BTK Preperitoneal Hernia Repair

Thank you for joining us for another episode of Behind the Knife. I am Sully Youssef. I'm owner of the chief residence here at Carolinas Medical Center. I'm joined again by professors Todd Henniford and Vedra Augenstein here at the Carolinas Medical Center. And then we are also joined by Monica Pultz, who is a recent graduate of the GIMIS fellowship here and is now on faculty at Baptist Health in Miami.

So thank you all for joining us for another episode today. We're gonna be discussing a topic that we deal with here at Carolina's Medical Center every day, which is the utilization of the preperitoneal space for open ventral and incisional hernia repair. This is our go to method of repair for hernias that are performed in open fashion at this institution.

Though we are not focusing specifically on minimally invasive technique, in this episode many of the principles that we discuss here are also applicable to other types of pre peritoneal repair. That we do perform laparoscopically and robotically here at this institution. And those are things like a conventional tap

repair, where we drop the peritoneum, close the fascia, place the mesh, and then close the peritoneum back.

And also our crossover ETAP, where we get in the retroactive space and then cross over to the preperitoneal space on the other side, before we really dive into the details of the preperitoneal dissection, though Monica, I want you to kind of. Talk to us and our listeners about the location and the placement of mesh types kind of conventionally.

And what you know about that. Sure, Sully, thanks. So there are multiple layers of the abdominal wall where one can place mesh and broadly you know, you can think of it as intraperitoneal mesh placement versus extraperitoneal mesh placement. Intraperitoneal mesh placement is most commonly performed laparoscopically or robotically.

This is not the same as a pre peritoneal repair. So in a pre peritoneal repair, mesh is placed anterior to the peritoneum and not intraperitoneally. This is an intraperitoneal mesh repair is also referred to as an eye palm technique, and it may or may not involve fascial closure. It's typical when

intraperitoneal mesh is being placed to use a coated or a barrier mesh to protect the underlying viscera from direct contact with the mesh.

And this barrier layer is sometimes composed of cellulose or collagen or absorbable fatty acids. Extraperitoneally, the most common location that mesh is placed would be in the retrorectus space between the posterior rectus sheath and the rectus abdominis muscles. Systematic reviews and meta analyses show that this has more favorable outcomes in terms of recurrence and surgical site infections than intraperitoneal placement of mesh or onlay or inlay mesh location.

So what is onlay mesh? Onlay mesh refers to mesh placement on top of the anterior fascia. Underneath the subcutaneous layer, an inlay mesh would be bridging mesh or mesh that is secured as a bridge between two fascial complexes. Bridging mesh is utilized when fascia cannot be closed primarily, and this is the least durable of all hernia

repair types and is generally avoided if other options are available.

The preperitoneal placement of mesh has long been popularized in other laparoscopic repairs of inguinal hernias such as TAP and TEP, which were introduced in the early 1990s. But it hasn't gained the same popularity in open abdominal wall reconstruction. And so the purpose of this episode will be to discuss the open technique, which can be utilized for even the most complex hernias.

Dr. Augenstein, we talked a little bit about the difference between intraperitoneal and preperitoneal mesh, but I think there's often still some confusion. What's the difference between, for example, an open Pre peritoneal technique in a TAR. Yeah, thank you, Monica. So, TAR is definitely different than a pre peritoneal repair and often people have confused these two techniques and even it's been manifested in the reviewers of hernia manuscripts.

So in a TAR, a pre peritoneal space can be accessed in the lateral abdomen. However, this is not a Totally

prepared, neural me repair, even though some of the mesh may be in that prepared neural space. So when you're performing a tar, a posterior rectus sheath is incised and the retro rectus plane is then developed.

So the mesh actually lays in that retro rectus plane, unless, until you get to the neurovascular bundles. And at that. time a longitudinal incision is made, and the posterior lamella of the internal oblique and the transversalis muscle is incised. So then that plane is further carried out into the preperitoneal space so that's where the mesh may lay in the same position and the transversalis fascia may also be divided at this point.

That time but does not have to be the case in the pre peroneal repair that we do here all the time. This retroactive space is not accesses, this is not a component separation by any means, and you don't violate any of those muscle and fascial planes for this type of repair. And it's completely pre peritoneal in the mesh essentially lays in this layer that is completely separated from the abdominal organs, from the

viscera.

Thanks, vra. We started doing the pre peritoneal repair that would've been about 2002 to 2003. And the reason we started doing this and people will talk about it, is just inherently more difficult. And honestly, if you spend your time actually learning this technique, we're able to perform it over 90% of our hernias and over 60% of the patients in whom we operate on have failed hernias.

Many of these patients have very complex abdomens. And we even perform this in patients who have fistulas and other real problems, including mesh infections. The reason we really started doing this is because we wanted wider overlap. We started seeing that, you know, narrow overlap increased the risk of recurrence, and I think that just makes sense quite honestly.

If you think about the engineering of the abdominal wall, people can have very narrow rectus muscles. And if you, I mean, even yesterday I operated on someone, examined somebody in clinic who's got a four centimeter wide rectus. And I would, I just want more. I just wanted more overlap. It just makes sense

that the drag on the mesh, to pull the mesh to the midline would be better with a wider overlap.

We even use this in like, especially in patients in whom we might do an external oblique release. You know, we're known for, now we use a lot more Botox, we've really decreased the number of patients with whom we do component separations, but I like laying my mesh well beyond the external oblique and helps prevent someone developing even kind of a rectangular more than an oval abdomen by having reinforcement where you've actually transected one of those, one of the obliques.

We do this in patients who have skin grafts, and indeed, most often when someone takes a big skin graft off the abdomen, they just cut the skin graft off and then throw it away. And then you're left with this huge hole. We actually will take the mesothelial layer. When your bowel is exposed to something like a skin graft, it'll develop a mesothelial layer just like peritoneum.

And we can take that down and extend it, often the full length of the skin graft. Often we never, and in true we often never enter the true abdomen. We never truly look at the

intestine. If someone has a history of bowel obstruction that's not associated with a hernia, And Sully, we did a case the other day just like this.

We, we opened the abdomen, did a formal adhesive lysis, but otherwise, I'm there to fix a hernia. If I don't have to look at the intestine, I don't look at the intestine. And even true, someone has intraperitoneal meshes. Some of these meshes, you can actually take a mesothelial layer down off an intraperitoneal mesh, and and stay totally extra, extra peritoneal.

Hostile abdomens don't really bother me as far as trying to get extra, say extra peritoneal. And if you do start an, in a pre peritoneal dissection and you booger up the per peritoneum, you can always go to a fallback of doing a retroactive repair. So as far as talking about the details of how to get into the pre peritoneal space, I think there are a few tips, and I either, if you're doing this open or if you're, for example, doing this robotically as we do in our practice a lot, I tell

my residents and fellows So you want to look for areas in the abdominal wall that have a little layer of fat, which is in the preperitoneal space.

So that could be potentially the spacerhetzius, and that's in my open cases. Usually, I will try to get into the spacerhetzius, go all the way down to the pubic symphysis, and then start transecting, essentially pulling the peritoneum back from lateral to medial. Some people will do this bluntly, other people use different cautery devices, kidney nurses but essentially, If you're in the right space, if you're lateral to the semilunar line and you have your hand in there, you can peel the peritoneum off the abdominal wall pretty quickly and fairly easily.

And then you can also, in the subxiphoid area, use the falxiform ligament. But either way, the hardest place to really take the peritoneum down is going to be right underneath your rectus muscle. And that's where it's probably going to tear the most, so, but if you get further out lateral, it's going to be a lot easier.

So Todd, how do you handle the peritoneum? As far as handling the peritoneum, and it

most often in patients who've had previous surgery, the peritoneum is actually plenty thick to sew together by itself. As Dr. Describe described in this in her dissection, you know, I stay extra peritoneal and sometimes I'll even take down bits of the post erectus sheath or even the transversus fascia, posterior transversus fascia to stay extra peritoneal.

So am I totally just taking the peritoneum down? I will take down what I need to stay extra peritoneal and develop a big space. If I make holes in the peritoneum and, you know, out laterally and especially subcostally, the peritoneum can get very thin, you just simply suture this back together again. We typically use just a two of vipral to close it.

And if it's a relatively big hole, you have trouble closing it. Then just like Uh, Reeves described in closing the retrorectus space, you can use just a bit of momentum. Just whip stitch the momentum in the space. You just want to exclude the intestine. In larger defects, if you have just

a big hole in the peritoneum, I often will use the hernia sac.

And so just cut the hernia sac free, defat it, and then lay it in and just whip stitch it in that position. And it actually works extremely well. So Monica, do you want to talk to us a little bit more about the actual mesh placement and kind of some tips and tricks for fascial closure? Yeah, absolutely.

So, you know, once the peritoneum has been closed and the viscera have been completely excluded, that's when we place our mesh. And like Dr. Henniford mentioned earlier, we can place a very, very large mesh with very wide overlap. Essentially, you get the same overlap as you do with a tar without dividing any muscle.

So oftentimes we have much more than 10 centimeters of overlap on all sides. The type of mesh that we use is dictated by the patient and the specific case. We generally do fixate the mesh. We fixate it superiorly, inferiorly, and on both sides laterally with a PDS suture using a suture passer in a transfascial manner.

If a subfascial drain is placed, we generally remove this prior to discharge. The fascia is closed using two running, slowly absorbable sutures prior to closing the skin and the subcutaneous tissues. One of the main goals for every hernia operation is being able to close the anterior fascia. We recently evaluated our data and found that when the anterior fascia is able to be approximated, that this, there's no difference in, in size in terms of the long term recurrence.

And so this is a goal for every operation for our group. So we close the peritoneum, we place the mesh, and then we turn our our attention towards trying to close this fascia. So typically we put cokers on the fascia on either side and see if it comes together without tension in the anterior midline.

When there is tension, we have a pretty stepwise approach to how we handle this. The first thing that we do is incise the posterior rectum. Rectus sheath on one or both sides. This is similar to the first step of a TAR

and also similar to the first step of an external oblique release that was initially described by Ramirez in the 90s.

If there's still tension on the abdominal wall after a posterior rectus sheath release is performed on both sides, then we determine how much space there is between the fascia. It is generally thought at our institution that external oblique release provides more myofascial release. And so when we perform this we have turned towards sparing the peri umbilical perforator vessels.

So a couple of centimeters above and five centimeters below the umbilicus, we leave an area of fatty tissue. And then we'll incise the external oblique, make a subcutaneous tunnel and connect our external oblique release inferiorly and superiorly. Typically we can do that with a Yankower suction to kind of connect our planes there.

But we have found that this is very successful and able to provide a significant myofascial release. We also do perform tar technique when that's available, but

that's usually for patients who need a smaller amount of myofascial releases compared to external oblique release. So now that we've talked about how we close the peritoneum, place the mesh, close the fascia, Dr.

Augustine, could you just talk about some of the common pearls and pitfalls to this approach? Sure, Solly. So, I think as in anything that we do practice, especially perfect practice is going to make you better. So, know what plane you're in. Sometimes peritoneum may be too hard and too thin to transition into, especially if you're doing this robotically.

I think you kind of get away with a lot more things when you're doing this open. But often I'll go into the pre transversalis space, either open or robotically, especially in the top of the abdomen. That's where, and that's completely okay. You're not dividing any muscle. This is not really a component separation.

And you can jump in and out of that plane as you need to. Work from easy to hard. This is typically what we do in our lateral to medial approach to prepared neodissection. And if it slows during the dissection,

don't be afraid to turn to another area where the dissection is more favorable.

So, do the easy stuff first and then get to the more challenging area. Another thing is don't feel defeated if this preperitoneal approach is not feasible. Certainly in some of the robotic cases where patients have had a midline laparotomy and there's a lot of scar on the abdominal wall, it can be very difficult and peritoneum can tear and you can place meshes in the other layer then at that point.

I think that's why it's important as a hernia surgeon to really be familiar with all of these layers in practice. Different approaches. And then the surgical outcomes are really dependent on more than just the pre peritoneal dissection, even though that is our favorite place at this point to place our meshes.

I think optimization of patients making sure to close the anterior fascia they're just as important in the short term and long term hernia outcomes as far as wound complications, hernia recurrence, and patient quality of life. Thanks, Vedra. When we first started doing this back in the early 2000s, it's interesting, the person who actually published this was one of our fellows when he was here, and

Yuri Novitsky, who described the tarsive beautifully, published our first set of results with over 100 patients in 2006, and we found good outcomes with that, and we've just continued it.

Our last publication was in surgery, where Mike Katzen, one of our residents in the lab, I guess it's about two and a half years ago, published over 1, 800 patients. And looking at very complex hernias. And in these patients, their defects were greater than 200 square centimeters. About 25 percent of those patients had dirty or contaminated wounds.

And 68%, 60 percent had failed, previously failed hernias. And what this demonstrated is just one, yes, we can do a pre peritoneal hernia, but it showed our improvement in outcomes. I've been a big proponent and I think everybody here, Vedra, Sully has taken up the banner, Monica did this we really have pressed to improve our outcomes by constant quality improvement.

And we did indeed demonstrate when we looked at our earlier data from about 2004 to 2012 to

2013 to 2021, we documented a significant improvement in hernia recurrence. We documented the wound complications had decreased by about half. And the other complications, including mesh infection and those things that are super important, 30 day readmission, all improved.

And it's not just because of the technique. And I think that indeed, you know, we want to be, you know, technical surgeons. We believe that, yeah a good operation can make you better. Indeed, a good bit of this is this constant quality improvement. And if you had asked me back in 2004 or 5 or 6, you know, if you'd asked me, do you think you're a good surgeon, my answer would have been, of course, it would have been, yeah, I think I'm a good surgeon, but there's no question that, you know, we have improved by looking at our data and we've eliminated, so in that paper that Yuri described in 2006, the number one predictor of complications with smoking.

And we eliminated smokers from our data from, you know, from our from elective surgery, urgent and emergent cases. Of course, we have to do what we have

to do, but otherwise, elective surgery, we've eliminated smokers as much as possible. We demonstrated about four years after that, that hemoglobin A1c, our break point was at 7.

2 in our data. And so now, we actually hold patients to a line at 7. 2. Weight loss has always been important, and we've known that for a good long time, but we do press that. But other things, such as Sully mentioned, doing perforator sparing external oblique releases, doing a no touch mesh technique. We using Expiril for our, for transversus abdominis releases that decreased our narcotic use by 65%.

We started in the penicillin allergy protocol when Bedra did a paper looking at patients in whom we gave, Something besides a first generation cephalosporin, if they were penicillin allergic, if you give them vancomycin or quiescent, significantly increase their wound complications, reoperations, and ultimately failure.

And we started a penicillin allergy protocol through our group, which is now spread to

13 different hospitals in our hospital system. And we've just found, you know, Alexis Holland, one of our residents in the lab, is actually going to be presenting this, where what veterans initial work Are then changing our protocol because of her work now has significantly improved our outcomes.

So this is constant quality improvement. Yeah, we want to be technically really good surgeons, but we press as hard as we can in looking at our own data to demonstrate we can improve and do better and combine that with wide mesh overlap, fascia closed. If you can do those things, you should expect good outcomes.

Absolutely. Awesome. And I think that's kind of the moral of the story for the group here is trying to get better every day. Monica, it's time of day for the quick hit section. Could you take that over for us? Sure. So just to summarize the discussion preperitoneal hernia repair, which is different than intraperitoneal or transversus abdominis release can be used to manage very large and complex hernias.

Major advantages of performing an open preperitoneal repair include excluding the mesh from contact with the bowel as well as very, very large and wide mesh overlap while sparing any muscle splitting techniques. When the peritoneum cannot be approximated, it can be buttressed with omentum, again, just to separate the mesh from the underlying viscera.

And it's important to have a really good understanding of abdominal wall anatomy, knowing what plane you're in, especially if you're moving in and out of the preperitoneal plane into, say, the retrorectus or the pretransversalis plane. Ultimately, hernia outcomes are multifactorial and depends not only on surgical technique, as Dr.

Henneford mentioned, but also on other factors such as preoperative optimization, as well as fascial closure. Thank you so much, Monica. So all the articles that we talked about today will be made available in the show notes for Behind the Knife. In addition, we are going to share with you all some videos of our open preperitoneal dissection,

which will also be available on the Behind the Knife website.

So make sure to check those out. For now, this is the Behind the Knife hernia team from Carolina's Medical Center reminding you to dominate the day. Thank you so much.