Restoring Abdominal Wall Restoring Abdominal Wall Function The Holy GrailFunction The Holy Grail
Brian Jacob MD FACSBrian Jacob MD FACS
My patient needs to do a sit-up after a My patient needs to do a sit-up after a successful hernia operationsuccessful hernia operation
Definition of dynamic abd wallDefinition of dynamic abd wall
What is a dynamic abdominal wallWhat is a dynamic abdominal wall
What is an adynamic What is an adynamic (or (or poorly functioningpoorly functioning) abdominal wall) abdominal wall
What we donrsquot wantWhat we donrsquot want
bull Bowel can adhere to polyester surface
bull Inadequate overlap
bull Inadequate fixation
What we donrsquot wantWhat we donrsquot want
What we donrsquot wantWhat we donrsquot want
Recipe for SuccessRecipe for Success
PathophysiologyPathophysiology
Wound HealingWound Healing
Midline or Defect Closure
Mesh TissueInterface
ldquoThe main challenge for surgery is to find the best technique in a given situation (patient hernia anatomy) which
provides the best overlaphelliprdquo Uwe Klinge Aachen Germany 2011
Matrix deposition the fibroblastMatrix deposition the fibroblast
Collagen FIBRILS then bond to form FIBERS
If something is wrong you need to search If something is wrong you need to search for the source of the problemfor the source of the problem
Volume please
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Type I tensile strength (mature collagen)
bull Type III thinner diameter aka immature collagen
bull Quality of a wound is based on a high type IIII rationdash Reduced ratio (higher proportion of type III)
bull Reduced stability of connective tissue
Type I IIIType I III
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patiens with recurring hernia after implantation of alloplastic prosthesis
bull N = 78 50 M 28 F
bull Primary inguinal 25
bull Recurrent inguinal 18
bull Primary incisional 11
bull Recurrent incisional 24
Type I III ratio Type I III ratio and indication for mesh removaland indication for mesh removal
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
N= 78 explants
N=46 N=18 N=14
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Reduced in patients with recurrent herniasndash Provides new possibilities for future research
regarding novel wound healing agents
MMP-2 (gelatinase A)MMP-2 (gelatinase A)
bull Proteolytic enzymendash Degrades collagen fibers (ECM proteins)ndash Degrades vessel wall integrity
bull Tumorogenicndash Implemented in colon breast lung adrenal
bull Connective tissue diseasesndash Aortic Aneurysmndash Ehler ndash Danlosndash Marfanrsquos syndrome
bull 1) indirectbull 2) directbull 3) recurrence
bull All groups were significantly higher (plt005) than CONTROL GROUP those without a hernia
Smigielski J Kolomecki K Ziemniak P et al Eur Surg Res 2009
Collagen Fiber CrosslinkingCollagen Fiber CrosslinkingWound Strength IncreasesWound Strength Increases
bull Stabilizes the collagen fibersbull Resists collagen breakdown
by enzymesbull Reaches up to 90 strengthbull Cellular turnover stops
Wo
un
d S
tren
gth
7 14 21 28 35 42 49 56 63 DAYS
Material are not all equalMaterial are not all equalbull Ongoing inflammatory processes can last at least a year bull This poor biocompatibility may lead to poor mesh
compliance
Novitsky YW Cristiano JA Harrell AG Newcomb W Norton JH Kercher KW Heniford BT (2008) Immunohistochemical analysis of host reaction to heavyweight- reduced-weight and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations Surg Endosc 22 1070-76
Ki-67
bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant
releasereleasebull PMN influxPMN influxbull Macrophage Macrophage
fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue
ndash 80 original 80 original strengthstrength
Why does the material matter
Tissue Ingrowth
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
My patient needs to do a sit-up after a My patient needs to do a sit-up after a successful hernia operationsuccessful hernia operation
Definition of dynamic abd wallDefinition of dynamic abd wall
What is a dynamic abdominal wallWhat is a dynamic abdominal wall
What is an adynamic What is an adynamic (or (or poorly functioningpoorly functioning) abdominal wall) abdominal wall
What we donrsquot wantWhat we donrsquot want
bull Bowel can adhere to polyester surface
bull Inadequate overlap
bull Inadequate fixation
What we donrsquot wantWhat we donrsquot want
What we donrsquot wantWhat we donrsquot want
Recipe for SuccessRecipe for Success
PathophysiologyPathophysiology
Wound HealingWound Healing
Midline or Defect Closure
Mesh TissueInterface
ldquoThe main challenge for surgery is to find the best technique in a given situation (patient hernia anatomy) which
provides the best overlaphelliprdquo Uwe Klinge Aachen Germany 2011
Matrix deposition the fibroblastMatrix deposition the fibroblast
Collagen FIBRILS then bond to form FIBERS
If something is wrong you need to search If something is wrong you need to search for the source of the problemfor the source of the problem
Volume please
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Type I tensile strength (mature collagen)
bull Type III thinner diameter aka immature collagen
bull Quality of a wound is based on a high type IIII rationdash Reduced ratio (higher proportion of type III)
bull Reduced stability of connective tissue
Type I IIIType I III
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patiens with recurring hernia after implantation of alloplastic prosthesis
bull N = 78 50 M 28 F
bull Primary inguinal 25
bull Recurrent inguinal 18
bull Primary incisional 11
bull Recurrent incisional 24
Type I III ratio Type I III ratio and indication for mesh removaland indication for mesh removal
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
N= 78 explants
N=46 N=18 N=14
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Reduced in patients with recurrent herniasndash Provides new possibilities for future research
regarding novel wound healing agents
MMP-2 (gelatinase A)MMP-2 (gelatinase A)
bull Proteolytic enzymendash Degrades collagen fibers (ECM proteins)ndash Degrades vessel wall integrity
bull Tumorogenicndash Implemented in colon breast lung adrenal
bull Connective tissue diseasesndash Aortic Aneurysmndash Ehler ndash Danlosndash Marfanrsquos syndrome
bull 1) indirectbull 2) directbull 3) recurrence
bull All groups were significantly higher (plt005) than CONTROL GROUP those without a hernia
Smigielski J Kolomecki K Ziemniak P et al Eur Surg Res 2009
Collagen Fiber CrosslinkingCollagen Fiber CrosslinkingWound Strength IncreasesWound Strength Increases
bull Stabilizes the collagen fibersbull Resists collagen breakdown
by enzymesbull Reaches up to 90 strengthbull Cellular turnover stops
Wo
un
d S
tren
gth
7 14 21 28 35 42 49 56 63 DAYS
Material are not all equalMaterial are not all equalbull Ongoing inflammatory processes can last at least a year bull This poor biocompatibility may lead to poor mesh
compliance
Novitsky YW Cristiano JA Harrell AG Newcomb W Norton JH Kercher KW Heniford BT (2008) Immunohistochemical analysis of host reaction to heavyweight- reduced-weight and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations Surg Endosc 22 1070-76
Ki-67
bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant
releasereleasebull PMN influxPMN influxbull Macrophage Macrophage
fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue
ndash 80 original 80 original strengthstrength
Why does the material matter
Tissue Ingrowth
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Definition of dynamic abd wallDefinition of dynamic abd wall
What is a dynamic abdominal wallWhat is a dynamic abdominal wall
What is an adynamic What is an adynamic (or (or poorly functioningpoorly functioning) abdominal wall) abdominal wall
What we donrsquot wantWhat we donrsquot want
bull Bowel can adhere to polyester surface
bull Inadequate overlap
bull Inadequate fixation
What we donrsquot wantWhat we donrsquot want
What we donrsquot wantWhat we donrsquot want
Recipe for SuccessRecipe for Success
PathophysiologyPathophysiology
Wound HealingWound Healing
Midline or Defect Closure
Mesh TissueInterface
ldquoThe main challenge for surgery is to find the best technique in a given situation (patient hernia anatomy) which
provides the best overlaphelliprdquo Uwe Klinge Aachen Germany 2011
Matrix deposition the fibroblastMatrix deposition the fibroblast
Collagen FIBRILS then bond to form FIBERS
If something is wrong you need to search If something is wrong you need to search for the source of the problemfor the source of the problem
Volume please
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Type I tensile strength (mature collagen)
bull Type III thinner diameter aka immature collagen
bull Quality of a wound is based on a high type IIII rationdash Reduced ratio (higher proportion of type III)
bull Reduced stability of connective tissue
Type I IIIType I III
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patiens with recurring hernia after implantation of alloplastic prosthesis
bull N = 78 50 M 28 F
bull Primary inguinal 25
bull Recurrent inguinal 18
bull Primary incisional 11
bull Recurrent incisional 24
Type I III ratio Type I III ratio and indication for mesh removaland indication for mesh removal
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
N= 78 explants
N=46 N=18 N=14
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Reduced in patients with recurrent herniasndash Provides new possibilities for future research
regarding novel wound healing agents
MMP-2 (gelatinase A)MMP-2 (gelatinase A)
bull Proteolytic enzymendash Degrades collagen fibers (ECM proteins)ndash Degrades vessel wall integrity
bull Tumorogenicndash Implemented in colon breast lung adrenal
bull Connective tissue diseasesndash Aortic Aneurysmndash Ehler ndash Danlosndash Marfanrsquos syndrome
bull 1) indirectbull 2) directbull 3) recurrence
bull All groups were significantly higher (plt005) than CONTROL GROUP those without a hernia
Smigielski J Kolomecki K Ziemniak P et al Eur Surg Res 2009
Collagen Fiber CrosslinkingCollagen Fiber CrosslinkingWound Strength IncreasesWound Strength Increases
bull Stabilizes the collagen fibersbull Resists collagen breakdown
by enzymesbull Reaches up to 90 strengthbull Cellular turnover stops
Wo
un
d S
tren
gth
7 14 21 28 35 42 49 56 63 DAYS
Material are not all equalMaterial are not all equalbull Ongoing inflammatory processes can last at least a year bull This poor biocompatibility may lead to poor mesh
compliance
Novitsky YW Cristiano JA Harrell AG Newcomb W Norton JH Kercher KW Heniford BT (2008) Immunohistochemical analysis of host reaction to heavyweight- reduced-weight and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations Surg Endosc 22 1070-76
Ki-67
bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant
releasereleasebull PMN influxPMN influxbull Macrophage Macrophage
fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue
ndash 80 original 80 original strengthstrength
Why does the material matter
Tissue Ingrowth
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
What is a dynamic abdominal wallWhat is a dynamic abdominal wall
What is an adynamic What is an adynamic (or (or poorly functioningpoorly functioning) abdominal wall) abdominal wall
What we donrsquot wantWhat we donrsquot want
bull Bowel can adhere to polyester surface
bull Inadequate overlap
bull Inadequate fixation
What we donrsquot wantWhat we donrsquot want
What we donrsquot wantWhat we donrsquot want
Recipe for SuccessRecipe for Success
PathophysiologyPathophysiology
Wound HealingWound Healing
Midline or Defect Closure
Mesh TissueInterface
ldquoThe main challenge for surgery is to find the best technique in a given situation (patient hernia anatomy) which
provides the best overlaphelliprdquo Uwe Klinge Aachen Germany 2011
Matrix deposition the fibroblastMatrix deposition the fibroblast
Collagen FIBRILS then bond to form FIBERS
If something is wrong you need to search If something is wrong you need to search for the source of the problemfor the source of the problem
Volume please
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Type I tensile strength (mature collagen)
bull Type III thinner diameter aka immature collagen
bull Quality of a wound is based on a high type IIII rationdash Reduced ratio (higher proportion of type III)
bull Reduced stability of connective tissue
Type I IIIType I III
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patiens with recurring hernia after implantation of alloplastic prosthesis
bull N = 78 50 M 28 F
bull Primary inguinal 25
bull Recurrent inguinal 18
bull Primary incisional 11
bull Recurrent incisional 24
Type I III ratio Type I III ratio and indication for mesh removaland indication for mesh removal
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
N= 78 explants
N=46 N=18 N=14
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Reduced in patients with recurrent herniasndash Provides new possibilities for future research
regarding novel wound healing agents
MMP-2 (gelatinase A)MMP-2 (gelatinase A)
bull Proteolytic enzymendash Degrades collagen fibers (ECM proteins)ndash Degrades vessel wall integrity
bull Tumorogenicndash Implemented in colon breast lung adrenal
bull Connective tissue diseasesndash Aortic Aneurysmndash Ehler ndash Danlosndash Marfanrsquos syndrome
bull 1) indirectbull 2) directbull 3) recurrence
bull All groups were significantly higher (plt005) than CONTROL GROUP those without a hernia
Smigielski J Kolomecki K Ziemniak P et al Eur Surg Res 2009
Collagen Fiber CrosslinkingCollagen Fiber CrosslinkingWound Strength IncreasesWound Strength Increases
bull Stabilizes the collagen fibersbull Resists collagen breakdown
by enzymesbull Reaches up to 90 strengthbull Cellular turnover stops
Wo
un
d S
tren
gth
7 14 21 28 35 42 49 56 63 DAYS
Material are not all equalMaterial are not all equalbull Ongoing inflammatory processes can last at least a year bull This poor biocompatibility may lead to poor mesh
compliance
Novitsky YW Cristiano JA Harrell AG Newcomb W Norton JH Kercher KW Heniford BT (2008) Immunohistochemical analysis of host reaction to heavyweight- reduced-weight and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations Surg Endosc 22 1070-76
Ki-67
bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant
releasereleasebull PMN influxPMN influxbull Macrophage Macrophage
fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue
ndash 80 original 80 original strengthstrength
Why does the material matter
Tissue Ingrowth
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
What is an adynamic What is an adynamic (or (or poorly functioningpoorly functioning) abdominal wall) abdominal wall
What we donrsquot wantWhat we donrsquot want
bull Bowel can adhere to polyester surface
bull Inadequate overlap
bull Inadequate fixation
What we donrsquot wantWhat we donrsquot want
What we donrsquot wantWhat we donrsquot want
Recipe for SuccessRecipe for Success
PathophysiologyPathophysiology
Wound HealingWound Healing
Midline or Defect Closure
Mesh TissueInterface
ldquoThe main challenge for surgery is to find the best technique in a given situation (patient hernia anatomy) which
provides the best overlaphelliprdquo Uwe Klinge Aachen Germany 2011
Matrix deposition the fibroblastMatrix deposition the fibroblast
Collagen FIBRILS then bond to form FIBERS
If something is wrong you need to search If something is wrong you need to search for the source of the problemfor the source of the problem
Volume please
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Type I tensile strength (mature collagen)
bull Type III thinner diameter aka immature collagen
bull Quality of a wound is based on a high type IIII rationdash Reduced ratio (higher proportion of type III)
bull Reduced stability of connective tissue
Type I IIIType I III
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patiens with recurring hernia after implantation of alloplastic prosthesis
bull N = 78 50 M 28 F
bull Primary inguinal 25
bull Recurrent inguinal 18
bull Primary incisional 11
bull Recurrent incisional 24
Type I III ratio Type I III ratio and indication for mesh removaland indication for mesh removal
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
N= 78 explants
N=46 N=18 N=14
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Reduced in patients with recurrent herniasndash Provides new possibilities for future research
regarding novel wound healing agents
MMP-2 (gelatinase A)MMP-2 (gelatinase A)
bull Proteolytic enzymendash Degrades collagen fibers (ECM proteins)ndash Degrades vessel wall integrity
bull Tumorogenicndash Implemented in colon breast lung adrenal
bull Connective tissue diseasesndash Aortic Aneurysmndash Ehler ndash Danlosndash Marfanrsquos syndrome
bull 1) indirectbull 2) directbull 3) recurrence
bull All groups were significantly higher (plt005) than CONTROL GROUP those without a hernia
Smigielski J Kolomecki K Ziemniak P et al Eur Surg Res 2009
Collagen Fiber CrosslinkingCollagen Fiber CrosslinkingWound Strength IncreasesWound Strength Increases
bull Stabilizes the collagen fibersbull Resists collagen breakdown
by enzymesbull Reaches up to 90 strengthbull Cellular turnover stops
Wo
un
d S
tren
gth
7 14 21 28 35 42 49 56 63 DAYS
Material are not all equalMaterial are not all equalbull Ongoing inflammatory processes can last at least a year bull This poor biocompatibility may lead to poor mesh
compliance
Novitsky YW Cristiano JA Harrell AG Newcomb W Norton JH Kercher KW Heniford BT (2008) Immunohistochemical analysis of host reaction to heavyweight- reduced-weight and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations Surg Endosc 22 1070-76
Ki-67
bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant
releasereleasebull PMN influxPMN influxbull Macrophage Macrophage
fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue
ndash 80 original 80 original strengthstrength
Why does the material matter
Tissue Ingrowth
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
What we donrsquot wantWhat we donrsquot want
bull Bowel can adhere to polyester surface
bull Inadequate overlap
bull Inadequate fixation
What we donrsquot wantWhat we donrsquot want
What we donrsquot wantWhat we donrsquot want
Recipe for SuccessRecipe for Success
PathophysiologyPathophysiology
Wound HealingWound Healing
Midline or Defect Closure
Mesh TissueInterface
ldquoThe main challenge for surgery is to find the best technique in a given situation (patient hernia anatomy) which
provides the best overlaphelliprdquo Uwe Klinge Aachen Germany 2011
Matrix deposition the fibroblastMatrix deposition the fibroblast
Collagen FIBRILS then bond to form FIBERS
If something is wrong you need to search If something is wrong you need to search for the source of the problemfor the source of the problem
Volume please
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Type I tensile strength (mature collagen)
bull Type III thinner diameter aka immature collagen
bull Quality of a wound is based on a high type IIII rationdash Reduced ratio (higher proportion of type III)
bull Reduced stability of connective tissue
Type I IIIType I III
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patiens with recurring hernia after implantation of alloplastic prosthesis
bull N = 78 50 M 28 F
bull Primary inguinal 25
bull Recurrent inguinal 18
bull Primary incisional 11
bull Recurrent incisional 24
Type I III ratio Type I III ratio and indication for mesh removaland indication for mesh removal
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
N= 78 explants
N=46 N=18 N=14
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Reduced in patients with recurrent herniasndash Provides new possibilities for future research
regarding novel wound healing agents
MMP-2 (gelatinase A)MMP-2 (gelatinase A)
bull Proteolytic enzymendash Degrades collagen fibers (ECM proteins)ndash Degrades vessel wall integrity
bull Tumorogenicndash Implemented in colon breast lung adrenal
bull Connective tissue diseasesndash Aortic Aneurysmndash Ehler ndash Danlosndash Marfanrsquos syndrome
bull 1) indirectbull 2) directbull 3) recurrence
bull All groups were significantly higher (plt005) than CONTROL GROUP those without a hernia
Smigielski J Kolomecki K Ziemniak P et al Eur Surg Res 2009
Collagen Fiber CrosslinkingCollagen Fiber CrosslinkingWound Strength IncreasesWound Strength Increases
bull Stabilizes the collagen fibersbull Resists collagen breakdown
by enzymesbull Reaches up to 90 strengthbull Cellular turnover stops
Wo
un
d S
tren
gth
7 14 21 28 35 42 49 56 63 DAYS
Material are not all equalMaterial are not all equalbull Ongoing inflammatory processes can last at least a year bull This poor biocompatibility may lead to poor mesh
compliance
Novitsky YW Cristiano JA Harrell AG Newcomb W Norton JH Kercher KW Heniford BT (2008) Immunohistochemical analysis of host reaction to heavyweight- reduced-weight and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations Surg Endosc 22 1070-76
Ki-67
bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant
releasereleasebull PMN influxPMN influxbull Macrophage Macrophage
fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue
ndash 80 original 80 original strengthstrength
Why does the material matter
Tissue Ingrowth
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
What we donrsquot wantWhat we donrsquot want
What we donrsquot wantWhat we donrsquot want
Recipe for SuccessRecipe for Success
PathophysiologyPathophysiology
Wound HealingWound Healing
Midline or Defect Closure
Mesh TissueInterface
ldquoThe main challenge for surgery is to find the best technique in a given situation (patient hernia anatomy) which
provides the best overlaphelliprdquo Uwe Klinge Aachen Germany 2011
Matrix deposition the fibroblastMatrix deposition the fibroblast
Collagen FIBRILS then bond to form FIBERS
If something is wrong you need to search If something is wrong you need to search for the source of the problemfor the source of the problem
Volume please
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Type I tensile strength (mature collagen)
bull Type III thinner diameter aka immature collagen
bull Quality of a wound is based on a high type IIII rationdash Reduced ratio (higher proportion of type III)
bull Reduced stability of connective tissue
Type I IIIType I III
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patiens with recurring hernia after implantation of alloplastic prosthesis
bull N = 78 50 M 28 F
bull Primary inguinal 25
bull Recurrent inguinal 18
bull Primary incisional 11
bull Recurrent incisional 24
Type I III ratio Type I III ratio and indication for mesh removaland indication for mesh removal
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
N= 78 explants
N=46 N=18 N=14
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Reduced in patients with recurrent herniasndash Provides new possibilities for future research
regarding novel wound healing agents
MMP-2 (gelatinase A)MMP-2 (gelatinase A)
bull Proteolytic enzymendash Degrades collagen fibers (ECM proteins)ndash Degrades vessel wall integrity
bull Tumorogenicndash Implemented in colon breast lung adrenal
bull Connective tissue diseasesndash Aortic Aneurysmndash Ehler ndash Danlosndash Marfanrsquos syndrome
bull 1) indirectbull 2) directbull 3) recurrence
bull All groups were significantly higher (plt005) than CONTROL GROUP those without a hernia
Smigielski J Kolomecki K Ziemniak P et al Eur Surg Res 2009
Collagen Fiber CrosslinkingCollagen Fiber CrosslinkingWound Strength IncreasesWound Strength Increases
bull Stabilizes the collagen fibersbull Resists collagen breakdown
by enzymesbull Reaches up to 90 strengthbull Cellular turnover stops
Wo
un
d S
tren
gth
7 14 21 28 35 42 49 56 63 DAYS
Material are not all equalMaterial are not all equalbull Ongoing inflammatory processes can last at least a year bull This poor biocompatibility may lead to poor mesh
compliance
Novitsky YW Cristiano JA Harrell AG Newcomb W Norton JH Kercher KW Heniford BT (2008) Immunohistochemical analysis of host reaction to heavyweight- reduced-weight and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations Surg Endosc 22 1070-76
Ki-67
bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant
releasereleasebull PMN influxPMN influxbull Macrophage Macrophage
fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue
ndash 80 original 80 original strengthstrength
Why does the material matter
Tissue Ingrowth
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
What we donrsquot wantWhat we donrsquot want
Recipe for SuccessRecipe for Success
PathophysiologyPathophysiology
Wound HealingWound Healing
Midline or Defect Closure
Mesh TissueInterface
ldquoThe main challenge for surgery is to find the best technique in a given situation (patient hernia anatomy) which
provides the best overlaphelliprdquo Uwe Klinge Aachen Germany 2011
Matrix deposition the fibroblastMatrix deposition the fibroblast
Collagen FIBRILS then bond to form FIBERS
If something is wrong you need to search If something is wrong you need to search for the source of the problemfor the source of the problem
Volume please
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Type I tensile strength (mature collagen)
bull Type III thinner diameter aka immature collagen
bull Quality of a wound is based on a high type IIII rationdash Reduced ratio (higher proportion of type III)
bull Reduced stability of connective tissue
Type I IIIType I III
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patiens with recurring hernia after implantation of alloplastic prosthesis
bull N = 78 50 M 28 F
bull Primary inguinal 25
bull Recurrent inguinal 18
bull Primary incisional 11
bull Recurrent incisional 24
Type I III ratio Type I III ratio and indication for mesh removaland indication for mesh removal
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
N= 78 explants
N=46 N=18 N=14
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Reduced in patients with recurrent herniasndash Provides new possibilities for future research
regarding novel wound healing agents
MMP-2 (gelatinase A)MMP-2 (gelatinase A)
bull Proteolytic enzymendash Degrades collagen fibers (ECM proteins)ndash Degrades vessel wall integrity
bull Tumorogenicndash Implemented in colon breast lung adrenal
bull Connective tissue diseasesndash Aortic Aneurysmndash Ehler ndash Danlosndash Marfanrsquos syndrome
bull 1) indirectbull 2) directbull 3) recurrence
bull All groups were significantly higher (plt005) than CONTROL GROUP those without a hernia
Smigielski J Kolomecki K Ziemniak P et al Eur Surg Res 2009
Collagen Fiber CrosslinkingCollagen Fiber CrosslinkingWound Strength IncreasesWound Strength Increases
bull Stabilizes the collagen fibersbull Resists collagen breakdown
by enzymesbull Reaches up to 90 strengthbull Cellular turnover stops
Wo
un
d S
tren
gth
7 14 21 28 35 42 49 56 63 DAYS
Material are not all equalMaterial are not all equalbull Ongoing inflammatory processes can last at least a year bull This poor biocompatibility may lead to poor mesh
compliance
Novitsky YW Cristiano JA Harrell AG Newcomb W Norton JH Kercher KW Heniford BT (2008) Immunohistochemical analysis of host reaction to heavyweight- reduced-weight and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations Surg Endosc 22 1070-76
Ki-67
bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant
releasereleasebull PMN influxPMN influxbull Macrophage Macrophage
fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue
ndash 80 original 80 original strengthstrength
Why does the material matter
Tissue Ingrowth
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Recipe for SuccessRecipe for Success
PathophysiologyPathophysiology
Wound HealingWound Healing
Midline or Defect Closure
Mesh TissueInterface
ldquoThe main challenge for surgery is to find the best technique in a given situation (patient hernia anatomy) which
provides the best overlaphelliprdquo Uwe Klinge Aachen Germany 2011
Matrix deposition the fibroblastMatrix deposition the fibroblast
Collagen FIBRILS then bond to form FIBERS
If something is wrong you need to search If something is wrong you need to search for the source of the problemfor the source of the problem
Volume please
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Type I tensile strength (mature collagen)
bull Type III thinner diameter aka immature collagen
bull Quality of a wound is based on a high type IIII rationdash Reduced ratio (higher proportion of type III)
bull Reduced stability of connective tissue
Type I IIIType I III
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patiens with recurring hernia after implantation of alloplastic prosthesis
bull N = 78 50 M 28 F
bull Primary inguinal 25
bull Recurrent inguinal 18
bull Primary incisional 11
bull Recurrent incisional 24
Type I III ratio Type I III ratio and indication for mesh removaland indication for mesh removal
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
N= 78 explants
N=46 N=18 N=14
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Reduced in patients with recurrent herniasndash Provides new possibilities for future research
regarding novel wound healing agents
MMP-2 (gelatinase A)MMP-2 (gelatinase A)
bull Proteolytic enzymendash Degrades collagen fibers (ECM proteins)ndash Degrades vessel wall integrity
bull Tumorogenicndash Implemented in colon breast lung adrenal
bull Connective tissue diseasesndash Aortic Aneurysmndash Ehler ndash Danlosndash Marfanrsquos syndrome
bull 1) indirectbull 2) directbull 3) recurrence
bull All groups were significantly higher (plt005) than CONTROL GROUP those without a hernia
Smigielski J Kolomecki K Ziemniak P et al Eur Surg Res 2009
Collagen Fiber CrosslinkingCollagen Fiber CrosslinkingWound Strength IncreasesWound Strength Increases
bull Stabilizes the collagen fibersbull Resists collagen breakdown
by enzymesbull Reaches up to 90 strengthbull Cellular turnover stops
Wo
un
d S
tren
gth
7 14 21 28 35 42 49 56 63 DAYS
Material are not all equalMaterial are not all equalbull Ongoing inflammatory processes can last at least a year bull This poor biocompatibility may lead to poor mesh
compliance
Novitsky YW Cristiano JA Harrell AG Newcomb W Norton JH Kercher KW Heniford BT (2008) Immunohistochemical analysis of host reaction to heavyweight- reduced-weight and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations Surg Endosc 22 1070-76
Ki-67
bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant
releasereleasebull PMN influxPMN influxbull Macrophage Macrophage
fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue
ndash 80 original 80 original strengthstrength
Why does the material matter
Tissue Ingrowth
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
PathophysiologyPathophysiology
Wound HealingWound Healing
Midline or Defect Closure
Mesh TissueInterface
ldquoThe main challenge for surgery is to find the best technique in a given situation (patient hernia anatomy) which
provides the best overlaphelliprdquo Uwe Klinge Aachen Germany 2011
Matrix deposition the fibroblastMatrix deposition the fibroblast
Collagen FIBRILS then bond to form FIBERS
If something is wrong you need to search If something is wrong you need to search for the source of the problemfor the source of the problem
Volume please
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Type I tensile strength (mature collagen)
bull Type III thinner diameter aka immature collagen
bull Quality of a wound is based on a high type IIII rationdash Reduced ratio (higher proportion of type III)
bull Reduced stability of connective tissue
Type I IIIType I III
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patiens with recurring hernia after implantation of alloplastic prosthesis
bull N = 78 50 M 28 F
bull Primary inguinal 25
bull Recurrent inguinal 18
bull Primary incisional 11
bull Recurrent incisional 24
Type I III ratio Type I III ratio and indication for mesh removaland indication for mesh removal
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
N= 78 explants
N=46 N=18 N=14
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Reduced in patients with recurrent herniasndash Provides new possibilities for future research
regarding novel wound healing agents
MMP-2 (gelatinase A)MMP-2 (gelatinase A)
bull Proteolytic enzymendash Degrades collagen fibers (ECM proteins)ndash Degrades vessel wall integrity
bull Tumorogenicndash Implemented in colon breast lung adrenal
bull Connective tissue diseasesndash Aortic Aneurysmndash Ehler ndash Danlosndash Marfanrsquos syndrome
bull 1) indirectbull 2) directbull 3) recurrence
bull All groups were significantly higher (plt005) than CONTROL GROUP those without a hernia
Smigielski J Kolomecki K Ziemniak P et al Eur Surg Res 2009
Collagen Fiber CrosslinkingCollagen Fiber CrosslinkingWound Strength IncreasesWound Strength Increases
bull Stabilizes the collagen fibersbull Resists collagen breakdown
by enzymesbull Reaches up to 90 strengthbull Cellular turnover stops
Wo
un
d S
tren
gth
7 14 21 28 35 42 49 56 63 DAYS
Material are not all equalMaterial are not all equalbull Ongoing inflammatory processes can last at least a year bull This poor biocompatibility may lead to poor mesh
compliance
Novitsky YW Cristiano JA Harrell AG Newcomb W Norton JH Kercher KW Heniford BT (2008) Immunohistochemical analysis of host reaction to heavyweight- reduced-weight and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations Surg Endosc 22 1070-76
Ki-67
bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant
releasereleasebull PMN influxPMN influxbull Macrophage Macrophage
fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue
ndash 80 original 80 original strengthstrength
Why does the material matter
Tissue Ingrowth
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Wound HealingWound Healing
Midline or Defect Closure
Mesh TissueInterface
ldquoThe main challenge for surgery is to find the best technique in a given situation (patient hernia anatomy) which
provides the best overlaphelliprdquo Uwe Klinge Aachen Germany 2011
Matrix deposition the fibroblastMatrix deposition the fibroblast
Collagen FIBRILS then bond to form FIBERS
If something is wrong you need to search If something is wrong you need to search for the source of the problemfor the source of the problem
Volume please
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Type I tensile strength (mature collagen)
bull Type III thinner diameter aka immature collagen
bull Quality of a wound is based on a high type IIII rationdash Reduced ratio (higher proportion of type III)
bull Reduced stability of connective tissue
Type I IIIType I III
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patiens with recurring hernia after implantation of alloplastic prosthesis
bull N = 78 50 M 28 F
bull Primary inguinal 25
bull Recurrent inguinal 18
bull Primary incisional 11
bull Recurrent incisional 24
Type I III ratio Type I III ratio and indication for mesh removaland indication for mesh removal
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
N= 78 explants
N=46 N=18 N=14
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Reduced in patients with recurrent herniasndash Provides new possibilities for future research
regarding novel wound healing agents
MMP-2 (gelatinase A)MMP-2 (gelatinase A)
bull Proteolytic enzymendash Degrades collagen fibers (ECM proteins)ndash Degrades vessel wall integrity
bull Tumorogenicndash Implemented in colon breast lung adrenal
bull Connective tissue diseasesndash Aortic Aneurysmndash Ehler ndash Danlosndash Marfanrsquos syndrome
bull 1) indirectbull 2) directbull 3) recurrence
bull All groups were significantly higher (plt005) than CONTROL GROUP those without a hernia
Smigielski J Kolomecki K Ziemniak P et al Eur Surg Res 2009
Collagen Fiber CrosslinkingCollagen Fiber CrosslinkingWound Strength IncreasesWound Strength Increases
bull Stabilizes the collagen fibersbull Resists collagen breakdown
by enzymesbull Reaches up to 90 strengthbull Cellular turnover stops
Wo
un
d S
tren
gth
7 14 21 28 35 42 49 56 63 DAYS
Material are not all equalMaterial are not all equalbull Ongoing inflammatory processes can last at least a year bull This poor biocompatibility may lead to poor mesh
compliance
Novitsky YW Cristiano JA Harrell AG Newcomb W Norton JH Kercher KW Heniford BT (2008) Immunohistochemical analysis of host reaction to heavyweight- reduced-weight and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations Surg Endosc 22 1070-76
Ki-67
bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant
releasereleasebull PMN influxPMN influxbull Macrophage Macrophage
fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue
ndash 80 original 80 original strengthstrength
Why does the material matter
Tissue Ingrowth
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Matrix deposition the fibroblastMatrix deposition the fibroblast
Collagen FIBRILS then bond to form FIBERS
If something is wrong you need to search If something is wrong you need to search for the source of the problemfor the source of the problem
Volume please
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Type I tensile strength (mature collagen)
bull Type III thinner diameter aka immature collagen
bull Quality of a wound is based on a high type IIII rationdash Reduced ratio (higher proportion of type III)
bull Reduced stability of connective tissue
Type I IIIType I III
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patiens with recurring hernia after implantation of alloplastic prosthesis
bull N = 78 50 M 28 F
bull Primary inguinal 25
bull Recurrent inguinal 18
bull Primary incisional 11
bull Recurrent incisional 24
Type I III ratio Type I III ratio and indication for mesh removaland indication for mesh removal
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
N= 78 explants
N=46 N=18 N=14
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Reduced in patients with recurrent herniasndash Provides new possibilities for future research
regarding novel wound healing agents
MMP-2 (gelatinase A)MMP-2 (gelatinase A)
bull Proteolytic enzymendash Degrades collagen fibers (ECM proteins)ndash Degrades vessel wall integrity
bull Tumorogenicndash Implemented in colon breast lung adrenal
bull Connective tissue diseasesndash Aortic Aneurysmndash Ehler ndash Danlosndash Marfanrsquos syndrome
bull 1) indirectbull 2) directbull 3) recurrence
bull All groups were significantly higher (plt005) than CONTROL GROUP those without a hernia
Smigielski J Kolomecki K Ziemniak P et al Eur Surg Res 2009
Collagen Fiber CrosslinkingCollagen Fiber CrosslinkingWound Strength IncreasesWound Strength Increases
bull Stabilizes the collagen fibersbull Resists collagen breakdown
by enzymesbull Reaches up to 90 strengthbull Cellular turnover stops
Wo
un
d S
tren
gth
7 14 21 28 35 42 49 56 63 DAYS
Material are not all equalMaterial are not all equalbull Ongoing inflammatory processes can last at least a year bull This poor biocompatibility may lead to poor mesh
compliance
Novitsky YW Cristiano JA Harrell AG Newcomb W Norton JH Kercher KW Heniford BT (2008) Immunohistochemical analysis of host reaction to heavyweight- reduced-weight and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations Surg Endosc 22 1070-76
Ki-67
bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant
releasereleasebull PMN influxPMN influxbull Macrophage Macrophage
fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue
ndash 80 original 80 original strengthstrength
Why does the material matter
Tissue Ingrowth
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
If something is wrong you need to search If something is wrong you need to search for the source of the problemfor the source of the problem
Volume please
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Type I tensile strength (mature collagen)
bull Type III thinner diameter aka immature collagen
bull Quality of a wound is based on a high type IIII rationdash Reduced ratio (higher proportion of type III)
bull Reduced stability of connective tissue
Type I IIIType I III
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patiens with recurring hernia after implantation of alloplastic prosthesis
bull N = 78 50 M 28 F
bull Primary inguinal 25
bull Recurrent inguinal 18
bull Primary incisional 11
bull Recurrent incisional 24
Type I III ratio Type I III ratio and indication for mesh removaland indication for mesh removal
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
N= 78 explants
N=46 N=18 N=14
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Reduced in patients with recurrent herniasndash Provides new possibilities for future research
regarding novel wound healing agents
MMP-2 (gelatinase A)MMP-2 (gelatinase A)
bull Proteolytic enzymendash Degrades collagen fibers (ECM proteins)ndash Degrades vessel wall integrity
bull Tumorogenicndash Implemented in colon breast lung adrenal
bull Connective tissue diseasesndash Aortic Aneurysmndash Ehler ndash Danlosndash Marfanrsquos syndrome
bull 1) indirectbull 2) directbull 3) recurrence
bull All groups were significantly higher (plt005) than CONTROL GROUP those without a hernia
Smigielski J Kolomecki K Ziemniak P et al Eur Surg Res 2009
Collagen Fiber CrosslinkingCollagen Fiber CrosslinkingWound Strength IncreasesWound Strength Increases
bull Stabilizes the collagen fibersbull Resists collagen breakdown
by enzymesbull Reaches up to 90 strengthbull Cellular turnover stops
Wo
un
d S
tren
gth
7 14 21 28 35 42 49 56 63 DAYS
Material are not all equalMaterial are not all equalbull Ongoing inflammatory processes can last at least a year bull This poor biocompatibility may lead to poor mesh
compliance
Novitsky YW Cristiano JA Harrell AG Newcomb W Norton JH Kercher KW Heniford BT (2008) Immunohistochemical analysis of host reaction to heavyweight- reduced-weight and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations Surg Endosc 22 1070-76
Ki-67
bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant
releasereleasebull PMN influxPMN influxbull Macrophage Macrophage
fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue
ndash 80 original 80 original strengthstrength
Why does the material matter
Tissue Ingrowth
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Type I tensile strength (mature collagen)
bull Type III thinner diameter aka immature collagen
bull Quality of a wound is based on a high type IIII rationdash Reduced ratio (higher proportion of type III)
bull Reduced stability of connective tissue
Type I IIIType I III
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patiens with recurring hernia after implantation of alloplastic prosthesis
bull N = 78 50 M 28 F
bull Primary inguinal 25
bull Recurrent inguinal 18
bull Primary incisional 11
bull Recurrent incisional 24
Type I III ratio Type I III ratio and indication for mesh removaland indication for mesh removal
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
N= 78 explants
N=46 N=18 N=14
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Reduced in patients with recurrent herniasndash Provides new possibilities for future research
regarding novel wound healing agents
MMP-2 (gelatinase A)MMP-2 (gelatinase A)
bull Proteolytic enzymendash Degrades collagen fibers (ECM proteins)ndash Degrades vessel wall integrity
bull Tumorogenicndash Implemented in colon breast lung adrenal
bull Connective tissue diseasesndash Aortic Aneurysmndash Ehler ndash Danlosndash Marfanrsquos syndrome
bull 1) indirectbull 2) directbull 3) recurrence
bull All groups were significantly higher (plt005) than CONTROL GROUP those without a hernia
Smigielski J Kolomecki K Ziemniak P et al Eur Surg Res 2009
Collagen Fiber CrosslinkingCollagen Fiber CrosslinkingWound Strength IncreasesWound Strength Increases
bull Stabilizes the collagen fibersbull Resists collagen breakdown
by enzymesbull Reaches up to 90 strengthbull Cellular turnover stops
Wo
un
d S
tren
gth
7 14 21 28 35 42 49 56 63 DAYS
Material are not all equalMaterial are not all equalbull Ongoing inflammatory processes can last at least a year bull This poor biocompatibility may lead to poor mesh
compliance
Novitsky YW Cristiano JA Harrell AG Newcomb W Norton JH Kercher KW Heniford BT (2008) Immunohistochemical analysis of host reaction to heavyweight- reduced-weight and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations Surg Endosc 22 1070-76
Ki-67
bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant
releasereleasebull PMN influxPMN influxbull Macrophage Macrophage
fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue
ndash 80 original 80 original strengthstrength
Why does the material matter
Tissue Ingrowth
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Type I IIIType I III
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patiens with recurring hernia after implantation of alloplastic prosthesis
bull N = 78 50 M 28 F
bull Primary inguinal 25
bull Recurrent inguinal 18
bull Primary incisional 11
bull Recurrent incisional 24
Type I III ratio Type I III ratio and indication for mesh removaland indication for mesh removal
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
N= 78 explants
N=46 N=18 N=14
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Reduced in patients with recurrent herniasndash Provides new possibilities for future research
regarding novel wound healing agents
MMP-2 (gelatinase A)MMP-2 (gelatinase A)
bull Proteolytic enzymendash Degrades collagen fibers (ECM proteins)ndash Degrades vessel wall integrity
bull Tumorogenicndash Implemented in colon breast lung adrenal
bull Connective tissue diseasesndash Aortic Aneurysmndash Ehler ndash Danlosndash Marfanrsquos syndrome
bull 1) indirectbull 2) directbull 3) recurrence
bull All groups were significantly higher (plt005) than CONTROL GROUP those without a hernia
Smigielski J Kolomecki K Ziemniak P et al Eur Surg Res 2009
Collagen Fiber CrosslinkingCollagen Fiber CrosslinkingWound Strength IncreasesWound Strength Increases
bull Stabilizes the collagen fibersbull Resists collagen breakdown
by enzymesbull Reaches up to 90 strengthbull Cellular turnover stops
Wo
un
d S
tren
gth
7 14 21 28 35 42 49 56 63 DAYS
Material are not all equalMaterial are not all equalbull Ongoing inflammatory processes can last at least a year bull This poor biocompatibility may lead to poor mesh
compliance
Novitsky YW Cristiano JA Harrell AG Newcomb W Norton JH Kercher KW Heniford BT (2008) Immunohistochemical analysis of host reaction to heavyweight- reduced-weight and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations Surg Endosc 22 1070-76
Ki-67
bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant
releasereleasebull PMN influxPMN influxbull Macrophage Macrophage
fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue
ndash 80 original 80 original strengthstrength
Why does the material matter
Tissue Ingrowth
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Type I III ratio Type I III ratio and indication for mesh removaland indication for mesh removal
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
N= 78 explants
N=46 N=18 N=14
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Reduced in patients with recurrent herniasndash Provides new possibilities for future research
regarding novel wound healing agents
MMP-2 (gelatinase A)MMP-2 (gelatinase A)
bull Proteolytic enzymendash Degrades collagen fibers (ECM proteins)ndash Degrades vessel wall integrity
bull Tumorogenicndash Implemented in colon breast lung adrenal
bull Connective tissue diseasesndash Aortic Aneurysmndash Ehler ndash Danlosndash Marfanrsquos syndrome
bull 1) indirectbull 2) directbull 3) recurrence
bull All groups were significantly higher (plt005) than CONTROL GROUP those without a hernia
Smigielski J Kolomecki K Ziemniak P et al Eur Surg Res 2009
Collagen Fiber CrosslinkingCollagen Fiber CrosslinkingWound Strength IncreasesWound Strength Increases
bull Stabilizes the collagen fibersbull Resists collagen breakdown
by enzymesbull Reaches up to 90 strengthbull Cellular turnover stops
Wo
un
d S
tren
gth
7 14 21 28 35 42 49 56 63 DAYS
Material are not all equalMaterial are not all equalbull Ongoing inflammatory processes can last at least a year bull This poor biocompatibility may lead to poor mesh
compliance
Novitsky YW Cristiano JA Harrell AG Newcomb W Norton JH Kercher KW Heniford BT (2008) Immunohistochemical analysis of host reaction to heavyweight- reduced-weight and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations Surg Endosc 22 1070-76
Ki-67
bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant
releasereleasebull PMN influxPMN influxbull Macrophage Macrophage
fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue
ndash 80 original 80 original strengthstrength
Why does the material matter
Tissue Ingrowth
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Type I III Collagen RatioType I III Collagen Ratio
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
bull Reduced in patients with recurrent herniasndash Provides new possibilities for future research
regarding novel wound healing agents
MMP-2 (gelatinase A)MMP-2 (gelatinase A)
bull Proteolytic enzymendash Degrades collagen fibers (ECM proteins)ndash Degrades vessel wall integrity
bull Tumorogenicndash Implemented in colon breast lung adrenal
bull Connective tissue diseasesndash Aortic Aneurysmndash Ehler ndash Danlosndash Marfanrsquos syndrome
bull 1) indirectbull 2) directbull 3) recurrence
bull All groups were significantly higher (plt005) than CONTROL GROUP those without a hernia
Smigielski J Kolomecki K Ziemniak P et al Eur Surg Res 2009
Collagen Fiber CrosslinkingCollagen Fiber CrosslinkingWound Strength IncreasesWound Strength Increases
bull Stabilizes the collagen fibersbull Resists collagen breakdown
by enzymesbull Reaches up to 90 strengthbull Cellular turnover stops
Wo
un
d S
tren
gth
7 14 21 28 35 42 49 56 63 DAYS
Material are not all equalMaterial are not all equalbull Ongoing inflammatory processes can last at least a year bull This poor biocompatibility may lead to poor mesh
compliance
Novitsky YW Cristiano JA Harrell AG Newcomb W Norton JH Kercher KW Heniford BT (2008) Immunohistochemical analysis of host reaction to heavyweight- reduced-weight and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations Surg Endosc 22 1070-76
Ki-67
bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant
releasereleasebull PMN influxPMN influxbull Macrophage Macrophage
fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue
ndash 80 original 80 original strengthstrength
Why does the material matter
Tissue Ingrowth
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
MMP-2 (gelatinase A)MMP-2 (gelatinase A)
bull Proteolytic enzymendash Degrades collagen fibers (ECM proteins)ndash Degrades vessel wall integrity
bull Tumorogenicndash Implemented in colon breast lung adrenal
bull Connective tissue diseasesndash Aortic Aneurysmndash Ehler ndash Danlosndash Marfanrsquos syndrome
bull 1) indirectbull 2) directbull 3) recurrence
bull All groups were significantly higher (plt005) than CONTROL GROUP those without a hernia
Smigielski J Kolomecki K Ziemniak P et al Eur Surg Res 2009
Collagen Fiber CrosslinkingCollagen Fiber CrosslinkingWound Strength IncreasesWound Strength Increases
bull Stabilizes the collagen fibersbull Resists collagen breakdown
by enzymesbull Reaches up to 90 strengthbull Cellular turnover stops
Wo
un
d S
tren
gth
7 14 21 28 35 42 49 56 63 DAYS
Material are not all equalMaterial are not all equalbull Ongoing inflammatory processes can last at least a year bull This poor biocompatibility may lead to poor mesh
compliance
Novitsky YW Cristiano JA Harrell AG Newcomb W Norton JH Kercher KW Heniford BT (2008) Immunohistochemical analysis of host reaction to heavyweight- reduced-weight and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations Surg Endosc 22 1070-76
Ki-67
bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant
releasereleasebull PMN influxPMN influxbull Macrophage Macrophage
fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue
ndash 80 original 80 original strengthstrength
Why does the material matter
Tissue Ingrowth
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
bull 1) indirectbull 2) directbull 3) recurrence
bull All groups were significantly higher (plt005) than CONTROL GROUP those without a hernia
Smigielski J Kolomecki K Ziemniak P et al Eur Surg Res 2009
Collagen Fiber CrosslinkingCollagen Fiber CrosslinkingWound Strength IncreasesWound Strength Increases
bull Stabilizes the collagen fibersbull Resists collagen breakdown
by enzymesbull Reaches up to 90 strengthbull Cellular turnover stops
Wo
un
d S
tren
gth
7 14 21 28 35 42 49 56 63 DAYS
Material are not all equalMaterial are not all equalbull Ongoing inflammatory processes can last at least a year bull This poor biocompatibility may lead to poor mesh
compliance
Novitsky YW Cristiano JA Harrell AG Newcomb W Norton JH Kercher KW Heniford BT (2008) Immunohistochemical analysis of host reaction to heavyweight- reduced-weight and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations Surg Endosc 22 1070-76
Ki-67
bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant
releasereleasebull PMN influxPMN influxbull Macrophage Macrophage
fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue
ndash 80 original 80 original strengthstrength
Why does the material matter
Tissue Ingrowth
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Collagen Fiber CrosslinkingCollagen Fiber CrosslinkingWound Strength IncreasesWound Strength Increases
bull Stabilizes the collagen fibersbull Resists collagen breakdown
by enzymesbull Reaches up to 90 strengthbull Cellular turnover stops
Wo
un
d S
tren
gth
7 14 21 28 35 42 49 56 63 DAYS
Material are not all equalMaterial are not all equalbull Ongoing inflammatory processes can last at least a year bull This poor biocompatibility may lead to poor mesh
compliance
Novitsky YW Cristiano JA Harrell AG Newcomb W Norton JH Kercher KW Heniford BT (2008) Immunohistochemical analysis of host reaction to heavyweight- reduced-weight and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations Surg Endosc 22 1070-76
Ki-67
bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant
releasereleasebull PMN influxPMN influxbull Macrophage Macrophage
fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue
ndash 80 original 80 original strengthstrength
Why does the material matter
Tissue Ingrowth
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Material are not all equalMaterial are not all equalbull Ongoing inflammatory processes can last at least a year bull This poor biocompatibility may lead to poor mesh
compliance
Novitsky YW Cristiano JA Harrell AG Newcomb W Norton JH Kercher KW Heniford BT (2008) Immunohistochemical analysis of host reaction to heavyweight- reduced-weight and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations Surg Endosc 22 1070-76
Ki-67
bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant
releasereleasebull PMN influxPMN influxbull Macrophage Macrophage
fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue
ndash 80 original 80 original strengthstrength
Why does the material matter
Tissue Ingrowth
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant
releasereleasebull PMN influxPMN influxbull Macrophage Macrophage
fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue
ndash 80 original 80 original strengthstrength
Why does the material matter
Tissue Ingrowth
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers
bull Completely Completely incorporates the incorporates the mesh materialmesh material
Why does the material matterTissue Ingrowth
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
McGinty et al 2005Jacob BP et al 2007
Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength
For
ce in
Nc
m
Strong tis
sue ingrowth = Durability
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
LVHRLVHR
bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap
bull All the while open repairs working best with a closed midline and mesh reinforcement
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Rosen et al JACS 2007
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences
bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough
Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis
Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Stock market exampleStock market example
bull In one year a successful investment will grow
bull A) 2
bull B) 5
bull C) 10
bull D) 15
bull E) 20 or greater
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
5cm x 10cm defect[50 cm2]
Hypothetical defectHypothetical defect
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Mesh with 5cm overlap (20 x 15)
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
20 x 15 mesh (5cm overlap)[300 cm2]
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Ingrowth = 250 cm 2 (300-50)
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Closing the defect increases the surface area for tissue ingrowth
By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
LVHR Closing the defectLVHR Closing the defect
bull By closing the defect during a LVHRndash Permits natural wound healing process at midline
bull Potentially will require to dissect out edge of fascia muscle and peritoneum
ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in
larger defects)bull Less bulging (known morbidity)
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
LVHR IPOM bridgedLVHR IPOM bridged
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Large defect sp LVHRLarge defect sp LVHR
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept
bull randomized trial intraperitoneal onlay mesh (IPOM)
bull with or without cauterization of the hernia sacndash No cauterization (n = 26)
bull 425 seromas (3 recurrences)
ndash With cauterization (n = 25)bull 125 seroma (one recurrence)
bull Sac obliteration may reduce seromas and recurrences
Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Close the defect during LVHRClose the defect during LVHR
bull 47 patients LVHR with defect closure
bull BMI = 32
bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS
bull No wound morbidities or seromas
bull Closing the defect during LVHR is feasible and safe
Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces
bull Mean fu 56 monthsbull Morbidities of the 608
ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)
bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity
more functional abdominal wall
bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm
Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Treat each case individuallyTreat each case individually
bull There is no single solution for every case
bull Success depends on your chosen technique mesh product and patient
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure
bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Size mattersSize mattersbull Defect Sizes
ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer
ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy
ndash Large gt 10 cm (gt100cm2)bull Close all defects
ndash Minilaparotomy orndash Component release if necessary
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
ECS to close the defectECS to close the defect
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution
bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques
bull Hybrid or Combination techniquesndash Use an open incision to assist your
laparoscopic mesh fixation
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
1) External Oblique Fascia releases (both left and right)
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE
midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)
Aka converting to laparoscopy
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR
RESULTS OF A PROSPECTIVE STUDY
bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure
bull double leg lowering and trunk raising
ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair
bull Prospective
bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY
bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months
bull Conclusion
bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)
Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Outcomes and defect sizeOutcomes and defect size
bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than
5 cm
bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size
were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of
recurrence after laparoscopic incisional hernia repair
bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic
technique to increase the mesh tissue interface plus
Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
bull 44 cases bull22 endoscopic 22 openbullendoscopic
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
Endoscopic versus open component separation in complexabdominal wall reconstruction
Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347
open lap
Hospital stay 11days 8 days
Wound complications 52 27
Wound related intervention
45 33
Recurrence 32 27
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS
JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair
Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS
and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES
Volume 21 Number 5 2011
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
outcomesoutcomes
Confirm durability with a crunch or sit-up but prove with a scoring system
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect
ndash More anatomic dynamic physiologicbull Need more proof that this matters
ndash Decreases seroma incidencendash Less bulging
bull cosmetic and functional benefits (esp in larger defects)
ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and
peritoneum
ndash Increases surface area for tissuevascular ingrowth into mesh
ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure
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