BTK_Episode 12

Hi everyone, and welcome to our 12th episode on challenging cases in emergency general surgery. We've got a great episode today, and it may be our last one, so we wanted to make sure to pick a tough case that promises to be jam packed with twists and turns. And as usual, we'll end with a fun game. I'm joined today by Dr.

Ashley Nadler, Dr. Jordan Ante, and Dr. Graham scale horn growth. That's right. So today we're gonna discuss an anatomic structure that as general surgeons, we rely on every day, but when things go wrong, it can really become a fickle foe. That structure, of course, is the abdominal wall. I'm so glad we're talking about this because it can be a real game changer.

Think of a patient with a relatively simple surgical problem, say appendicitis or a bowel obstruction. Now add an old midline laparotomy incision that was complicated by a wound infection. Suddenly that case is much more challenging and your approach may be quite different.

Agreed, and that's for those patients with abdominal walls that are being relatively well behaved.

I don't know about you guys, but I've been seeing a number of folks with previous hernia repairs mesh in various places, and they've been coming in with recurrent hernias or mesh infections or even inter cutaneous fistulas. These cases really aren't always right out of the textbook. Yes, Graham, that's the hard part.

So what's the role of the emergency general surgeon for patients with complex abdominal wall problems? What's the emergency? And once we've dealt with that, what else, if anything, should we do and when should emergency general surgeons use mesh themselves? Which patients benefit from dedicated hernia surgeons or interdisciplinary hernia groups?

Now, most of these questions are pretty hard to answer, so a lot of today's podcasts will based on our opinions, which are likely very specific to our own clinical context. You know, in full disclosure, there's no way we're gonna be able to tackle all the different. Problems you could potentially run into when it comes to abdominal walls, but we're gonna try and focus on some things that are pertinent to what you might

experience clinically.

Certainly, and especially when it comes to hernias. There's lots of different approaches and each can lead to great patient outcomes when used in the right circumstance for sure. But all the more reason to discuss the pros and cons of different approaches and see what the commonalities are. So, without further ado, let's get into a case.

That sounds good. So I recently saw a 56-year-old male in the emergency department. He came in with abdominal pain, nausea and vomiting, and a large bulge in his abdominal wall. His medical history included obesity. His BMI was around 40. He had obstructive sleep apnea, hypertension, diabetes, and he was a smoker.

His surgical history was notable for a lap coli, and that was followed by a portside hernia that was repaired with mesh. And then of course, he required a subsequent ventral hernia repair with mesh. He wasn't really able to gimme the details of the operations. So Marika, how would you get started with this patient?

Hmm. Sounds like a fun case. So as long as the patient is stable and not peroney, I'd start

by reviewing all of the previous operative records available to me, their hospital courses, and review any recent abdominal imaging I have in my disposal. I think that's a really important place to start. So knowing the details of your patient's past surgical history.

Also, as much as it's always important, it's particularly important, these cases when you're dealing with the abdominal wall. Specific details you need to know about prior hernia repairs are. What was the approach? So say open versus laparoscopic or robotic. Did they use mesh? If so, what type of mesh might they have used and what layer of the abdominal wall did they put it in, and did they reconstruct the abdominal wall or is it just some sort of bridging mesh?

So how is the mesh actually located relative to the other structures? I agree, Jordan, that information is gonna let you know what to expect if and when you're in the operating room and what your options are. For me, the next thing I need to do is my history and thorough physical exam. Focusing on the abdomen.

Since it sounds like this is gonna be a case of a

hernia, I want to know exactly where the hernia is and the extent and size of it. I also wanna check for other potential hernia sites such as bilateral groins in a patient with obstructive symptoms. You wanna look for changes in the overlying. Skin that might make you worried about incarcerated or strangulated bowel and get a sense of how easily the hernia or hernias reduce and see if you can feel the hernia defect itself or just its contents.

Of course, you're always checking for distension and peritonitis as well. That's great, Ashley. And then, you know, I'd probably move on to my standard abdominal workup to figure out what is going on. So in this case, I'd involve basic abdominal labs, so typically A CB, C, electrolytes, LFTs, lipase, lactate. I'd also get some imaging, in this case, a CT with PO and IV contrast.

I generally use PO contrast, but I'm worried about an obstruction or if I'm looking for a leak, especially on the foregut, and I get IV contrast for pretty much everyone. I'm worried about serious pathology, so most ventral hernia patients, I'm, I'm getting an abdominal CT

scan unless it's a very small uncomplicated hernia.

But this doesn't sound like the case here. You know, one of the things that we don't talk about in surgical training enough is how to review CT scans and how to tailor your approach to the presentation for the obstructed patient. I really wanna understand if there's a transition point where it is what.

Potentially could be causing it. And are there others to suggest a closed loop? So I'm looking to see if the bowel is getting hung up at a hernia or if it's adhesive within the hernia, or looking for internal hernias in patients with previous r and y surgery. I also wanna get a sense of the bowel itself.

Is it enhancing normally? Is there free air, free fluid? Is there stranding in the mesentery, stranding around the bowel? Finally, I also look distally to see if contrast or gas is making its way past it. I think that's a nice way to think about the scan. So all of these factors, the exam, the imaging, the blood work you know, to some degree things like a normal lactic can of course be falsely reassuring, but they have a role to play.

They go into your calculations as far as which hernias you can attempt reduction on, and which ones you should just take directly to the operating room. Now this approach might be a little bit institutional, depend on and might depend a little bit on your access to the or as well as your ability to perform procedural sedation in the emergency room.

There's certainly a lot of nuance and you wanna know exactly what you're planning on doing. The last thing you want is for your obstructive patient to aspirate while they're getting sedation or to reduce some dead bowel. Dead bowel into the peroneal cavity. Agreed. That's a nightmare for us and for the patient.

Obviously I find the smaller hernias that are minimally tender in patients with no peritonitis or hemodynamic instability relatively socially acceptable blood work and no scary findings on ct, like a bunch of free fluid or air and the hernia sac can safely be reduced in the emergency department.

Once you start seeing some of those other factors though, I get a bit less excited about it and prefer to just take them to the operating room. That's a nice dichotomy, Ashley, and I think it's really important to look at it this way for several

reasons. Of course, like Jordan said, we don't wanna miss dead or threaten bowel, but operating resources can be limited and there are patients much like this one who would actually benefit from pre rehabilitation, if that's possible, and, and potentially an elective repair down the road.

So this particular patient has already failed two hernia repairs. They're obese, they're a smoker. They're really at such high risk for another recurrence unless they can lose some weight and quit smoking before surgery. Ah, yes. Wouldn't it be great to operate on exclusively pre habilitated patients? But we are of course, emergency general surgeons, so this is not a luxury we have.

Let's suppose this hernia is resulting in a bowel obstruction as the bowel enters the hernia and that the patient is having a lot of pain and we're not able to reduce this hernia, or we don't think it's safe to reduce and we have to take them to the operating room. Jordan, can you give us some tips and tricks for how you would initially approach an incarcerated incisional ventral hernia in the operating room?

Sure. So as with any

patient with obstruction, communication with anesthesia preoperatively is really important. These patients are really high risk for aspirations, so I like to place the na a nasogastric tube beforehand and decompress 'em before induction and, and my expectation. Anesthesia colleagues use rapid sequence intubation.

As far as their strategy your surgical approach is gonna have to be tailored to the patients. If I think I can safely get ports in and it's within my skillset you can consider start starting laparoscopically. You'll be surprised how much space you have in some patients once the abdominal walls relaxed.

If I think there isn't gonna be any room or the hernia is much too difficult or complicated to deal with laparoscopically like in a case like this, where I expect the repair to be exceedingly complex. Or of course, if the patient's an extremis, then I just open. Yeah, there's nothing wrong with open surgery, especially to fix a life-threatening problem in a sick patient.

So to start, I try to get in somewhere. I will find somewhat normal anatomy, so if this patient had a previous midline, I might go just above it where the abdominal wall

layers will hopefully be more normal. Once I get into a normal tissue plane, I start working my way towards the pathology, dividing adhesions as I go.

How much dissection to do really depends on the situation. You need to find and fix the problem, but don't necessarily have to divide every adhesion and dissect out everything if you don't need to do so in order to find and fix and address the problem. I agree. And that's especially important if the adhesions are not friendly.

It's all about weighing the pros and cons and like you said, more dissection might need to lead to more. Enter autotomies. As you all have suggested it's about tailoring the approach to the patient. So really we wanna find the transition point and make sure we've dealt with that and any other possible areas of concern.

So after we get in safely and dissect everything out, we need to assess the bowel, dead bowel needs to come out. Bowel, that's clearly fine, is easy. Leave it in. But what about the stuff in between? How do I, we identify and how do we manage threatened bowel? Yeah, so these decisions can be really hard bowel that's obviously pink and peristalsing is great Bowel, that is black comes

out often.

There's bowel that's somewhere in between. There's a number of things you can do depending on the resources you have at your institution. First, and this is what I often do, you can just cover the bowel up in a moist, warm towel and wait to see if it pinks up. I usually wait, you know, five minutes, 10 minutes to see if this happens.

Sometimes you can feel for a pulse in the mesentery, see if it's peristalsing. In some centers, you can also use indocyanine green. I've heard of using a woods lamp, but never have done it myself. The other question I ask is, what will the consequences of resection be in this patient? If it's just a small area of the small bowel and a patient?

With all of the rest of their bowel, it's probably not gonna be that big of a deal to resect it. However, in a Crohn's patient or someone who's already had a prior bowel resection or has a very large area of questionable bowel that may not heal well, resection obviously can have a greater impact in side effects.

So what about plant second looks? Do you guys think that these have a role in emergency general surgery? Yeah, I think that's a great question. One that comes up fairly frequently. I find with these cases you often have a lot of additional things that need doing, like more adhesiolysis explaning, some infected mesh if required, et cetera.

If I'm really unsure about whether a piece of bowel needs to come out. I'll make sure it's warmed up and reduced, and then I'll usually go and work away in another area for a while and then come back and assess later if I remain unsure. I think bringing back for another look is totally reasonable.

Of course there's less data on this in acute care surgery than in the setting of trauma, but I think in most cases outside of extremis, it's avoidable. Good points and definitely a controversial area. Okay, so you've evaluated everything resected, the dead or questionable bowel maybe. The next decision to make is what are you gonna do with the existing mesh?

I tend to leave, well incorporated mesh alone, especially if I think I'm gonna get into more Mies trying to get it out or any Mies. But if there's mesh that isn't

well incorporated, I would remove that. I do this because it's not really helping the patient, and I worry it'll become infected in this setting.

That makes sense. And I'm glad you brought up mesh because now that you've treated the emergency you have another decision to make and that's what are you gonna do about the hernia? So how are you gonna repair it? And specifically, are you going to use mesh? If so, what type and what layer are you gonna put it in?

Would that change if you had to resect bowel or are you worried about an enterotomy, Marika? What's your approach? For the easy answer to start. If I was able to divide the mesh in the midline and there was no bowel resection, then it's much easier and I can just use the mesh to close in lieu of the fascia.

If the mesh was tattered or destroyed during my dissection or from the hernia recurrence, or if I decided to remove it for concern of infection related to ischemic bowel and its resection, then I have to consider if I can bring the fascia together primarily, or if I need something to bridge the gap.

Yeah, I think that's a really good way to think about it. But, you know, many great plans don't work out so great. So what if you're bringing

the or what if you're in the process of closing and what's left of the fascia you have just really isn't coming together, or maybe anesthesia's telling you that your peak pressures are starting to shoot up as soon as you're starting to close the patient.

What do we do now? I hate when this happens, but not unexpected by the sounds of this case and the prior repairs. So some degree of increased pressure will happen and may be tolerated, but you don't wanna create abdominal compartment syndrome obviously, for the patient. I'd like to test the fascia before I close by using coker on either side of the fascia to pull it together in the midline just to see how it'll.

How it'll join and what will happen. Of course, I make sure to communicate with anesthesia to make sure that their pressures are okay and that the patient is relaxed. An NG tube can help, and often I find that I can start closing the, from the top and the bottom of the fascia to see how far I get, and often I'm pleasantly surprised how it comes together.

Yeah I found that too, and this is especially relevant in those patients that have been left open for a second look, but yeah, sometimes closing's hard. I do the exact same thing. I start from

the top and from the bottom and if I really can't get fascia together, I'll place a biologic mesh. But I really try to avoid that.

And, and again if you have to do it I really try to make it as small an area as possible. What do you guys do in this situation? Do, do you think there's any role for retention sutures? Does anyone use a mesh suture? So we don't have the luxury of using biologic meshes in Canada for emergency cases, so I have to decide if it's safe to put in a polypropylene mesh, which it likely is not if we are resecting dead bowel.

Although there is some debate on this. So if I feel I need to bridge the gap, then I will use a Vicryl mesh in the contaminated or dirty setting. But I will also consider leaving the hernia completely alone and just closing skin if I have to, especially if I think the hernia's gonna recur anyway with a Vicryl mesh, and especially if the patient is currently unstable.

I. Yeah, I think that's a solid approach. You know, another issue that comes up in this scenario is whether or not to open any new layers. The way I think about it is that my first goal is to deal with the life-threatening emergency, which is the bowel

obstruction in this case. My second goal is to restore function of the abdominal wall if feasible in this setting.

But the best repair for this patient may involve component separation, but I'm really hesitant to ever do that in the emergency setting. You know, I expect that a patient like this will likely recur, but I'd rather optimize them for, you know, for their future operation and perform an elective component separation when they have the.

Best chance to recover well, that operation's likely gonna be their last chance at resuming regular abdominal wall function and reconstituting a typical abdominal wall anatomy. So I want that to be the best possible chance. If it's just a matter of mobilizing a bit of subcu tissue off the fascia, maybe getting a bit of a additional length that way, I don't really shy away from getting into that layer in the acute setting, however.

Okay, so let's switch up this scenario a bit and say you decided the bowel didn't look too bad, and so no resection was needed. You end up placing a mesh in the retro rectus space to reinforce your repair. Now the patient comes to see you in a

week in your clinic, and they have a wound infection. What now?

Okay. Well, I'd approach it like any other wound infection but it always makes me more worried when, when I know there's mesh. So I'd start with making sure I had my set of vitals. I recognize that I'm in clinic, so if they end up being sicker, I would need to get them transferred over to the hospital to get more workup and treatment.

I. If it just looks like a superficial wound infection, I'd probably open it up and pack. And it's really if I had concerns for systemic signs of infection or something more that's the patient that I'd be more inclined to get blood work and imaging for. Really looking for things like abscess, enterotomy, et cetera.

The dreaded infection with mesh nightmare. So let's make this as unpleasant as possible and say there's an intraabdominal collection underneath your mesh. It sucks, but don't overthink it. It's a collection and it needs to be drained, so as long as the patient is stable, I would ask IR to place a drain, ideally with a lateral approach to get around the mesh and not see the infection to it

if it isn't already infected.

Such hopeful thinking, but I'd be worried that the mesh is already infected in this case. Now, just because the mesh is infected doesn't always mean that it has to come out, especially with light and medium weight, modern polypropylene meshes bonus if it's already well incorporated, but that doesn't necessarily have to be the case.

In my experience, I find that the majority of these can be salvaged, however. You're likely, you're likely looking at drainage, long course antibiotics, repeat CT scans, and still the potential for removal. So I always make sure I'm pretty upfront with patients about the significance of this complication and the length of the expected course and just how significant it can be.

Now all that being said, if on your initial scan you see that your mesh is just floating in a sea of horrid abscess, you might decide that it's worth it just to remove it right there to each their own. So let's say that you decide to leave the mesh in place, you drain the abscess for now, but they develop a chronic infection or fistula.

Ashley, what are you doing next and what are you going back in and what are you gonna do in that case? So I would assess the timeline from surgery at this point to see if I'm still in an operable window or if the abdomen is likely to be frozen at this point. If it has been less than two weeks and I'm concerned this patient had an anastomotic leak or a MiStent enterotomy that's resulting in this, then I would consider taking them back to the operating room for definitive control, assuming we're further out and that the patient is well but has a fistula, then I would generally admit for further assessment and management to start, this would include a CT to define the anatomy, ensure there's no untrained collections, and drain them if there are any wound care.

Which may include pouching the fistula to get a sense of the output and skincare and a nutritional assessment. If the fistula is high output, I would make the patient NPO and start them on TPN. If it's low output, I may be able to avoid that. Either way, I'm looking at waiting up to six months to see if the fistula will heal before planning to go back in for a repair.

If the mesh is contributing to the fistula, it likely won't heal, however, and I'll be back in the OR to remove it and repair the fistula. It's a hard and long course for the patient and the surgeon. And with that excellent discussion, it brings us to the real reason anyone listens to our podcast, the game we have chosen to call this one Repair or Despair.

We are gonna throw some tough situations at the players, and since these are complicated cases, what we're looking for is some quick details on how you'd repair it, what you do with the mesh, if there's one present, and how you deal with the bowel or complicating factors. So without further ado, let's get started.

Question number one. 55 year olds heavy active smoker with a prior laparotomy for perforated duodenal ulcer presents with incarcerated hernia in the epigastrium, and a CT scan that shows transverse colon in the hernia with free fluid

and free air. Dr. Nadler, how would you approach this? Alright, so we talked a bit about this before, but I would book them and consent them for a laparotomy.

I would open on some normal healthy midline if there was any available without a laparotomy scar to try and get into normal tissue above and below the hernia itself. And then I would work my way making the incision big enough. Separating as much of the adhesions or bowel that's attached to the abdominal wall to isolate the transverse colon and find the area of the perforation.

And then I would resect based on what I found and the patient's stability either doing an anatomic resection or a focal damage control resection of the transverse colon, depending on how sick the patient is. Okay, great. And then what would you do with the abdominal wall? Again, depends how sick they are.

I, it doesn't, it depends how big the hernia is, but I would try and do a

primary repair if I could in this case, or I would be planning a damage control if they were too sick to tolerate that at this point. Okay, great. Okay, great. Ashley, does anybody else have any other thoughts about this? So I totally agree with what what Ashley suggested.

I think as far as I'm concerned, the big questions I have to ask myself are how much bowel needs to be resected? You know, how, what, how sick is the patient? Am I gonna be able to do a primary anastomosis, et cetera? I. But likely in this case with feculent contamination, I'm gonna be resecting the bowel, assuming they're stable and it's suitable to do so.

Performing some sort of primary anastomosis and then hopefully just mobilizing the fascia a little bit and performing some sort of primary fascia closure to get the patient closed, get at a Dodge deal with the likely recurrence of that hernia at a later date. Okay, great. Anything else you wanna add, Graham?

No, I agree. Sounds like this patient needs a resection and a primary repair. I would definitely tell the patient before the operation that they have a really high chance of recurrence, but in the intervening time, we'll treat the

emergency now and we'll try and pre rehabilitate them for surgery. I try to make sure that my resection if possible wasn't too close to the watershed areas, but I, I agree with with Jordan and Ashley.

Yeah, same. Okay, let's move on to the next question. Jordan, we'll start with you for this one 70-year-old female who's post update two from a massive ventral hernia repair with a tar component separation and polypropylene mesh. She gets taken back to the OR for a missed bowel injury and you find moderate contamination throughout the abdomen from a small bowel perforation.

What are you gonna do? Yeah, if there's anything I can think of that's just purest heartbreak, it's this type of case, both for, of course, the surgeon and the patient most importantly. So you know, the, you're taking this patient back to the, or, first and foremost, you're trying to deal with that bowel injury and make sure that you deal with the life-threatening aspect of this.

So likely you're gonna just go right through your mesh from the get go. Open things back up. Wash out all that contamination, identify and either

fix or resect the bowel injury and make sure that you're not dealing with any other injuries once you've gotten to that point. I think you have to make a call based on the amount of contamination that you have based on patient stability, how extensive of repairs you've had to do as to what you're gonna do with this hernia at this point.

I suspect in most of these cases with a patient that's been brewing in small bowel content for another day. Or sorry for a couple of days. Unfortunately, you're just gonna be explaning that mesh and then closing the fascia primarily with the expectation that they may get a recurrent hernia in the future, and you'll have to deal with that accordingly.

I think given that your mesh is going to be mostly isolated from the, you know, with a tar repair, is gonna be mostly isolated from the peritoneal cavity, there is a feasible circumstance here where your amount of contamination is very limited. And with a lightweight polypropylene mesh. I think in the ideal circumstance, you could certainly consider putting a new mesh in and kind of recreating your initial, your initial repair but really, really challenging situation.

I think you're gonna be in a

tough spot no matter what. I'm totally open to other opinions here. I know this is a tough case. Yeah. Ashley, have you ever had to deal with something like this? Yeah, this is a really tough situation when this happens. Fortunately rare, but it can happen in these complex surgeries.

So, it is tough. I think the hardest part is we can all manage the bowel injury and we're used to that as acute care surgeons, but it's harder to decide what to do with the mesh. So I think as Jordan's. Stated it very nicely removing it if there is extensive contamination, but potentially trying to leave it if it's pretty contained and minimized.

Really just irrigating copiously if you are gonna consider the mesh, but you're gonna have to watch the patient closely, obviously, in both situations. Mm-hmm. And how hard is it to remove this mesh? Haven't had to do this yet. Has anybody been faced with this? I have unfortunately although it was before I finished my residency, but I could tell you it was early on in the course.

And so the mesh hadn't really sucked into place or anything like that.

So essentially it was just a matter of taking down the trans fascial sutures and removing the mesh, and it came out quite easily. Oh, great. Great. Okay, let's move on to the next scenario. A 42-year-old female with Crohn's in a previous a PR.

She has a moderate size midline ventral hernia, as well as a parastomal hernia with previous mesh repair at the ostomy site and comes in because it is now recurred. Graham, how would you like to tackle this? Yeah, I mean, another tough case, so I'd. I wanna know a little bit about two things.

Number one how symptomatic she is from these hernias and really what's the state of, of her Crohn's and, and how well controlled is she? So it seems like there could be quite a range between somebody who's incredibly symptomatic versus I. You know, maybe even just a radiologic recurrence. Of course if she's symptomatic, then I'd wanna do something and I'd work with our gastroenterologist to optimize her Crohn's disease in this setting.

If I had to take her back. It really kind of depends on

exactly where and how big the the hernias are. And, and also if she has specializing Crohn's that may have affected the parastomal mesh. From her previous repair. So this might be one of the times where I would actually recite a stoma, even though that's controversial to do at baseline.

But if I was concerned about Crohn's disease affecting the mesh I might reduce everything and put it on the other side. And then I ba decide based on the size of the hernia and where it was, what what exactly I was gonna do for the midline. Dr. Nather, would you do anything different?

No, I think that's a very reasonable approach. I think Graham stated the main thing, is this really an emergency or not? So, hopefully it's not, but I, I really like what Graham's approach was, if it is. Mm-hmm. So if we assume that her Crohn's is well controlled, and this is a recurrent peral hernia do any of you have a preferred approach to these in terms of the, the type of repair or reciting hernias?

I can, I,

I can say from my perspective, I'm not personally a huge fan of reciting these unless you absolutely have to. I just find you end up in a situation where you've got a high likelihood of a new hernia that's gonna develop in a, in your new stoma site, as well as create or having your old site with the potential to develop a hernia there or recurrent hernia depending on what you do at this time or at this particular time.

So, personally, if it's possible, I would like to do some sort of combined repair, assuming that we move forward for preparedness for one reason or another, if it's incarcerated or otherwise. You know, I would wanna do one combined repair that provides kind of a robust closure of her abdominal wall and mesh coverage that includes both the midline hernia as well as the parastomal hernia.

So ideally, you know, if I were able to create kind of an ideal situation here where we don't have to resect bowel, the Crohn's is controlled, et cetera I'd want to bring the fascia of the midline together. I'd want to have a mesh that you know. Underlies that entire

area, whether you do a tar or whatever your repair of choice is and depending on the size of the hernia.

And then also do some sort of hernia repair at the parastomal site, potentially overlapping with the midline hernia repair. So, you know, usually something like a sugar baker repair in that mesh may so over or may also overlap with whatever mesh you use in the midline. Okay, great. Anything else to add, Graham?

No, that's a nice approach. Mm-hmm. Mm-hmm. I agree. Alright, so last case for today, a 61-year-old male with a massive scrotal hernia containing colon, small bowel and omentum. The bowel is strangulated dusky but alive. You're unable to reduce the massive contents back into the peritoneal cavity.

Jordan, I'm sure you've seen this before. What is your approach? I, I've only seen these types of cases by virtue of having terrible luck. So you're, you're not wrong there. So I think first and foremost, like any other case you

want to deal with. Reducing the hernia, dealing, dealing with the hernia contents as appropriate.

In this case, given that they're strangulated and the bowel is dusky, you want to try and get that reduced in any way that you can and make sure that that bowel doesn't end up in or completely infarcted. If you end up in a situation here where say you have approached this through a groin incision and you are unable to completely get this reduced 'cause it's such a massive amount of intraabdominal contents that a.

Gone down into the scrotum. I, I don't see how you can get away with, with fixing this, without having, or without making a midline laparotomy to at least start or at least open up the belly and try to reduce this content into the belly. And then you can kind of use that to facilitate whatever groin repair that you do.

Now, you know, once you have that stuff reduced, presumably if this patient has a massive scrotal hernia, the next problem you're gonna have to deal with once you fix the groin hernia is the. Potential, huge loss of domain that the

patient has had in predominantly, and that can be an exceedingly difficult problem to deal with.

So first things first, you know. Communicate with your anesthesia colleagues. Make sure that the patient is as relaxed as possible and see if there's any feasible way in which the patient's abdominal wall is gonna come together. I think if it's not, you can consider doing things like resecting omentum to buy yourselves more intraabdominal space to make up for some of that domain that the patient's lost.

And if you really have no way of potentially getting his abdomen closed, I think you have a couple options at that point. You can do things like. Temporary abdominal closure by yourself. A little time live to fight another day and come back and kind of reassess after the patient's been stabilized and aggressively dire.

Or if you really can't get the fascia closed, you can consider doing things like a bridging mesh, skin only closure, et cetera. Things that you may have to do, accepting that it's going to be morbid, but to get yourself out of dodge and get this patient safely out of this situation.

It's interesting. I, I have never heard of resecting the omentum to make up for some extra space.

That's a really interesting idea. I wanted to to ask if anyone has any experience with some of these temporary abdominal closure devices, especially if you're hoping to eventually get the abdomen closed, but leaving them temporarily open, I often find even harder. To close the abdomen second time round.

So has anybody seen any success with these or would would anybody ever consider one of these in this situation? Ashley, anything else to add to this case? I. Yeah, I think great comments made so far. So far. I think that one of the things we, like Jordan brought up the idea of removing part of the omentum, and I think those are some of the maneuvers, one of the maneuvers I would do before even converting to the laparotomy.

Obviously it sounds like that was unavoidable. That would be unavoidable in this case, given the extent of the hernia that they're describing. But if you need to do that to even try and reduce. The contents back through the inguinal canal. So you can extend the inguinal canal, obviously being cautious of

where the femoral vessels are you.

So there's maneuvers to make that work. You can try putting kind of direct constant pressure. Often these chronic hernias have a lot of adhesions between the organs and the sac, so you may do a lysis of adhesions to try and kind of separate what's contained within the sac and reduce them sequentially.

So just kind of thinking of kind of that. Step, step up approach, although it sounds like this would be quite an extreme situation where really you couldn't avoid doing a laparotomy. But I would obviously try and do all those things to get to that point and work my way up before doing a laparotomy to try and reduce a inguinal hernia.

Yeah, that's a really good point. Thank you for bringing that up, Ashley. All right, so that's it for repair or Despair. Thank you all for participating. Given that this may be one of our last episodes, I would like to give the sign off to our founding father of the group and, and fearless Leader Graham, you can take it away.

Well,

that's, that's fun. Thank you everyone who's who's listened to any of our episodes. And, and thank you to all three of you. I've just learned so much from you and, and it's just been so fun to do this. So, one final time. Dominate the day I.