Behind the Knife ABSITE 2025 - Hernias

(upbeat music) Welcome to Behind the Knife, AppSight Review 2025. Be sure to check out our brand new Free Study 8, which includes all 32 review episodes, brief written summaries, high yield images, and flashcards. Simply create an account on our website or app, and you will find the entire course in your library. And don't forget our AppSight Review book, available on Amazon. Dominate the day, and dominate AppSight. - Hi, all your BTK fans, it's Scott here, and Behind the Knife is proud to collaborate with MedTronic to support the future of hernia care. For almost 40 years, MedTronic has partnered with surgeons to develop and pine your products that support your clinical outcomes and surgical preferences. MedTronic's approach has been focused on providing surgeons with choice. From polyester to polypropylene mesh, permanent to absorbable fixation, open, laparoscopic, and robotic techniques. For MedTronic, it's all about choice. By offering a dedicated team who are focused and trained on hernia repair, MedTronic can offer value-add, consultive support to surgeons regardless of their purchasing decisions. Learn more about Transorb, self-cripping, resorbable mesh, max-tack, motorized fixation device, and the rest of their portfolio on MedTronic.com. - Okay, and we're here with Behind the Knife's Ab site review. It's the topic today is hernia. So let's just go with some basic principles. So John, when we talk about the basic principles that we always ask medical students, what is a basic principle of a good hernia repair? What do we always talk about? - Yeah, the obvious answer to that is attention-free repair. - Exactly, we're always going for that attention-free repair. We're gonna talk about a few tactics we use to get that attention-free repair. But when it comes to recurrences, Kevin, so what's the most common cause of a recurrence of any type of hernia? - I believe it's wound infection. - Yeah, yeah, that's an easy answer on the outside if they ask you what's the most common condition that leads to a hernia recurrence, it's wound infection. So we all know hernia's lead to bowel obstructions. It's the second most common cause in the United States. Of course, next to it, occasions, 'cause we have a lot of people that have surgery in the United States, worldwide, however, hernias can lead, are the number one cause of small bowel obstructions. So let's get a little bit into anatomy. So, John, when we talk about hernias, especially abdominal wall hernias, it's important for us to understand the different layers of the abdominal wall. So can you just walk us through the body, starting from the outside, superficial, and going deep, the layers of the abdominal wall, and let's say just right off the midline. - Yeah, there's a great picture in our book regarding this, but if you're gonna go from skin to deep, it'll be skin, subcute fat, or a campus fascia, scarpless fascia, anterior rectus sheet, rectus muscle, posterior rectus sheet, pre-paratoneal fat, and finally paratoneum. - Yeah, so again, yeah, great reference to the image in the book, it has all those layers. That's gonna be really important to really intimately understand that anatomy and how we can exploit those different layers when it comes to herniar repair. And that's a lot of questions actually on the outside, is which layer do you divide when you're doing this component separation versus that component separation? So make sure you have that down cold. Going out a little bit laterally. So John walked us through, going through the rectus sheet. Kevin, how about if we're lateral to the rectus sheet? What are the layers there? - Yeah, it starts the same, but it changes a little bit, and you start with the skin, and then you go through subcutaneous fat or campus fascia. Then you go through scarpless fascia, then you go through the external oblique, then the internal oblique, then the transversus abdominis, then the transversal fascia, then the pre-paratoneal fat, then the paratoneum. - Yeah, that's good. So again, you ought to know these layers down cold, and be really familiar with the abdominal wall anatomy, because those different layers can be very important when we talk about our different types of abdominal wall reconstructions as to which layers that we can exploit. So back immediately, John, we walked us through the layers. Where did that transition? So you were walking us through the rectus sheet, probably a little bit higher up on the abdomen. Where does that posterior rectus sheet end? - Yeah, and it's a good landmark. So I always use the umbilicus, and you go about the third of the distance between the umbilicus and the pubic if it's syphysis, which is known as the arquivine. - Yeah, so at that arquivine, all layers of the rectus sheet pass anterior to the rectus sheet, and that becomes important when we start talking about our extra paratoneal repairs, our taps, we exploit that space in our minimally invasive hernia repairs, as well as it's important to know when we talk about doing our posterior component separations and our tarrs. And reality is a little bit more complicated than that. You're below that arquivine, you'll read some different things, whether that's just in that pre-paratoneal space, there's your transversal's fascia, which actually has two layers, a parietal and visceral layer that you can exploit and sometimes split those layers. But just to keep it simple, below the arquivine, all layers of the rectus sheet pass anterior to the rectus muscle. Kevin, so what's the blood supply to the rectus, here at Vascular Surgeon? What are the vessels that supply the rectus muscle? - Well, you know I love a good blood vessel, and so the blood supply to the rectus is the inferior and superior epigastric vessels. And where do those vessels come off of? So we encounter the inferior epigastric a lot in vascular surgery when we're exposing the common femoral artery. It differentiates the external iliac from the common femoral artery. You'll see that the superior extent of the common femoral artery. And then the superior epigastric arteries are the continuation of the inferior mammary coming off of the subplating arteries. - All right, well, I'm excited you did learn something with those ships. So John, go ahead, a favorite question we like to ask medical school students is about Hasselbach's triangle. What are the borders? And what's the anatomy of a Hasselbach's triangle? - Yeah, it's almost impossible to really visualize this. And so unless you have a picture in front of you and somebody who's experienced with her knee repairs, you know, explaining it to you. But from a test point, the medial border is the rectus abdominis. The inferior border is the ingloral ligament, the lateral border of the epigastric vessels. And what all this means is that if you have a hernia within Hasselbach's triangle, that's a direct space hernia. - Okay, so you mentioned that inferior border being the ingloral ligament. Tell me a little bit more about the ingloral ligament. What anatomic structure is it continuous with? What abdominal wild air is it formed out of? - Yeah, clinically it's usually the ligament you can feel the easiest in that space. It's an extension of the external oblique fascia. - Yeah, great. So your retrial oblique fascia comes on and it's got its insertion sides down on the surfaces and the ASIS. So it's an extension of that external oblique fascia. That's kind of rolled over there inferiorly. And as Kevin mentioned, it's a very good anatomic landmark for your femoral artery as well in a clinical situation. So let's talk a little bit. Let's switch from the groin and talk a little bit more about the umbilicas. Another favorite spot for hernias. So our umbilicas is a natural weak spot where we can form hernias. And the reason for that is because there used to be a lot of embryologic structures that pass through the umbilicas. So let's go through some of those and what we're going to do is I'm going to tell you the structure that goes through the umbilicas and then you're going to tell us what it's clinical significant is as adults. So first, let's go for the jawn, umphalic mesenteric duct or the vitalin duct. What is a clinical significance in adults? - Yeah, that becomes the mechols diverticula where you can then developed mechols diverticulitis. - Yeah, so if you have an unobliterated umphalimusectoric ducts, you can have a little mechols, which is very common, can cause lots of problems. It can be, well, it can be asymptomatic most commonly, but it can cause problems bleeding obstruction, all the diverticulitis, as you mentioned, all those things. Kevin, what about the median umbilical ligament? - This becomes the ureacus. - Look, yeah, it can become a ureacus or a pain ureacus. I'm moving back to jawn, now then, immediately all with an L unbilical ligament. What is that? - Yep, those are your obliterated umbilical arteries. - Okay, and what about the, what is the round ligaments of the liver, the ligamentum terescap, and what is that a bremnet of? - It's a remnant of the obliterated umbilical vein. - Okay, so as I mentioned, all the stuff at one point traveled through your umbilicus, leaving that natural space where you could either congenitally or acquire a defect in a hernia there. - When do all those structures are the midgut rather, herniate through that umbilicus during development and when does it return jawn? - Yeah, it really takes you back, but the midgut herniates at six weeks in developmental period, and then it returns at 10 weeks. - Okay, right, so the midgut during the embryologic developments, I know everybody loves embryology, is it herniates through six weeks and then returns typically at 10 weeks. What if that fails in that process? There's some abdominal wall defects. What are those, Kevin, and how do you differentiate those? - Yeah, I'm gonna take this one. So, the emphalus seal, the way you kind of determine the difference between the two, and this is what for test-taking purposes, the emphalus seal is a defect within the umbilical stock, within the umbilical ring. So, it herniates through the umbilical stock. A gashoschesis is to the inferior or to the right of the umbilical. And, Kevin, which one of those is more associated with birth defects? - Yeah, that's the emphalus seal, great. - Okay, so let's go on to some different types of meshes. It's really important to be familiar with meshes. It's something you don't often think about as a resident, but I tell you what, the first day a staff here fix an urni on yourself, you'll be happy to spend some time reviewing what types of meshes to use in different situations. The thing to remember is there really is no one-size-fits-all. So, meshes pass to be tailored based on what anatomic location you're wanting to put it in, what layer of that abdominal wall is that we talked about. What type of repair you needed? How big is the urni? Some different patient factors. There are some general, there's a lot of different brands out there. It's honestly hard to get information on meshes because a lot of the data is proprietary, so it can be very confusing. It's helpful to break it down as some general categories of meshes, so Kevin, what are the big main categories of meshes? And how do you distinguish between those? Yeah, so you can think of it really as synthetic and biologic, and then there's a whole bunch of variations of synthetic. And so you have the absorbable and partially absorbable. So first you have your non-absorbable synthetic. So this is your polypropylene or polyester kind of permanent mesh. Then you have your non-absorbable synthetic with a barrier. So it's the same thing, but with a polyester mesh with a collagen barrier. So this has the extra barrier to prevent adhesions. Then you have your partially absorbable synthetic. So this is polypropylene with PDS polymer matrix. And then you have your biosynthetic, which is a biodegradable polymer, and then you have your full biologic, which is an acelular porcine dermis. Yeah, so depending on what type of repair, how long you want the mesh to be there, how long you want to stick around. If you want it to be permanent, where you're putting it, how much tensile strength you need, you're gonna, those are your big categories, and you can really, again, tailor it to your individual patient in individual situation. So the mesh material, the pore size, whether it's macroporesis versus microporesis, the weight. This is all going to affect its bioreactivity and how it behaves in the body. So it's really important to understand those characteristics when you're choosing a mesh for a hernium. So for all comers, you're really your go-to mesh is gonna be your light and medium weight, macroporesis, polypropylene, or polyester mesh. So a synthetic permanent, light to medium weight, macroporesis mesh is gonna be your go-to for most circumstances. Now, the caveat being, if you need to know what layer you're putting in. So if it's extra peritoneal, an uncoated mesh is generally what you're going for. If it's intraperitoneal, you want that barrier to prevent adhesions as Kevin alluded to. So, John, let's say you were dealing with a stringulated bowel in a contaminated field. So big obese patient comes in, a smoker, has a bowel obstruction and dead bowel in a hernium. What are you going to, what kind of mesh are you gonna go for there? - Yeah, I think this is, you know, talked about a lot and it's been a lot of different studies on this. So it's a relative contraindication for the use of synthetic mesh. Now, what the newer mesh developments is the light weights and macropores and polypropylene meshes. You could consider it, especially if it's not extremely contaminated field. But most people would just go to using a biologic mesh. - I still think that's a safe answer on the boards. You know, there is, as you mentioned to some data, recent data, rosins data coming out using synthetic mesh in the contaminated fields. But there are some nuances to that data, you know, getting that minimally contaminated versus grossly contaminated, you should try to get that mesh outside of the peritoneal. You know, for the boards, I would still stick with the safest answer, which is using a biologic mesh in those contaminated fields. Okay, so Kevin, moving back now that we've understand our mesh is, let's talk about some different types of hernias. So, umbilical hernias. Tell me a little bit about umbilical hernias. - Yes, so these are usually congenital. Most of them in pediatrics go away on their own, but sometimes they can persist or sometimes they can, you know, become new hernias later in life. Well, how do you, so, what's usually in most commonly, what's the contents of these small and dolcal hernias, and then what are your different repair options? - Yeah, so for the most part, it's just pre-peritoneal fat that's protruding through these and dolcal hernias. And as far as repair options, you have a lot of different repair options, but in generally of the open versus laparoscopic, and if it's a small one less than a centimeter, you can consider a primary repair or if it's a pediatric patient that generally do the primary repair. - Yeah, so that's an important thing there. For pediatric patients, generally try and avoid putting mesh in, so usually primary repairs. For these very small and billed hernias, less than a centimeter, you know, less than your index finger, you can get away with a primary repair. You know, I think we've seen, especially in American population, as patients are getting more and more obese, we see these small and billed hernias becoming problematic and growing and becoming to the point where they even need abdominal wall reconstructions after pre-habilitation. So they can be pretty problematic, but this just goes back to, you really gotta know what the size of the hernia, those different layers that you're dealing with and how to best approach those, but there's a lot of options. You talked a little bit about pediatric and billed hernias, so expand on that a little bit. You said most of them will close spontaneously? - Yeah, the vast majority of them, and so wouldn't you repair them then? - So it's hard to convince parents of this, but you really have to just watch and wait until about five years old, 'cause most of them will close. - So yeah, okay, so you said at least five years old or right about their time there about to go to school, they're persistent, you should probably fix those and I would agree with that. You know, John, a favorite question for boards and a challenging clinical scenario in real life is your serotics with umbilical hernias. So let's talk a little bit about that. So we know that 20% of patients with cirrhosis will develop umbilical hernias, and there's a lot of reasons for that. And these patients tend to be not the best operative candidates and have poor nutrition. They have a high rate of rapid enlargements and a high rate of complications to include incarceration, evisceration, wound breakdown with the sideys drainage, parents anditis. How do you approach these patients? - Yeah, this is a clinical question that, you know, I didn't think I would be facing as much, but it's definitely a hard problem to deal with. But in general, if a patient has advanced serosis and is a transplant candidate and is gonna get the transplant soon, you just repair the herniat of the transplant. However, if the transplant is gonna be out three to six months, you know, around that time, it should be repaired electably. The goal in general with dealing with these umbilical hernias is to control the asideys and try to optimize them medically the best you can to make sure that your herniar repair works and also doesn't as an explosive sideys within the abdomen. - Yeah, so yeah, I would agree with that. So, you know, I think ideally, even if they're not necessarily good to get a transplant, I think a lot of times these patients are best managed in transplant centers, just 'cause they have the infrastructure and the ancillary services to medically optimize that patient. So, the key there, what you mentioned, was getting that asideys under control. So, Maxwell medical control asideys. So, how about when you go to repair that herniat, what are some tips and tricks there? - Yeah, it depends on the patient's clinical scenario. So, if they are producing lots of asideys, you wanna, you know, drain them and do a pair of synthesis, you know, before and after. And also do them routinely afterwards to try to do the best work of getting, to make sure that herniar repair is not, is being exposed to significant amount of asideys. - Yeah, so controlling the asideys postoperatively is very important. You need to make sure that you're closing all layers, including the parts in the M, and really get a good closure to protect that wound. You'll hear some people talk about leaving drains versus not leaving drains. In general, on the board, I would try not to leave drains and then opt for serial, a pair of synthesis postoperatively to control the asideys. In addition to all the medical management of the asideys that you can do. Now, let's say that you're in a situation where you do have that skin breakdown and you have a leaking umbilical wounds. That's a little bit different than that electric repair. So, how do you approach that? - Yeah, this should raise some, you know, red flags when you see this on a test question because this isn't just approaching a herniat this point. You have to now kind of switch to like a resuscitation and managing an infection situation. So, you would start resuscitation, you know, IV fluids, and you'd also start antibiotics, and then this also now triggers an urgent repair. Additionally, the difference is, you know, you could push mesh in a patient to getting an elective repair, but you wanna avoid mesh in the circumstances due to the infection risk. You have to assume that if they are leaking from the umbilical wound, that asideys inside their abdomen is exposed to the external environment and is infected. This also requires aggressive postoperative asideys management. They are higher risks than even the elective repair. And once again, that includes serial paracetesis and diuretics. And this helps avoid your wound complications dehiscence. And unfortunately, just based on this patient being a serotic and having a sideys and having now a new infection, this places them a pretty high mortality rate. - Yeah, unfortunately, it's not a fun situation. I think we've all probably been in these situations and they're certainly not fun. And at the end of the day, you're just trying to get that patient out of dodge so that they can live and fight another day. So let's move on to something that is more manageable and that's in little Arneas. So Kevin, what is the, again, we like to ask med students, what's the difference between a direct and an indirect Arnea and how do you distinguish the two? - Yeah, to keep it simple, an indirect is a lateral to the inferior epigastric vessels, whereas a direct is a medial to the inferior epigastric vessels. Again, yeah, so like we mentioned before, that direct is through that house box triangle, a medial to those inferior epigastric vessels. What's the, John, etiology of an indirect Arneo? - Yeah, most of the time, these are congenital. It's also the Arneed C, typically a younger population. And by congenital, I made a patent processes for that vaginalis. - Yeah, okay, how about direct Kevin? - So this is acquired through weakness in the floor of being a little bit out, okay? But what predisposes people to form direct or acquired Arneas, John? - Yeah, it's basically the same stuff you put your risk for everything. It's obesity, smoking, poor nutrition, ascites, anything that would increase your abdominal pressure. - Yeah, unfortunately, it's also all the things that increase your chance of a recurrence. So it's all the things you don't want your Arnea patient to have is the reason why they have Arne in the first place. So you can be pretty challenging, and this is why the concept of prehabilitation has become so important when it comes to Arnea repairs. Back to the basics, though, Kevin, the spramatic cord. What this travels through Arnea will canal in men at least. So what are the contents of the spramatic cord? - Yeah, so you have your cremest eric muscles, your testicular artery, your vas deferens, your pamphorum plexus, your ilioingonal nerve, and the genital branch of the genital femoral nerve. - So yeah, that's an important, just identified and know those structures and know they go through the Anglea canal again. Where we're going for that low hanging fruit, those easy answers on the abseides, and you make it lucky with some of those. Well, what about the cremester muscles, the cremester muscles, that is. What are, what abdominal wallayer forms those cremester muscles, John? - Yeah, that's the extension of your internal oblique muscle fibers. As a reminder, for your angle of ligament, is formed from the extension of your external oblique. So we need to be careful with these. One of the more common complications of Arnea repair is chronic pain afterwards, so that it's important to know the nerves. Well, we're talking about an open inguinal artery repair, Kevin. What are the key nerves that we need to have an understanding of where they're at? - Yeah, so there's a couple of them, and that's the ilioingonal nerve, the genital branch of the genital femoral nerve, the iliohypogasic. - And which of those is the most commonly injured during an open inguinal artery repair? - Yeah, definitely the ilioingonal nerve. - Yeah, so you need to watch for that, you have passes right underneath that external oblique when you're opening that external oblique, identify that. Some people routinely divide it, some people will selectively divide it, some people try to preserve it at all costs, but just be aware that it's there and watch for either injury or get incorporated into the mesh, which can lead to some problems with post-opened pain. How about laparoscopic or a robotic hernia repair, a minimally invasive? What is the nerve situation there, John, and which ones can get injured? - Yeah, this is everything lateral to include the lateral femoral contiguous nerve. That's your triangle pain and usually it occurs to inappropriately placed tack or if you dissect out too laterally during your inguinal repairs. - Yeah, absolutely, I'm always harping on the resonance that are laterally doing those minimally invasive repairs to stay right on the parrots of knee and not dig into that lateral abdominal wall, avoid putting any attacks, avoid thermal, using thermal energy out there just to avoid injuries to those nerves that can be quite a problem post-operatively. Switching back to opening wall hernia repairs, there's the tried and true, a lot of different named hernia repairs. Let's just quickly go through what those are and what you're so into what? 'Cause again, we want to pick up those easy points on the upside. So Kevin, you're classic, the cine tissue repair. What are you so into what? - So this is the conjoined tendon, which is a mix of the transversalis and the internal oblique and you sew that to the inguinal ligament. - Great, conjointended and guinoligment. John, the one we don't see often is the sholdice tissue repair, we're seeing less and less of them. - Yeah, you don't see them as much. A lot of people, if you're doing tissue repairs, we'll do some sort of like modified sholdice, but it's similar to the BC repair, but it's closed in four layers. So once again, sewing the conjoint tendon to the inguinal ligament, not in two layers, but in four layers. - Yeah, yeah. Honestly, don't worry, don't stress too much about the four layers of a sholdice repair. You're not gonna get asked on the upside. Kevin, but lichtenstein repair. - Okay, yes, the lichtenstein repair, that's the more classic mesh repair. And so you sew to the inguinal ligament, and then the mesh also is sewn to the conjoined tendon and slash transversalis. - Yeah, so this is our first, really kind of tension-free repair. It's kind of interesting, if I could go off on a little bit of a tangent, that we started using mesh in order to decrease pain in a hernia repair from the tension, and now all you do when you turn off a TV as you see, the lawyers threatening to sue for pain after a mesh repair. And the reality, the pain we would be seeing after inguinal are your repairs would be a lot more if we work as a mesh than if we were, but that's the medical legal system for you. So John, how about a plug-and-patch? What does that mean? - Yeah, the plug-and-patch is kind of my favorite term. It's a very simple term for a very simple procedure, but basically you're taking lichtenstein repair and doing a normal mesh placement and putting a plug inside the internal ring that would theoretically scar down and prevent anything from coming back up in it. - Yeah, it might be your favorite one to say, it's my least favorite one to see. Also kind of falling out of favor. What you'll see sometimes are these plugs turned into these meshamas. And I see them a lot of recurrent hernias where I have to go and dig these plugs out of that internal ring and it is not fun. So it is still done, but also falling out of favor, thankfully, Kevin, how about the pediatric repairs? What's some just broad strokes, basic principle of a pediatric ingloria repair? - Yeah, this always blew my mind. You just do a high ligation of the sac. - Yeah, high ligation of the sac. And when you think about it, it's congenital from that process of vaginalis so you just closing that off. The ingloral floor really isn't the issue. So with, and again, as we mentioned, pediatric patients, you wanna avoid putting mesh in, 'cause pediatric patients grow mesh drinks that's usually not a good combination. And John, switching over now to outside of open repairs back into things that were probably more familiar with them this day and age, which is the minimally invasive laparoscopic robotic repair. What are our options for minimally invasive ingloria repairs? - Yeah, and that's also my preferred way of dealing with ingloral femoral hernias, and I'll tell you why. So there's two different types of repairs. So you have your total extra parotinial repair, also known as your tap. And you have your trans abdominal pre-parotinial repair known as the tap. And now it goes for both laparoscopic and robotic. The benefits of this approach is that it covers not just the indirect and direct space, but it also covers the femoral spaces, 'cause you can see everything in place mesh from the inside. - Yeah, me too, it's my favorite, 'cause again, you can look at all those spaces, you cover all those spaces with a nice big piece of mesh overlap, it makes it dummy proof. I don't have to think about what are the four different layers of this old ash repair. It's the same operation for every little hernia. How about in a laparoscopic repair, we talked a little bit about avoiding laterally. So where do you fixate the mesh? - The main point of fixation is Cooper's ligament, and that's immediately. And then you would fixate the mesh. If there's multiple different ways of doing fixation, but if you're using attacking or you're sewing it in, it'd be Cooper's ligament and then maybe the abdominal wall. - Yeah, there's a lot of options for this now. More and more, we're going to a minimal fixation. So at most, one or two points of fixation there immediately, there's self-fixating meshes, there's fiber and glues that people are using, and the trend is rightfully so to less and less fixation, which I think does have an effect on post-operative pain. You know, I think we mentioned this earlier, a little bit, you know, triangle pain, triangle of doom. What in where, let's do the triangle of doom first. What in where is a triangle of doom? - Yeah, so this contains the Iliac vessels, and then medially with the apex at the Iliopubic track, and is bounded by the vas deferens medially in spermatic vessels laterally. - Okay, and how about the job of the triangle of pain? - Yeah, that's that portion out laterally where it contains all your nerve structures. It's lateral, if you're looking inside, it's lateral to this dramatic vessels of below the Iliopubic track. - Okay, let's talk briefly about femoral hernias. We were just talking about tingle hernias. Like I said, I'm a minimally invasive surgeon, so it's kind of all the same to me when I go to my minimally invasive repair, but there are some distinctions in regard to the patient and things you have to think about. So John, who's at the highest risk for femoral hernias? - Yeah, the classic test questions for this, so you have to look out for the female patients and in the elderly. - Yeah, so women are more at risk for femoral hernias. Now, be careful, because in women, still the most common growing hernia is an inguinal hernia, yet they are higher risk than men of femoral hernias. So a little bit of, can be a little bit confusing there, so just make sure you have that straight. Kevin, where is the actual defect in a femoral hernia? - So this is below the inguinal ligament and medial to the femoral vein. - Yeah, so it goes below that inguinal ligament. So that will affect things when you go to do an open repair. So how is that different than your, why won't your Bessini repair work with that, John? And what do you do in an open repair? - Yeah, in an open repair, it's also known as the McVey repair, a Cooper's repair, is that the difference is that you have to open the inguinal floor and you have to close the space by suturing the conjoing tendon to Cooper's ligament. - Yeah, so don't say, especially if you're in an oral board scenario, be careful. If you have a femoral hernia, you gotta do that McVey, Cooper's repair, your Bessini is not gonna cut it, because that defect again is below the inguinal ligament. Okay, that's enough about femoral hernias. It's something more rare, but you still see, and it's kind of fun, is the obturator hernia. So what is an obturator hernia, Kevin? - So this is a herniation through the weakness in the obturator membrane. - How does it present? What kind of patients do you see this in? - So generally, this is in thin elderly patients that present with the bowel obstruction. - Right, yeah, usually very thin elderly patients coming with a bowel obstruction. And what kind of things, John, might you see? It's difficult on physical exam, unlike other hernias. So what might you see on physical exam? - Yeah, that's the classic howship rhomburg sign. And this is shown with grine or thigh pain with internal rotation of the hip. And it's present about 50% of the time when patients present with obturator hernias. - Yeah, so it's kind of a cool thing, but it's not reliable, as you say, it's present about 50% of the time. I mean, really, and this is the 2020s, your CT scan is gonna be the way you diagnose these. It does have a high morbidity and mortality. Again, that's mostly related to the patient population. As we said, these are often elderly thin, often malnourished individuals, and they do have a tendency to strangulate. So how do you approach these, Kevin? What would you do if they, like, calls you, I don't know why they'd be calling you, as a vascular surgeon, but let's say that they did call you as a little lady who's got an incarcerated bowel obstruction with an obturator hernias on the CT scan. - Yeah, so you have to take these patients to the OR fast. You need early surgical exploration and reduction is required. Sometimes you need to actually incise the membrane to reduce the incarcerated bowel. And what are your options for? So let's say you take them, you reduce it. You know, you can do this either open or minimally invasive, but now you're staring at this whole down in the obturator foramen, how you what are you gonna do with that? - So generally you can repair this primarily with permanent suture, and you can plug the defect with the round ligament or the medial umbilical ligament. - Yeah, so it's difficult, it's a difficult spot to get to. This is, I think, an advantage of that laparoscopic or robotic repairs, you can get down there, I'll regularly visualize the obturator canal when I'm doing my minimally invasive inglomor hernias. There's not a lot to sew to, so it can be a little challenging, especially when the tissues are very thin. And you obviously have some vessels and nerves that travel through that that you have to be careful not to tag. So you have to get a little bit creative. Using those structures you mentioned, either the round ligament or the medial umbilical ligaments to patch our good options. You can cover with mesh, although it can be challenging for mesh fixation in that area, but it's certainly an option, okay. So you'll see them at some point in your career, they're rare, so it's good to think it through and you certainly might see it on the outside. So moving on from there, lumbar hernias, another rare but sometimes seen hernias. What are the different types of lumbar hernias, John? - Yeah, there's two types, the green felt and the petite hernias. The green felt, the landmarks for this is bordered by the 12th rib, the paraspyle muscles and the internal bleak. I'm regarding the petite. This one is bordered by the lat dorsai, the iliac crest and the external bleak muscle. - Okay, great, Kevin, diastasis recti. This is something we see on a daily basis that referred to the general sort of clinic. What is this and how do you approach it? - Yeah, I see lots of influencers on Instagram telling you how to fix this. So this is a weakening and widening of the lignia alba, so it's not a true hernia. And there's no risk of incarceration or strangulation and repair is not required. Plication can be performed, but it's mainly cosmetic. - Yeah, so we see this a lot again. It's just a widening of that lignia alba. The initial treatment is physical therapy. There are exercise programs that are bordered as dined to improve the abdominal wall function and improve these. But the caveat I would be is if you have a combined diastasis with a ventral or umbilical hernia, there is evidence that there's a higher rate of recurrence of the hernia. If you don't, plyche the diastasis at the time of the repair. And there's a number of options that are becoming more and more available, minimally invasive, etep, that type of thing for addressing these diastasis recti, but for the most part, and what's likely going to be the answer on the upside is patient reassurance. Because these aren't true hernias. There's no risk of incarceration or strangulation. Okay, so moving on to ventral and incisional hernias. It's a very broad topic. It's something that's gonna be very difficult. But let's just try and hit some high points that might help us out on the upside. So John, risk factors for an incisional hernia. We mentioned some earlier, but let's go over more. - Yeah, these are the same as always. It's the wound infections, obesity, COPD, and most commonly, but you'll see on test that ain't a real life is smoking. - Yeah, great. So again, it's all the things you definitely do not want your hernia patient to have or be doing, and it sets them up for a recurrence. It is also what sets them up for having or hernia in the first place. That's why in recent years, this idea of prehabilitation has become very crucial to having successful herniate outcomes. Number one, you need to get them to stop smoking prior to elective repair. You need them to lose weight. Oftentimes, I'm a bariatric surgeon. So I get a lot of hernia patients, or a lot of bariatric patients, rather in my herniac clinic, where we'll stage them, we'll do a bariatric procedure, and then after they lose weight, we will go and do a definitive repair of the hernia. It's that important that they lose weight and stop smoking. So if you get this patient with a BMI of 45, and as a smoker and a diabetic, on the exam, don't just rush to the operating room. You need to work on getting them ready, which sometimes can take up to a year or longer to get them ready for surgery. Kevin, what are your options for placing a mesh in these patients? - Yeah, very simplistically you have the options of an underlay, an inlay, or an onlay. - Yeah, you used to see, inlay, you used to see more, it's the highest risk of recurrence, usually inlay meshes, or if you do an inlay mesh, you're in a bad spot where you can't get things together and you're not in a good place to do a component of separation, and you're often those are temporizing procedures that will need to be addressed down the road. It's a very high risk of recurrence. But in general, underlay, onlay, as we talked about, there's different layers that you can exploit to get that mesh outside of the paratonea versus putting an intraparatoneal, what we talked about before, you kind of go to meshes, are your light and medium weight macroporis, polypropylene or polyester synthetic meshes for width or without a barrier for most situations. So John, what if you're in the situation where you have a very large hernia, and let's say that the patient's been optimized, we did a sleeve on them, there got their BMI down to 29. They're not smoking, we've considered them optimized for surgery, but still you have a large, 12-centimeter defect, and you're not gonna be able to get that together, what are your options? - Yeah, I hope you figured this out. Prior to go to the operating room and planning purposes, and there's a lot of different criteria you can use to determine if you're gonna need to do this or not. But the basis is a component separation, and there's a couple different types of variations that are regard to different types of layers that are sized where you place your mesh and different approaches. - Yes, let's just go through those. And again, like you mentioned earlier, refer to that in the companion book, there's a great image that has the different layers, and it actually has what you insize for these different separation, so let's go through that. 'Cause a lot of times this will be the question on the outside, is what layer do you insize with, say, anterior component separation, so John? And an anterior component separation, what layer are you insizing? - Yeah, you're insizing the external oblique. - Okay, how about a posterior component separation, you know, let's say a retro-reptus repair? - Yep, you insize the posterior rectus sheath, and then place the mesh in the behind the rectus muscle. - Yeah, so you're insizing that, you're developing that retro-reptus space. Again, there's ways to do that minimally invasive versus open, but the principles are the same, and you're blaming that mesh in that retro-reptus space. Now, how about a posterior component separation with a transversus abdominis release? - Yep, also known as a targ, but this is where you insize the transversus abdominis. - Yeah, okay, great. So the targ, you're entering that retro-reptus space, you're developing that retro-reptus space, and then laterally just medial to those neurovascular bundles, you're gonna insize that transversus abdominis and release that transversus abdominis muscle and develop that space. You give you a nice big mesh overlap, a nice visceral sac to cover your viscera and protect your bowels from that mesh. You know, typically when we talk about sizing mesh in what area we're gonna need to exploit, my general rule of thumb and what I use is I take the size of the defect and I add 10 to it. So, you know, you have a 10-centimeter defect, you're gonna need a 20, at least a 20 centimeter mesh, whether or not you can put that in the retro-reptus space where you need to develop that tar plane that is based on the patient's anatomy. So, you know, we know that your transversus abdominis release is able to achieve as much faster release as an anterior component separation. However, the advantage is that you have fewer wound complications 'cause you're not raising those big skin flaps. So the tar has become really the preferred approach and the anterior component separation has fallen a bit out of favor. But there are still certainly in circumstances where you would need to do an anterior component separation. All right, so given a lot of work has gone into figuring out what the optimal sutra closure method is, different types of suture, how big of bites. So, and this goes into your primary closure of your laparotomy is in addition to your hearty repairs, but what is an optimal sutra closure method? - Yeah, so generally you want small bites with an absorbable suture. So, five to seven millimeter bites and probably a slowly absorbed suture like PDS. - Yeah, great. A slowly absorbed suture, five to seven millimeter bites. You know, we mentioned minimally invasive versus open techniques for all this. There are good lapar robotic approaches that have been described and are done pretty routinely at this point with low wound work. And for a test taking, if you're sometimes you'll get forced to go to the OR for whatever reason and a patient who's obese. Just remember that minimally invasive approaches are preferred in obese populations and sometimes that's the principle they're getting at with those questions on the absite. Okay, so that wraps up our discussion of hernias as always, we're going to end with some quick hits. Are you guys ready? - Let's do it. - All right, so John, quick to it. Hernia that occurs at the junction of the semi-lunaris and the arculal line. - That's your Spagelian hernia. Or it also knows intramuscular hernia. - Yeah, so Spagelian hernia, these can be very difficult to diagnose on physical exam because that external bleak is intact. So the patients usually do not have a bulge. So if you have a patient that presents with classic symptoms, non-contrast CT can be very helpful in identifying these. There are a relatively high risk for incarceration. So if you do identify them, you should repair them. Okay, so Kevin, appendix in an ingotal hernia sack. What is that? - That's your amyon hernia and do a primary repair in appendicitis. - Yeah, so amyon hernia, and if you have appendicitis, within the appendix that's in the hernia defect, you obviously wanna, that's a contaminated field, so you wanna be careful with that. John, Mechel's diverticulum in a hernia, what's that called? - That's our elitres hernia, the trays hernia. Kevin, let's say your patient has both an indirect and a direct hernia, what's that called? - So that's your pantalune hernia. - John, what's a sliding hernia? And so what's unique, what's unique about it that you have to consider during your repair? - Yeah, that's your retroperitinial structure that makes up a portion of the sacks. You have to be careful not to open the sack during the repair of a sliding hernia. - Exactly, so an organ is making up some component of that hernia sacks, so if you're open to the hernia sack and you're doing an open repair, you very likely could open that retroperitinial structure that's an organ, so you definitely don't wanna do that. Kevin, a Richter's hernia? What's the significance of a Richter's hernia? Well, first off, what is it and what's the significance? - So part of the bowel wall, typically the anti-mesenteric border of the bowel is present in the hernia sack. And so this can present as strangulation without. - Great, John, we covered this briefly, but what's the most common hernia in females? - Yep, that's your indirecturnia. The femoral hernias are more common in women than in males, but the indirecturnia still remains the most common for both men and women. - Great, yeah, sometimes I could be tricky and they'll ask you that, and it's a trick question. It's definitely a trick question, so don't fall for it. - Okay, so Kevin, so let's say during an equal hearty repair and the skeletonization of the cord, you can't find a hernia, what do you do? - So in this situation, you need to open the floor and look for a femoral hernia. - Exactly, exactly, if it's not making sense, you need to look for a femoral hernia. Like we said, that femoral hernia travels under the equal ligament. It's not always apparent on physical exam and you don't always have imaging, and sometimes it's not clear on imaging either. So if you're not seeing that hernia sack, then look for that femoral hernia. - Okay, Kevin, child see serotic with massive societies and umbilical hernia with intermittent obstructive symptoms. What do you do? - So you do tips first to control the societies before considering an repair. - Excellent, yeah, we talked about the importance of controlling that side. He's absolutely essential, John. Well, aproscopic email harder repair and you tack the mesh to the Cooper's ligaments and you get pulsatile arterial bleeding. What happened? - No, I hate this thing. It's the corona mortis. It's the branch between the obtrator and the externally olieic artery. We should have been more careful, Kevin. Placing a suture during open and little hernia repair and you get sudden bleeding. Those dam veins, femoral vein injury. What do you do? - Future out and hold pressure. - Yep. - femoral vein injury, just pull the suture out. Don't tie it down or just gonna rip the vein open. Pull the suture out and hold pressure. It'll be okay. We stick needles into veins all the time and it's fine. John, groin pain, significant medial thigh pain with internal rotation of the hip. You mentioned this earlier, what is it? - Yeah, that's the rare obtrator hernia. And also the name is the obtrator side or the howship rhomburg side. - Exactly. As far as it only got about 50% of the time. Kevin, we have a patient's one month saspose and open and little hernia repair with a proline mesh. And now we have a wound infection and you have perioded fluted around the mesh. Well, what's the, what do you do? - Yeah, in this situation, you have to expand the mesh. - Yeah, I would say that's getting a little bit controversial. There are with the newer macroporous polypropylene meshes there are mesh salvage techniques. But if you have, you know, gross perioded pus coming out of your wounds and yeah, you're probably gonna do to explain that. Okay, John, so you have a young female with a minimally symptomatic umbilical hernia that she noticed during pregnancy. She does desire future pregnancies. What are you gonna recommend? - Yeah, I see at least one of these, probably every month in clinic, but you wanna talk to her and counsel her about deferring her hernia repair until after she's completed all plan pregnancies of possible. - Yeah, absolutely, especially if it's minimally symptomatic. You wanna defer that until they're done. - Okay, then you know how you repair and you can't reduce the sat, what do you do? - So you can wag your proximal portion and that will reduce it into the abdominal cavity. And then you keep the distal portion open to reduce the chances of a hydrosil. - Yeah, so the abandon the SAT technique, you can do this minimally invasive event that has good data that it turns out just fine. Okay, so I think that does it for our hernia app site review. So hopefully that'll be guys on the exam and until next time. - Thanks for listening and thank you to Medtronic for supporting surgical residents preparing for the 2025 app site. Since 1949, Medtronic has relentlessly pursued therapies that change his lives. Today we thank Medtronic for supporting surgical residents as they relentlessly pursue their dreams. From all of us up behind the knife and Medtronic, dominate the app site.