal portion and that will reduce it into the abdominal cavity and then you keep the distal portion open to reduce the chances of a hydrocele. Yeah. So the abandon the sack technique, you can do this minimally invasive and it has good data that it turns out just fine.

Okay. So I think that does it for our hernia ab site review. So hopefully that'll help you guys on the exam and until next time.