1. SurgerySurgery Abdominal Wall Reconstruction: Patch the tire or rebuild the car? Michael J. Rosen MD, FACS Associate Professor of Surgery Chief, Division of Gastrointestinal and General Surgery Director, Case Comprehensive Hernia Center Case Medical Center Cleveland OH

2. SurgerySurgery Take Home Message We do not have the ideal ventral hernia repair yet. Mesh has not been the ultimate solution to this problem. Tension free repair might not be appropriate for the abdominal wall Is the linea alba a tendon?

3. SurgerySurgery Approaches to Tendon Repair

4. SurgerySurgery Objectives of a ventral hernia repair Prevent hernia contents from protruding through hernia orifice Provide durable repair with low recurrence rate Perform the procedure safely with minimal patient morbidity Reduce postoperative wound complications and mesh infections Reconstruct a functional dynamic abdominal wall, with medialization of the rectus muscles

5. SurgerySurgery Technical Objectives of Ventral Hernia Repair Gain access to the re-operative abdomen Perform adhesiolysis without enterotomy Expose entire hernia defect Repair defect –Tissue based repair –Mesh based repair –Combination

6. SurgerySurgery Primary Repair Unacceptably high recurrence –Burger JWA, et al 63% Ann Surg 240:4, 2004 –Anthony T, et al 54% World J Surg 24:95, 2000 –van der Linden FT, et al 49% Neth J Surg 40:127, 1988

7. SurgerySurgery Suture vs Mesh Repair Luijendijk et al. (Netherlands), 2000  Prospective randomized trial  181 patients: suture vs mesh repair  Primary hernia (154) or first recurrence (27)  Midline incisional hernia < 6cm  Single defect--no previous mesh  3-year follow-up (physical examination) NEJM 2000;343:392-397

8. SurgerySurgery Suture vs Mesh Repair  Suture Repair  97 patients  Mean defect size (20 cm 2 )  Running #1 Prolene suture  Mesh Repair  84 patients  Mean defect size (24 cm 2 )  Polypropylene mesh NEJM 2000;343:392-397

9. SurgerySurgery Suture vs Mesh Repair  Recurrence Rates  Suture repair : 46%  Mesh repair : 23%  Defects < 10 cm 2 :  Suture repair : 44%  Mesh repair : 6%  Complications  Suture: Wound dehiscence (1)  Mesh: SBO (1), infection (3), bleeding (1) p=0.005* NEJM 2000;343:392-397

10. SurgerySurgery We have not found the ideal solution to ventral hernia repair Prospective Randomized Trial Level 1 Evidence 6 cm defects 10 years Primary repair62% Failure Mesh repair32% Failure Burger J. Ann Surg 240:4, 2004

11. SurgerySurgery I. LaPlace’s Law II. Pascal’s Principle Laplace’s Law T=P (intraperitoneal) * r (raduis) /2h (wall thickness) 

12. SurgerySurgery Is there a better way to create a functional abdominal wall using minimally invasive hernia repair techniques?

13. SurgerySurgery Objectives of Functional Abdominal Wall Reconstruction Medialization of the Rectus Muscle Durable repair Minimal wound morbidity

14. SurgerySurgery Outcomes Component Separation AuthorYearNDefect cm 2 CompsRecurrence Ramirez1990112160% Dibello19963522511%9% Girotto19993314027%6% Lowe20003024040%10% deVries20034323435%30%

15. SurgerySurgery Component Separation

16. SurgerySurgery Ramirez OM, et al. PRS. 1990.

17. SurgerySurgery

18. SurgerySurgery

19. SurgerySurgery Periumbilical Perforator Sparing

20. SurgerySurgery Advantages Preserve main blood supply Similar advancement Low tech Easy to perform Disadvantages Large dead space communicates with midline wound seroma and abscess rates may not change

21. SurgerySurgery Minimally Invasive Component Separation Access the lateral compartment directlyAccess the lateral compartment directly Avoids large subcutaneous flap dissectionAvoids large subcutaneous flap dissection Avoids division of abdominal wall perforatorsAvoids division of abdominal wall perforators Decreases complexity of postoperative wound infectionsDecreases complexity of postoperative wound infections

22. SurgerySurgery avr

23. SurgerySurgery

24. SurgerySurgery 24 Rosen et al. Am J Surg 2007

25. SurgerySurgery 25 Porcine Model Laparoscopic versus Open CSM

26. SurgerySurgery 26 Porcine Model Laparoscopic versus Open CSMLaparoscopicOpen % Release 5.35.695 3.14.176 4.05.375 6.87.294 4.05.573 6.06.592 5.36.088 4.04.491 6.27.583 4.75.389 Total Release 86%

27. SurgerySurgery Rosen MJ et al Oct 2007 Hernia N=7 Mean Defect 338 cm 2 LOS5.4 days Recurrence10%

28. SurgerySurgery What is the next step?

29. SurgerySurgery avr Minimally invasive abdominal wall reconstruction

30. SurgerySurgery Isolation of the External oblique via balloon inflation via balloon inflation Balloon/ Instrument port avr

31. SurgerySurgery Cutting of the External Oblique External oblique Insufflator / camera port 2 cm Internal oblique Space created by balloon Instrument port avr

32. SurgerySurgery avr Following cutting of the External Oblique on each side the bowel is freed of adhesions. Instrument port Insufflator / camera port

33. SurgerySurgery avr A suture is passed through the right rectus.

34. SurgerySurgery The suture is handed off and pulled to below the left rectus muscle

35. SurgerySurgery avr The suture is then pulled up through the left rectus muscle and out the same skin incision.

36. SurgerySurgery The suture is tied forcing the rectus muscles together. Vertebra avr

37. SurgerySurgery avr The knot is pushed under the skin.

38. SurgerySurgery Vertebra avr

39. SurgerySurgery avr

40. SurgerySurgery Conclusions There are many options for reconstructing the abdominal wall. The concept of bringing the rectus muscles back together in most patients makes sense Minimally invasive component separation is a reasonable option and might be beneficial when used earlier in the treatment algorithm.

41. SurgerySurgery Conclusions Everyone does NOT need a functional dynamic abdominal wall –Obese –Elderly Some people do DESERVE a functional dynamic abdominal wall –Young –Thin –Active, Manual Labor