CLIN IC A L NE WS
Clinical Pearls in Hernia Repair: Avoiding Errors By CHASE DOYLE
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us Abdomi inis Releas se Transversus Abdominis Release There are several places to start, including mid-rectus, over the transversus abdominis, below the arcuate line and the falciform ligament. Choosing the right place depends on the patient’s history and the part of the peritoneum or posterior sheath that is most preserved. “Medial tension is key,” Dr. Blatnik said. “I do this with three clamps, evenly spaced, with cautery along the way.” Dr. Blatnik encouraged surgeons to gain experience differentiating the peritoneum from the transversalis fascia, a thin aponeurotic membrane that lies between the inner surface of the transverse abdominis and the parietal peritoneum. This is an important distinction, especially in the subcostal region where the peritoneum can be very thin, he said. When doing a release, Dr. Blatnik underscored going laterally around thin or challenging areas before working back. If a difficult closure is anticipated, use the ‘Mesh is not always a nice flat piece hernia sac as part of posterior closure, he said.
ernia repairs can be a challenging surgical problem, even for experienced surgeons. During MedStar Georgetown University Hospital’s Abdominal Wall Reconstruction 2021 Conference, Jeffrey A. Blatnik, MD, noted several tips and tricks for avoiding errors when performing these complex procedures. According to Dr. Blatnik, an associate professor of surgery at Washington University in St. Louis, the most important step is to understand the limits of the hernia, the patient and the hospital, respectively, before the procedure. This means considering the patient’s age, medical conditions, the size of the hernia, complications from prior operations and several other factors. “Having these limitations in the back of your mind when you start to evaluate complex hernia patients can help you avoid making the first error of operating on somebody that you or your facility lack the resources to take care of,” Dr. Blatnik said. Dr. Blatnik shared the following clinical pearls:
Getting Access Surgeons should develop a plan to get that can easily peel away. I will into the abdomen by studying the CT Closing the Posterior Sheath scan and abdomen. Previous repairs and not compromise the abdominal the presence of old mesh are complicatFor patients with a straightforward wall to remove every centimeter, ing factors for hernia repair. midline hernia without a hernia repair “I try to get into the abdomen away especially if I’m not there for history, closing the posterior sheath from previous surgery,” said Dr. Blatnik, can be a straightforward process. For infection. Take care of unnecessary who noted that this is primarily done many patients, however, this part of via sharp dissection. “I use a scalpel to damage to the abdominal wall.’ the surgery may require creativity. feel the fibers of the old mesh as I divide For a posterior sheath that won’t —Jeffrey A. Blatnik, MD them, and I like to open the entire midclose, Dr. Blatnik advised getting latline before dissecting out laterally.” eral and saving the part with the greatWith respect to lysis of adhesions, Dr. Blatnik recommended est tension for last. By removing the safety towel at that point, “finding a plane out lateral and circling back.” He also advised some of the tension can be relieved. “It’s also important not to “staying on the bowel side of things” to avoid inadvertently mobi- rely on suture to pull the edges together, and if it still won’t close, lizing the colon or injuring the peritoneum. then patch,” he said. Dr. Blatnik also recommended using omentum for small holes Dealing With Old Mesh and absorbable mesh for larger holes. Lateral holes in the posteOld hernia mesh is not only incredibly painful for patients but rior sheath should be closed transversely to avoid additional midis the greatest predictive factor of challenges. Dr. Blatnik recom- line tension. mended dividing the mesh down the middle while opening the Closing the Fascia abdomen and then freeing underlying adhesions first. “When removing old mesh, the lateral edge of old mesh is key,” Run primarily with long-term absorbable suture. As the tenhe said. “If the mesh ends medial to linea semilunaris, you can sion increases, however, surgeons should transition to figure 8 usually salvage the posterior sheath. If it ends lateral to the linea sutures, and if there is a big lateral defect from a transverse incisemilunaris, however, you’re going to lose some peritoneum.” sion, a barbed suture is recommended. Dr. Blatnik also advised Dr. Blatnik advised leaving old mesh in position while doing a keeping an eye on airway pressures as the fascia is closed. release and removing it at the end. He also suggested using land“Ultimately, do everything you can to preserve the peritonemarks, such as tacks or sutures, when working around old mesh um,” Dr. Blatnik concluded. “And when the going gets tough, get ■ to mark borders. lateral and work your way back to the midline.” 20
OR Management News • Volume 16 • December 2021
