Tough Situations In Ventral Hernia Repair: A Community Perspective Rodrick McKinlay, MD, FACS Rocky Mountain Associated Physicians Minimally Invasive Surgery Symposium Salt Lake City, Utah February 23, 2011

Disclosure Consulting agreements with Ethicon Endo-surgery and Covidien

Goals Identify difficult situations in ventral hernia repair Discuss strategies to manage, prevent, or avoid difficult situations Discuss economic viability of a hernia practice

A snake in every gulch Enterotomy Loss of abdominal domain No (or “undesirable”) mesh available Unusual hernia locations

Enterotomy Most ventral hernias require at least some adhesiolysis May be severe in recurrent vhr with previous use of mesh or multiply operated abdomen

Pre-op VH Discussion Discuss possibility of enterotomy Plan if enterotomy occurs: Repair and proceed if no spillage Repair and postpone if spillage, especially if mesh required

Avoiding enterotomy intra-op Make first access site away from scar/hernia Use cautery/harmonic scalpel sparingly Permissive bleeding Work on known to unknown Leave mesh on bowel instead of vice versa

Managing Enterotomy Options Open and repair Repair and proceed if no (minimal??) spillage Repair and close if moderate or more spillage, or when in doubt, and return for staged repair Repair but use biologic instead of synthetic

Loss of Abdominal Domain How many would tackle this hernia? Difficult to do laparoscopically Favor open component separation technique Prepare for long case (2-3 hours+)

Intra-op Dissection Creation of flaps widely Deliberate adhesiolysis Identify musculo-fascial planes

Component separation Incise fascia just lateral to rectus sheath through external oblique aponeurosis Rib cage to anterior superior iliac spine Gain 5-6 cm on each side

Place biologic implant Underlay technique, 5 cm Interrupted permanent suture Re-approximate fascia

Still Can’t Reach Despite all the mobilization, bridging defect in upper abdomen Options Leave a bridge Place synthetic over biologic

Completion Two days on ventilator, one week in ICU, one week on wards, post-op rehab

Mesh availability Certain mesh products are on contract, discounted rates to hospital Other mesh products purchased by hospital but not on contract because of frequent use Others “on consignment”, hospital pays as product brought in Hospital may apply pressure to use mesh that is on contract

What to do if desired mesh not available? How many have experienced this? Best to avoid by checking two days before, but not always practical Use less desired product Call rep and wait for desired product (how long?) Cancel case Do not use mesh at all

Unusual hernia locations Epigastric Use transfascial sutures inferior to ribs, tacks above ribs; caution around pericardium Suprapubic Mobilize bladder if necessary Generous use of transfascial sutures as low as possible

Economics of VH Repair: Component Separation Codes: 15734 Abdomino-fascial flap, bill R and L separately 15330 Biologic 49560/5 Ventral hernia repair/recurrent 49568 Mesh implant Reimbursement: Insured patients: $4000-4800 Medicare: $1900 Medicaid: $1850

Economics of VH Repair: Standard Lap and Open Repair Lap repair reimbursement Insured patients: $700-$1200 Medicare patients: $600 Medicaid patients: $500 Open repair reimbursement Insured: $800-1500 Medicare: $700 Medicaid: $600

Ventral Hernia from community perspective, bariatric practice Large, complicated hernias seen Lap hernia repair offered with good success, but they are often interested in “skin removal” Movement toward increasing use of component separation technique Favorable economics for component separation technique, less so for “standard”

Questions