Episode 2-Flank hernia final

Hello, welcome to Behind the Knife. I'm Ryan Ellis, a general surgery resident at Cleveland Clinic. And I'm Sarah Maskell, another general surgery resident at Cleveland Clinic, representing the hernia team here with Dr. Prabhu and Dr. Baffa. My name is Ajita Prabhu. I'm a staff hernia surgeon here at the Cleveland Clinic.

My name is Luke Baffa. I'm an assistant professor at the Cleveland Clinic. Today we're going to be talking about a challenging scenario in hernia surgery, lateral abdominal wall hernias. That is a hernia that's lateral to the rectus sheath. So let's get started with a case. Our first case is a 57 year old male who presents the outpatient clinic with a right blank hernia.

He has a history of a right nephrectomy through a blank incision for renal cell carcinoma several years ago. He has a 5 centimeter defect on his CT that is about 12 centimeters from the midline. Dr. Prabhu, how would you approach this patient in terms of workup and surgical approach. Well, for the first part, this patient's had a nephrectomy and he's already been

imaged.

So I don't think that he would require any additional imaging. I don't think that he would require any IV contrast, but that's something to think about if they've had any amount of nephrectomy, which he's had a full right nephrectomy. So, it sounds like his imaging's okay. I always like to see these people in the office.

In person to examine them. I don't think an image is enough to make a decision on how I will approach the patient. Because a lot of the approach also depends on the patient body habitus and the appearance of the scar, etc. As far as seeing the patient in clinic, I would want to get a look at where the incision was and what the hernia looks like.

Now that you've assessed the patient, what would be your surgical approach? For this case, if he's an appropriate body habitus patient, he's not overly obese even so, the hernia defect appears to be greater than 10 centimeters from the midline, so it's 12 centimeters from the midline here on the CT scan.

I would likely position this patient in a lateral decubitus position with the right side up. in a bean bag, and we could also talk through what that would

look like in terms of where do you pad and what do you do with the bed and everything else. But for me, I'd come right down on the hernia defect itself through an incision, usually right at the area where the old incision was, although occasionally you will have to make the incision in a slightly different location based upon where the hernia defect is centralized.

Approach it through an open, open incision over the defect. Would you do anything different, Dr. Buffa? You know, sometimes it depends a little bit to me. You know, when I think about a patient like this, the first thing I always think about is from if they're for cancer, I always think, just take a moment and just stop and think about what's the cancer status.

Are they in remission? What's their prognosis? How long are they going to live? Just because you don't want to put them through a relatively morbid procedure and then they pass away in, you know, six months or something. So, I always take, whenever I'm doing a hernia, particularly a patient who has a history of cancer or it's from a cancer operation, I kind of take a, take a one step back for a second and say, okay, am I going to do the right thing for this person by improving their quality of life by putting them through a major operation?

And is the

cancer affecting, going to affect that? But assuming that that's all good, I think robotics has a, does, and minimally invasive approach does have a role. Without a doubt. And that depends on, to me, that comes down to size of the hernia and location. And I always That size depends on how close it encroaches to the semilunar line, which is the lateral border of the rectus muscle.

And if that gets really close to the lateral border of the rectus muscle, that semilunar line, and it extends very posteriorly, like let's say the entire flank is just blown out, to me that's not a robotic case. That's, that should be done open, because robotics is really hard when it spans the entire flank to get a good repair immediately.

And then a good repair posteriorly and that, that would be for me, I never want to compromise anything robot just to do the case robotically. So I would say I would do that case open. But if it's a small,

let's say really posterior defect that's greater than 12 like three or four centimeters, just maybe the lateral border of their flank incision, like that's a great case for robotics and that's a great application for that.

So you're kind of getting to it, but is your determination in robotics versus open mostly on your mesh overlap, your ability to get mesh overlap? Yeah, I think that's fair to say. I just, one thing I think is crucial when I think about robotics is I want to make sure I'm giving patients the same repair I would open and I wouldn't be compromising anything just for small incisions.

Now, Dr. Prabhu kind of mentioned how she'd make her open incision. What consideration are you thinking about, like, for robotic port placement? Yeah, so robotic port placement, that, that again depends on where the defect kind of extends and how medial it extends or how lateral that defect extends. But you need to think about giving yourself space for the robotic arms to reach anterior and then also to have space for your medial overlap.

So if the robotic, if the hernia defect extends very close to that semi lunar line, your robotic ports have to be pretty far on the contralateral abdomen in order to give you space to reach up in the abdominal wall, plus 5 or 6 centimeters of mesh overlap medially. And that can be really hard from the lateral decubitus position.

Can you Dr. Prabhu, can you talk through some of the considerations when you're placing a patient in lateral decubitus, like what you're being careful to protect? Absolutely. There are several really important considerations when putting a patient into lateral decubitus position for a flank hernia repair or lumbar hernia repair.

So the first thing is getting the bed appropriately positioned with a beanbag on it so that you can make sure the patient is fully supported in every aspect. And then, once you have the patient asleep, You would put them in lateral decubitus position on a bean bag with an axe roll underneath the downside, or the axilla on the downside to prevent a brachial plexus injury.

I'll usually position them with a double arm board,

and that may or may not involve pillows as well to make sure that everything is appropriately padded and that the arms are secured. Before you secure the patient to the table though, and before you position them like that, I always put a Foley catheter in for these patients.

Once I get them up on their side, I make sure that their umbilicus is aligned with the break of the bed. Because before you desufflate the beanbag, you want to make sure that you flex the bag, bed, to open up that space between the costal margin and the ASIS. So, with the patient in lateral decubitus aligned with the break of the bed, Then I'll have the team break the bed so that we open up that space between the costal margin and the ASIS in order to allow us to have plenty of space to work.

Once we have that and we have a pillow between the legs then at that point I'll make sure that the safety belt is on the patient and I usually will Make sure that all the areas between the patient and the beanbag are padded with foam. And then I make sure that the legs are secured in at least two

places with tape all the way around the circumference of the bed.

And then in the upper, above the costal margin, I'll usually put a towel across that and make sure that the patient is circumferentially taped around the bed that way as well to make sure that if we have to manipulate the bed during surgery that the patient doesn't slide off in any direction. And then finally just making sure those arms are well secured to the double arm board.

Dr. Bethe, in addition to that, any other considerations for prepping a patient for robotic approach? No, sometimes again, depending on where the hernia defect lies, if you don't need to go that posterior, then instead of maybe being in a full lateral decubitus position, sometimes I do more of a lazy Lateral decubitus position, particularly if I need more medial coverage and access to that kind of more of a midline kind of surgery.

So, I would say sometimes I don't go fully that way, at which point it's more like a rolled up blanket that I bump underneath their side. Sometimes I'll even airplane the bed a little bit just to give me a

little bit more angle. And that's a little bit of an easier position. You don't have to have as much padding around it.

But I don't always do full lateral decubitus. Can you talk through The planes that you typically like to dissect for the for these lateral hernias and what the boundaries of your dissection typically are for where you place the mesh. Absolutely. The first thing for everyone to keep in mind is that when you're making an incision over one of these lateral type defects, it's not uncommon for the external oblique musculature to be completely intact and for the surgeon to wonder exactly where the hole is.

So it's not that uncommon to have to divide the external oblique muscle to find the actual defect itself. So once you get through that aspect of it I usually will try to identify the hernia sac and I'm pretty quick to open up the hernia sac. I usually don't from an open approach necessarily try to stay in the pre peritoneal plane the entire time because often it's the easiest to get your bearings and identify where you are by opening up the hernia sac

itself.

Once you do that, you can get on top of the hernia sac to stay in the pre peritoneal plane. I usually will stand on the patient's ventral side or medial side when I'm making that initial incision. I open up the hernia sac and then get on top of the hernia sac and my quickest first move will be to get on top of the hernia sac and get all the way back around to the lateral aspect of the psoas.

Once I do that, I know where I am in space. And so When I'm on the lateral aspect of the psoas, for the most part, I can dissect up underneath the costal margin and down towards the pelvis, with essential impunity for that part of the dissection, particularly in this case where the kidney has been removed and there's not a ureter which will be on the medial aspect of the psoas.

For a repair for a large hernia though, you're going to go to the lateral aspect of the psoas and then continue to pull the viscera back around towards you in the hernia sac to where you get all the way to the medial aspect of the psoas and you can identify the ureter and the iliac vessel. So, that's usually the first thing that I'll do.

The next thing that I'll

do is dissect down from laterally to medially, down to the pubis and Cooper's ligament and sometimes this will involve dividing the transverse salus fascia in the lower abdomen because much of this dissection is below the arcuate line. So, that will allow me to drop into that nice tap plane and get all the way around medially to my pubis.

Then on the ventral or medial aspect of the dissection, I'll usually walk around the table so that I'm standing on the patient's lateral aspect. I work laterally to medially, again on top of the hernia sac, and I'll work my way towards the lateral edge of the rectus abdominis muscle. Now here is where the reverse tar would come in if that's something that we have to do, and I think you guys have that on the agenda to talk about, so I'll leave that for the moment.

But just to say, my medial border of dissection, depending on how far away I am from the rectus abdominis muscle, might be to the lateral edge of the rectus abdominis. Otherwise, I might be on the posterior rectus sheath all the way towards the midline. In the upper portion of the dissection, I'll get underneath the costal margin, and sometimes we will have

to divide the transversus abdominis muscle right where it hits the diaphragm to get that nice clean plane underneath the costal margin, and then again in the lower down to the pubis and Cooper's ligament.

Most of the time, if you have that big of a dissection, you can then easily close the hernia sac and lay out a nice big piece of mesh to get plenty of overlap. What are your considerations for mesh fixation? Like, I know there's pros and cons for fixing it to certain aspects of bone or tissue. And how do you make that decision in the game time?

That's a great point to bring up. I think that the answer to that question actually starts in the pre op clinic. And that is with setting expectations for these. Because oftentimes with these flank incisions or flank blowouts, if they're traumatic or coughing hernias or whatever they are, There is often an element of denervation to the abdominal wall that has been done.

And the patients need to understand that they, no matter how good of a job you do, and how much mesh you put in, and how many muscles you pull back together, they are always going to bulge some on that side,

almost indefinitely. And just setting that expectation up front with the patient, and knowing that, Hey, listen, it doesn't necessarily mean your hernia's back, it doesn't mean anything's wrong.

But your muscles in the flank don't necessarily work very much anymore and you're not going to be perfectly symmetric any longer But you can get 80 to 85 percent better than where you're at now and just setting that expectation up front I think helps a lot of people on the back end and particularly talk about durability because that's a very common People come back with complaints of bulging and if you just have a brief conversation with them before you do the surgery I think that helps a lot on the other end as far as mesh type, I tend to use a heavier weight, I think most of us do in the flank a heavyweight uncoated polypropylene mesh that just gives a little bit more stiffness and firmness to the repair, and again kind of combats the denervation element to it and then for fixation of that, I Used in fellowship I used which was like six or seven years ago now I used to fixate these pretty routinely to Cooper's we used to tack it down to the psoas tendon with his orbital

sutures and then we would sew it to the costal margin and with a couple PDS sutures as well I have since abandoned that practice for the majority of them Without much detriment.

I don't believe to my outcomes, but fixation here is still I think a relatively unanswered question as far as evidence based medicine goes. we Kind of referenced it because at Cleveland Clinic we have an algorithmic approach that we've published and we'll include in the show notes. But what if instead of a patient with an isolated flank, you had another patient who had a history of a liver transplant and now has midline and lateral defects combined with about 20 centimeter defect.

How would that change your approach in this case? Well, for a liver transplant, these are unique patients in that they most commonly will have either a Chevron incision or a so called Mercedes Benz incision. And to me, it's important to overlap.

all of the incision if possible. So for me, a straightforward midline approach is the best thing to do.

Many times these abdomens are actually quite easy to get into because related likely to their immunosuppression, they don't usually have a lot of intra abdominal adhesions. So I'll usually make an up and down incision and get in in the upper abdomen and then take everything down. As far as the dissection itself goes the thing that's difficult about posterior abdominal wall or posterior component separation on both sides is that the scar kind of runs right through the costal margin on both sides or right underneath the costal margin.

So, I will usually do a similar approach to what I might do for a parastomal in that I will do The top dissection first, and I'll do a transversus abdominus release. I'll do the bottom dissection next, and do a transversus abdominus release. And then I'll get around the area that's a scarred area, so I minimize the trauma to the posterior elements of my repair.

And then I'll do the same thing on the

other side. So, it's a little bit of a more challenging anatomic dissection, but for me, a midline approach is the way to go every time. Yeah, and I would also add, it's, this, and this was very I didn't have a lot of liver transplant at any institution I was at before, and so this was very new to me since I've been here.

But I'd also add to that I 100 percent agree that a midline is where you want to start. And this is something I've learned, is that you also, even though this feels very illegal, you can also open up with a midline and the chevron incision that they've done at the same time, and that gives you pretty unparalleled exposure.

It feels wrong but it definitely helps you if you're struggling. What makes you decide that you want to do the lateral extension? Do you like anticipate that preoperatively, or it's intraoperatively you're having difficulty dissecting? I, yeah, it's usually, I always start with just the midline, and then see how far I can get.

And oftentimes it's the right side that has a much more lateral extent to the chevron rather than the left. The left usually only goes maybe through the

rectus muscle only, but the right side can be very posterior and where they go. And so that can be tough to dig out for the reoperative field.

And so I'll, I won't hesitate to make that incision back through that. Dr. Prabhu, we've referenced this just a minute ago and about our experience with 464 patients with flank hernias and your team's algorithm to approach for the positioning and where to place your incision.

Could you talk to us a little bit more about what was the onus behind that? Absolutely. There are several different factors that we will take into account when we decide not only how to position the patient, but where to make our incision for the repair. Part of the decision making hinges on, or I should say the first branch point in the decision making hinges on whether the lateral hernia involves a midline or not.

If we're looking at a hernia that's off the midline, then the next thing that we look at is how far from the midline. is the closest extent of the defect. Once the defect starts to get greater than 12 centimeters away from the midline, we're

really looking at a difficult exposure if we don't make a lateral incision.

So if it's an isolated flank hernia defect, more than 12 centimeters from the midline, most likely we're going to put the patient in a lateral position and make a lateral incision. If the hernia defect is less than 8 centimeters from the midline, depending on the size of it, Either way, in terms of its width, we're going to place the patient supine, and then we might make a lateral or a midline incision based upon the size of the hernia.

So for a smaller hernia, we might make a lateral incision. For a larger hernia, we might make a midline incision. For the midrange hernias from 8 to 12 centimeters, We try to determine what's going to be the most difficult part of the dissection. And so the patient can be either lateral decubitus or supine, depending on what the most lateral or medial aspect is.

And then the incision might be lateral or it might be a midline incision. So that's for hernias that don't involve the midline at all. For hernias

that do involve the midline though, we look at the width of the combined defect. If it's less than 15 centimeters, We'll place the patient supine and go through a midline incision.

If it's greater or equal to, greater than or equal to 15 centimeters, then we'll place a patient supine and go through a midline plus or minus a lateral extension. This is all based on our experience with these patients, which has been extensive over the years. A little bit of trial and error, but then a lot.

of this depends on what is the most difficult part of the exposure and where are we going to have the hardest part getting mesh overlap. I don't know, Ajita, and see if you agree with me by saying this. I, in my mind I've always thought that that algorithm, it sounds like a lot, but in reality it comes down to me to two, to basically two questions.

One is, do I need access to the midline? So, if you need access to the midline of the admin you should not be allowed to keep a disposition. So that, whether you're like, the hernia needs more mesh overlap there, I'm worried about XYZ, I want to cover a midline scar, whatever. If you want access to the midline, you

can't be allowed to do cubitus.

And the second question is, what is going to be the really hard part of the dissection? And if you just think about those two things, I think then you kind of follow the algorithm. That's kind of what it's based off of in my opinion. But I don't know if, if you have, those are the two main questions that I, you know, think about whenever I preoperatively plan for stuff like this.

I agree. I think that's fair. And I would say the only other consideration I usually make hard and fast is if the patient has had a transplanted kidney. I will in every case make an incision in a lateral. location. That doesn't necessarily mean that the patient will be positioned in lateral decubitus, but the incision will certainly be right over the area where the transplanted kidney is because I want to make sure that I always have the best possible exposure to the transplanted ureter so that it does not get injured during the course of the operation.

As hard as it is in the forward direction, can we ask you a little bit about your considerations for doing a reverse tar? Essentially what that is just as a name.

Implies, is it a transverse pseudomonas release in reverse? So, as you're start you would, instead of starting as a transverse pseudomonas release goes from the midline, you would traditionally incise the posterior reticheath, get out to the semilunar line by identifying the neurovascular perforators, and then incise medial of those perforators and enter into the pre transversalis or pre peritoneal plane, and then you would extend that dissection out into the retroperitoneum.

And the TAR is exactly, the reverse TAR is exactly that. It's the reverse of that. And where you are not starting at the midline, but you're starting in the retroperitoneum. And you work your way backwards. So you go into the retroperitoneum, just like Dr. Berboux had said previously about she starts, you know, by identifying the psoas and then working her way, you know, down to cupers and then up and then works her way immediately, and that's exactly what it is.

And that means that you would develop all of the retroperitoneal components to the medial border, the psoas, down to the cupers, underneath the rib, costal margin,

and take the peritoneum off the diaphragm for as far as you can get underneath the rib the costal margin, and then medially, you would go to the semilunar line.

And what I mean by that is anteriorly, and this also feels weird, but you then divide right through the semilunar line. So you will You know, just with cautery, anterior fascia, you just go right in until you see the rectus muscle. And so you open up the anterior reticule sheath, and you open up the semilunar line, and you'll see it all right in front of you.

And that feels like an illegal move again but it's exactly what you need to see in order to do the surgery safely. And you take your pre peritoneal dissection towards where you've opened up anteriorly, and then you will then identify the posterior reticule sheath as it comes and attaches to the semilunar line, and you want to be medial to that and incise that posterior adduce sheath and you'll drop down the posterior adduce sheath with your peritoneum and you'll extend that caudate and cephalade on both sides in order to create basically a

transverse release in reverse and you'll get back to the midline, you'll get to the linealba.

And I only do that if if again I'm worried about mesh overlap medially. This seems a lot like kind of flying blind. Dr. Perbu, do you have any recommendations or tips for identifying the perforators as you near the semi lunar line as they perforate the antireq, or the rectus sheath? I think that anticipating their presence there is probably the best way to avoid.

Damaging them or inadvertently destroying them or bovine through them. So I think anticipating where they are, I think what Dr Befa said was really important as well, which is having done the cephalad, caudal and dorsal dissections before you get to the medial aspect, you know where you are in space.

So what that means is. the anticipation of where the deep inferior epigastric is going to be running, which will be a lot closer than where you think it's going to be as you come around from the inferior aspect coming around from lateral to

medial where you're doing the dissection and essentially what is the tap plane.

The surgeon has to be very aware that the epigastric will be readily apparent way more quickly than you're used to. That thing can easily be mobilized with the right angle dissector as long as You anticipate its presence there and you can get it up with your muscle body. But I think that's one of the most important things to look out for.

And the other thing I will say is many people think they can just jump into the preperitoneal plane deep to the posterior erectus sheath on that ventral or medial aspect of the dissection. And I would just tell you from sad experience that most often that is not the case. That's an experience. It's exceedingly difficult to section so it's worth it to watch some videos of a reverse tar if you haven't learned how to do it before, because truly, battling through the holes in the peritoneum if you happen to be so unfortunate as to make them, can make the case go a lot longer, it can be a lot more technically difficult, and ultimately will result in you having to do a reverse tar anyway, but also puts the patient at risk of an intraparietal

herniation after surgery.

So, our final scenario doesn't quite get covered by the algorithm. Bilateral flank hernias, no necessarily midline component. How would you approach somebody with those bilateral hernias differently than either of the first two scenarios? So, For a patient with this problem, it's complicated. It depends a little bit on the patient's body habitus, but to me, once we're 10 centimeters from the midline, and these seem to be 7 centimeters width at that location is significantly risky to get to the lateral aspect of that from anything but a flank incision for me.

So, I've actually encountered this exact clinical scenario before, and for me, I approached it. I operated first on the side that was more bothersome to the patient, but did both of them at the same operation. So I placed the patient in lateral decubitus position on the more symptomatic side up and operated on that one first.

And did a flank incision, repaired the hernia, closed

everything up, put our sterile dressings on, took everything down for all the drapes, re prepped and draped the patient in the contralateral lateral decubitus position and repaired the other side that way. To me, It's really hard once you start getting a big flank hernia out laterally you're going to be limited from a midline approach, particularly if it's a bigger patient, it's going to be really hard to get around that lateral aspect of the psoas muscle, and that puts your lateral aspect of the repair at risk.

So I would do them both at the same operation in a healthy patient but would do this in a lateral decubitus position for each one of those. This scenario is probably the most challenging from a positioning standpoint that you could probably get. And, to me, I think the easiest, to me, I would not, I would not violate the midline if I didn't have to, if they didn't have a midline already.

You know, I think, to me, that would, I don't think I would necessarily do that. I don't know if there would be anything wrong with that, but I just, to me, I just don't think,

why would you make an incision in something that isn't already there. And they already have bilateral flank incisions. And I would agree with Dr.

Grabue. I think I would do one side and flip and do the other, even though that would be kind of a painful transition and a long time in the operating room. But I would prefer to do that rather than open a midline that has not been opened before. So, it still blows my mind to see these patients that have large bilateral flank hernias without an incision.

Can you guys talk us a little, talk to us a little bit about like the anatomy and the mechanism for like a traumatic event that would cause these large hernias? Absolutely. So, first of all, these are relatively uncommon injuries to be seen in clinic because the force. With which the patient has to decelerate to cause this kind of injury can also often shear the aorta in half.

So many of these patients don't survive these acute deceleration injuries. However, when we do see it, usually it is because there's been an acute deceleration, and that

causes the lateral complex to essentially completely avulse off of its insertion at the iliac crest. The other scenario sometimes you'll see is with coughing, and they tend to be very high up adjacent to the costal margin, and they occur because at that junction, when your body's generating enough valsalva to create a strong cough, there's an opposing forces at that junction where the costal margin comes, where your obliques are pushing down and in And your costal, your inner costals are pushing up and in, and they're basically just pushing, there's an area that they're going in opposite directions, and you'll just avulsure, transversus abominus, it's often a transversus abominus and sometimes an internal bleak injury.

Often times people will have that, or severe smokers and chronic coughers and COPD, and they also a lot of times report a lot of bruising that occurs, so it's really, truly is like a traumatic traumatic injury to the

flank. Dr. Buffa, can you please talk through some of the landmines to avoid when you're doing these dissections?

Yeah, of course. I have also had the great experience to step on some of these landmines myself, so I, not all of them, although some of them. So the retroperitoneum can be somewhat confusing for general surgeons because we aren't often operating there. The IBC, those are always the major vasculature that you want to Consider and oftentimes it can be a lot closer that you're operating on closer to those things than you think you are.

And then always, of course, the ureter and whether it's been transected or has been reimplanted somewhere. You know, those are definite things that you're going to want to know about to where exactly those ureters course. And then lastly, the nerves. And the nerves can cause, can be a source of chronic discomfort and chronic pain, post operative pain.

And those come, you know, around from the spine and innervate the cutaneous and myocutaneous

abdominal wall, as well as the lower abdomen and groin. So, you know, these are all. Really important things just to keep in mind as you're operating back there and knowing what's been done is critically important I think in this, in these scenarios.

What expectations do you set for patients in clinic? For a particularly large defect in the flank or lumbar position, those are the ones that, on rare occasion, I might say, like, okay, if this is a big defect, I'm more likely to fixate my mesh, and I'll tell the patient ahead of time, hey, look, you know, the places for fixation aren't that much when it comes to these flank defects.

So sometimes that might involve the ribs, it might involve the iliac crest with bone anchors, et cetera. And so if I'm anticipating that ahead of time, I usually will tell the patient that you know, this can make the recovery more challenging in terms of pain. And then as Luke had mentioned earlier, also just recognizing that their contour may never be back to perfect again after this type of operation.

That's all we have today on the topic of

lateral hernias. Thank you so much Dr. Prabhu and Dr. Beffa for spending time with us and getting to talk. We'll wrap things up really quick with some quick hits. So lateral hernias can be technically challenging given their proximity to bony structures and lack of fixation points.

These hernias can be approached in a variety of ways including open, laparoscopic, robotic. And they can also be approached through a midline or flank incision. That algorithmic approaches considering the presence of concomitant midline defects, distance from the midline, and hernia width can help guide surgeons in their approach to these hernias.

And from all of us at Behind the Knife, Dom, Nate, Dave.

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