Chapters Transcript Live Recurrent Incisional Hernia Repair Dr. Sean P. Harbison, MD, MSEd, performs a recurrent incisional hernia repair live from Penn Presbyterian Medical center. we're going to be fixing a recurrent Incision of hernia on a female who is 82 years old and she has had numerous hernias from previous surgery. And this hernia has a bowel caught within the hernia. If you're looking here, you can see a big giant seemingly gaping wound. But it's really not a gaping wound. What we've done is we've taken what is called a panis, which is basically her role of fat. That's her belly button and we've taken it all off. And what dr fisher is doing now is he's raising a flat and that's the skin and the subcutaneous tissue. And we're heading up towards the patient's head and we're raising these flaps so we can close the abdomen without any tension later over here. If you see this is her hernia and this is um this is the hernia sac hernia sacks, like a bubble on an inner tube, if you will. It's a weak point in the strength lair. And at some point I believe she had a colostomy which would be here and that always breaks down because that's through her six pack muscle or her oblique muscles over on the side. I'm john fish from a plastic surgeon. I work at penn here with dr harvesting. I think what dr harvesting was saying, I think it's really, really important as it relates to doing a co surgery. That is a surgery with two different attending. So I'm a plastic surgeon Sean zah, a very busy general surgeon who has a diverse practice and we both, it takes a lot of complex harmonies and I think that we have very much synergistic skill sets. So we can tackle basically any hernia problem. I think that you'll kind of see that manifested today as we to have big horizontal incision. We removed several of our old scars and we repair multiple hernias of hers kind of together today. So to reduce a hernia means to essentially push it back now extrude these out of the top of your to what we're using Now, scholars is another type of stapler called to. It's for to be honest with you, it just lays down to can I have a curved mayo scissors? Don't do anything yet. This lays down two lines of staples. And you see, we've extruded this like a piece of, I don't know, glue. Elmer's glue at the one end. So below where I'm cutting, it's stapled and we've created get back in if you will, that's what dr fisher was talking about. Okay, let's go, oh, that looks so nice. Once you, once you reduce the hernia, scholars, then what you want to do is to provide a strength layer. Yeah. Well, the, that the to stapler that we placed. Um either he did it wrong, which I don't think we did, but that's always a possibility. Uh or it misfired. I have an Alice please. So I may be And that's nemesis longer. All right. No, I took it under. I want a 90. Yeah. Thanks. I didn't know you had one up. Oh, okay. I'll take another Alice while we're waiting. And then After you reduce the hernia. I know it's like five minutes on this question. Uh huh. Yeah. And very often I mean so you could just so the two sides of the strength letter together, whether that be muscle or fascia, you could so that together and put a mesh on top of it or underneath of it. Or if you can't get the strength layer together at all, you could just so a mesh right in the middle. Like what we call a bridge. And each of those have their benefits in their risks. They're good parts and bad parts. So the best hernia repair that's out there is um do put all of the strength player back where it should be. Put the muscles back where they should be. Um And then put a piece of mesh underneath. Like putting a patch on the inside of your tire is better than putting a patch on the outside of your tire. So that's what we're gonna attempt to do here is I don't know if you guys have to go and do other stuff, but we still have a ways to go because we're gonna raise some flaps and dr fisher is going to come and take over again and we're going to try to uh Right okay. Yeah, that's great. So there's your anastomosis there. Michael, please. Um When I was a resident. I did a neurosurgical procedure. I wasn't the main doctor of course. Um That lasted about 23 hours. Um And of course we took breaks and stuff. You can catch this little staple line. Great. Well you know the one doctor would be in here, you saw dr fisher just take a break. Um And he when I saw other patients and did other things and now he's going to come back and do the same thing scissors please. Mhm. Said one more. Yeah. Oh uh uh Go to the bathroom. Yes. I rarely I rarely ever would take a break. Even if it was like a six or an eight hour operation. I would probably stay there the whole time. And once you get engrossed in doing the operation. I mean time just flies by and you don't really get tired or you don't really notice if your feet are tired until afterwards. And then you know because you know your adrenaline is running high and you're very can have scissors please. You're very concerned about doing the the write operation and doing making the right decision for the patient. I have one more micro please. Thanks and a debate. Sure. That's not protected. Be careful. Right. Mhm. Okay. I'm not one of one question. I good. What? That's fine. Better. So a man I would say yes. Yeah. Those um those skills translate. Okay. Lots of irrigation can have a pool sucker john I think we're we're done. So you can see okay and pretty a sack is all mhm Yeah. The next. Yeah, it is. We'll take like five years ago. Corner. Yeah, this is nothing. Thanks. Yeah. Okay. This way, but I don't see anything. Mhm. Yeah. Uh huh. You man, this is, yeah. Mm hmm. Yeah. Good. There it is. And football is a whole of government. Yeah, I took that down and help me pull the servant. Mhm. Thank you. Hi Cron. Now we're I'm running into some old stuff here. It's old future material. That's the hernia sac and you can see that there's two holes here. Come visit me anymore. Yeah. Alright, irrigation please. Yeah. You know what you think about it? It's really, really good. I just can't talk about the tools. These so most of most surgical tools have names, economist names after famous surgeons, these instruments and hold it called Coker's ko ch Theodore. Coca is very famous for thyroid surgery. He was um burned Switzerland Back in the 1900s. There was no such thing as IOD I salt and graders were endemic. So tons of people got greater. So it was a very common operation to take a thyroid to do next surgery. He actually I think is I think there's seven insurgents who have ever won the Nobel prize could have some sponges. Yeah, yeah. Oh yeah. Um surgeons remember we're very much viewed upon as like as worker bees and we used to be the same level as barbers and in England nowadays, traditionally surgeons are called mister um because there were of a lower rank than the internal medicine doctors and now they took that as like a mark of of honor. Yeah. Right, correct. Mm. Mhm. So that's there on the abdominal wall. These coca and coca clamps. Another. Yeah. Yeah. We just want to wash everything out. Mm hmm. The solution to pollution is dilution when they come up with that. No, I'm not that original. You are that. Yeah. Yeah. All right. One more. Mhm cowl. Go ahead. Yeah. No, it's just after we did this bowel resection, we want to wash everything out. Um and then we will uh watch everything out and if I'm still here will change our gloves and Yeah. Years. Yeah. Has anyone? Yeah. Spiritually. Mm. Mhm. It's on the High court. Darya. Yes. Yeah, wow. Yeah. But they often, No. Yeah. Do you start off not being bothered by there? No, I guess a graphic part of medicine or does everybody kind of start off a little crazy about it and you just have to get used to it because we love studying at or is a little bit about um I think it's it's normal for you to be a little the first time you're in surgery. I think the first time I had to like sit down and I was like, oh my God, I don't know, blackout. Um But after that time it's it's it's interesting. Uh I think once you study a lot more medicine, whether it's textbooks or literally google pictures online um You get you get used to it. So yeah, the first time obviously no one should be expecting to just breathe through surgery as if it's it's a normal day but you'll you'll grow on it. The smell was something that I was alarmed about. I think that's probably why I got more nervous but particular smell it was like for the scholars who cannot. Yeah. Yeah. I think it was the kata riser and the smell of burning burning. No and if you do start off first day though are and it doesn't bother you at all. Does that mean you found your calling or that you should try something else? I hope that's not like that doesn't determine your decision for your career. I guess it is a positive sign that if you can withhold the strong smells. But yeah I mean if you can't stand it that's that's definitely a red flag because you're gonna have to get used to it. There's also other perspective, yeah medicine is not just burning in surgery. So ah pr well investigators he does radiosurgery on cancer so he rarely has to like make big incisions make that burning smell with Qatar risers but he still does, he technically still does brain surgery. It's just using radiotherapy. Mind expanding a little too somewhat a p. I. Is for the scholars. Yeah. So I mentioned P. I. Which is a principal investigator and that just means he's like my mentor for my research research generally ps will uh lead a research team with a common goal a common science. Uh And uh he specifically is an M. D. PhD which means MD. He's a medical doctor and he's also a peak uh did his research and did the destruction I think it was on brain cancer. So um he is able to do research that directly involves patients. And as an MD PhD he uh kind of do clinical china. So that's just another aspect of medicine when you're trying to do something on the frontier of a new science you can be an M. D. PhD. And that involves research and medicine to get, is it true that you don't have patients under anesthesia to operate most of brain surgery? I know sometimes and it's depicted closely and yeah the patients could be awake or at least just numbed locally but yeah um yeah so I pediatric neurosurgery and they I think they usually put them under um you know that I'm taking a lesion out of the brain. That's just that makes perfect speech or um how you move your fingers or your toes. Sometimes you need to be awake so they can test it like throughout the surgery. Um If you're making decision you want to make sure that that was the right incision and nothing else is impaired then you tell the patient, Hey, can you say this word or can you still speak spanish or basically french areas in your that coral is that you can So they just want to be able to test throughout surgery in case they can fix it right then. And there kind of like to come down here, yep. Yes, exactly. Time, yep. There's not a lot of areas of medicine when it comes to surgery. I guess you could do. Yeah, that's true. You have to send it to. Yeah. Mhm. Dr harvest. Just curious. I know because work do you work patients? We've talked about match and the present conserve it. Pretty large teeth. So whenever you get a chance, just the fellow in the scholars observed. Um Yeah, highlighted. Yeah. So, what um what we're doing now is we're making a flap. Tell me is creating a flap of the what we call a retro breakfast flap. And if you can see a way over here, there's muscle. It looks like meat because it is. And that's the hair rectus muscle. Um it's her six pack muscle that in the strength layer or are going uh in her posterior rectus sheath, which I'm shaking here is going down. Mhm. All right. Yeah. Yeah. Yeah. Okay. How you doing? We're working? We're doing uh may have gotten in the wrong clean a little bit there. We're ready for you, john Yeah. Okay. All right. I would go for some low hanging fruit. So there's a there's a couple of different designations of mesh. Um There's mesh that ah is man made and it's synthetic and it's made out of plastic or gortex or ah any combination of the above. You have a whole you're off there. How about that? And um Mhm. There's all kinds of different way where it's about to stop. Stop, stop, lift up the more you lift up the easier it gets. Yeah. There you go. Mhm. Yeah. No, that year. Yeah. A lot my feet are wet. Our security. Yeah. I don't think so. For a small valve, but I'm not against it. He has an aura gaster blended. Okay, We will. She's sticky right here. Okay. So there's synthetic mesh, which is can be plastic or gortex or something in it. It doesn't go away. Um The most common kind is probably Alice please. Type of plastic called polypropylene. I got a three minute, please. Yeah, correct. Yeah. Very common kind is blue and it's called pro lean. Mhm. Mhm. It's always been There you go. Keep it down. Right. Right. Sorry. I'm only half seeing what dr fisher is doing. And we're keep going. All right. Then. There's there's absorbable mesh and that goes away. Um And depending upon the kind of message takes either shorter or longer time to go away. The city has a direct honest very and absorbable mesh can be synthetic meaning man made. Like a man made future melts away. She has like no rectus. That I think this is the edge of directors coming. Let me get that back. Isn't really maybe not feels like the edge of itself. And then there's biologic mesh which is made out of college in to be the collagen of a pig. Uh huh. Which we call a loader because it's an aloe graft. It's not the same species. Um No, it took if I click it or somebody took it. And then there's also um So what suburbia? 30 The bottom one. Yeah. 39. Yeah. The there's one made out of human collagen just called zen matrix because it's a Xena graph. That's really sticky. Huh. Right. Yeah. Uh huh. There it is. There we go. Yeah. What do you mean? Nothing doesn't feel totally right about that. That's all. Well, batch of ask Tony companies are not writing up there. I agree with you, man. Yeah. Yeah. Okay. Just make something up. Yeah. Mhm. Uh Hold on. Yeah. What does this mean? That's good. Yeah. Just don't listen to that letter. Mhm saying this area. We start with the government a lot of this. That's the energy. Yeah. Yeah. Mhm. Yeah. This is just Mhm. And so scholars. We choose the mesh based upon what the clinical situation is and what we want the mesh to do. And sometimes we don't use mesh at all. That we all mhm. I honestly don't know what. Mhm. But if we can we think that the recurrence rate. Mm hmm. Is better if we Mhm. Kind of thing. If we do use mesh. Mhm mm hmm. Her behind red light around here. Uh Both because um mesh uh I can't mesh as his own strength. And it also causes a scar reaction around it. Which that adds intrinsic strength. Mhm. An additional strength. And it starts with you as a background. Yeah. Yeah. The scar tissue is has strength and it will help us to repair the hernia complex. Look. Do you really? I mean, I wouldn't say it if I didn't look at the look at the Yeah. Yeah. Just give me a sponge. A lateral edge. I thought you were trying to sell me that. This was the medial edge of it out here. I know I'm with you. It's not like you were right. Yeah. Okay. Now this is the harder side because we have two holes. Okay. Again. Yeah. Yeah. Got a body. Yeah, honey. Yeah, expert sure, shine it over to me please. I got one. That's analysis please. Right? Yeah, that's muscle there. I like that better. Good. Other Alice. Please. Very believing the linear album tonight. Here, Jason. You can see when the elbow stays up there then. Mr craig list. Right? The best fresh rose I find space sometimes. It's easier to know where it's a little less. Thanks. This is this record weird. Just that's the edge of it there. I decide is shorter for some reason. Oh, probably this. Huh? Could be peace. Oh, that maybe lateral to it. Yeah. I'm not totally sure. We're just going to respect that. Should don't you think? Sean? That's really yep, useless at this point that all it is. Let's please. Other Alice. Please. You don't really need it for tissue coverage. What's that honey? You don't need it for tissue coverage. Right. Thanks. She's just so kind of a lot. Is she paralyzed? Yeah. Yeah. Yeah. Go ahead. Hurt me tomorrow. See now, where are we relative to this deep? About 10 minutes. Yeah. Yeah. Mhm. Bring the whole rectus muscle up here. Okay. I'm impeding you tell me I knew you would anyway, but got a clip actually a All right. Uh huh. Yeah, we're right on it. If you have enough, maybe close it this way. And you know, I like that idea actually. What's the bow beyond 35 still. I want it on 35 weeks. Okay. Mhm. Yeah, fucking Yeah, man. Mhm. Got a Richardson. Mm hmm. Yeah. Mhm. Yeah. I always take it 1/2. I'm just gonna bust through. Mhm. I agree with your idea. Trying to close it. You had that plan last night when you're thinking about the All right. Just this morning. Get that Richardson. She has a so much, you know, scarring and oedema that Her rectus muscle or her six pack muscle scholars is like completely non existent on this side. Mm hmm. Is it my golden, I'm 35 now. Hey, get a good job. Thanks little bit. This It's weird looking. Yeah. Mhm. one of her past breakfast. That's very much possible. Yeah. Mhm. No. Uh you know, Okay. Just kind of pulling a little bit away. I've got inside the Yeah, trump was Mhm. Mhm. Yeah. Yeah. Yeah. When you start to light up the area, Yeah. You can keep an eye on now. Yeah. That's I think where I think you passed the rectus there. Yeah, I know. Mhm. Yeah, 100% with you. That's something. Yeah. Yeah. You know what? I want to go back? Well, he feels a lot hotter than 35. Yeah. Only uh It goes from 35. Talk to you right now for the record. Mhm. Yeah. Stop. Yeah. Yeah. Yeah. Oh no. Almost back up. You know, we need some three of aiko pops. Yeah. Oh my God, this call is different. Oh. Uh huh. Yeah. Few of the questions that our students were submitting. All right. And one was in response to sure make the comment that dr Harverson had made about there being muscle tissue missing. Is that something that it happens because of a certain condition? It just happens over time. Uh What would lead to that with this specific patient? She's had multiple previous surgeries and due to her diverticulitis. And she's also had um her main thing is her size. How wait. And with the previous surgery that can create some abdominal ventral hernia years. So that's that's the this specific patient, yep mm. Some of our scholars were wondering what the stages of the hernia repair because obviously this patient has undergone right phases of it. Okay. So yes, so Dr Harbison has done his part as far as freeing the bowels, making sure there's no adhesions. So Dr Harbison is mainly gi surgeon um specifically responsible for the patient's anatomy. Dr fisher is the plan now he's going to repair and um just making the journey earth uh reduce the hernia. So as far as where we're in the procedures that were done, hold on. We're pretty much at the home stretch now where we did the bowel resection. And so we're just going to do the repair parts for the hernia, yep. And what's the recovery for? Something like this for a patient? It sounded like she was in her eighties um is not going to be with her size and her age. That's that's definitely going to be considering considerable as far as time wise. So she'll have a longer stay, sometimes they stay upstairs in the hospital Up to three days. But um nowadays they do go home a lot faster. We try to get them out up and out of bed walking just to prevent any blood clots and and the embolus. So even with like um uh huh happened back to me, you can go home the same day now today. Yeah. I know that one of my teammates had I think her appendix removed, they had used a robot for that. I know we have had recordings of robotic surgeries. Is that something that both dr fisher and dr harvey as well dr harvey. So with plastic surgery, does that just require fewer robots with that stock? That's a few robots. More plastic surgery, it's more hands on. But definitely doctor harvesting has uh he has scheduled robotic cases um monthly, wow. Yeah. It sounds like you guys had a fleet of robots here at Penn presbyterian, is that correct? Absolutely. G. Y. N. Now, general surgery dr sam Logan after harvesting uh dr chorus um thoracic is now doing um robotic surgeries. Dr peck it. And of course um started off here at Penn with prostate david lee. He's done so many robotic cases and that's all he does is just robotic prostatectomy. Okay, sure. I'm like oh the scholars wondered of anesthesia that used a patient under paralyzed. So we're kind of wondering if that Not the norm 1st. Okay. No it's normal, it's just that sometimes the medicine tends to wear off and they just want to make sure you give more so every relax, wait. Mhm. So is it a for lack of a better term cocktail of things that get a patient to where she's you know in a state of I'm just next to operate like this one particular type of. Mhm. So perfect. Mhm best are messed her up there. Some another question. Um And they're just wondering what what drugs but being under. And also when asked when they're saying she's paralyzed, are there faster? Huh? It says to everything. Everything from head to toe, any and nervous system. Everything just shuts down. Um So yeah, that's everything in the body is being peril. General millions. Normally it's propofol. Let's go on. Like what Michael Jackson dies from? Yeah, but he had too much and it shut everything down completely. Got it. So, but here we actually monitor and see how much is going in. They're breathing. You know, everything. So everyone at a different rate, it'll never Yeah, you would never harm any. But the answer the certified registered, there's a mess artists. They normally take care of all that. Why we're up here, I'm dealing with behind them. Something literally. Exactly. Yeah. Okay. Hell but not go back to my other room and if the front desk has any issues, just have him call in here. All right, we're on hold. Uh huh. That's it. This is Yeah. So scholars were struggling over on this side trying to get Create a space in between two layers of tissue. Yeah. Get that sponge stick for me. And Because of all their surgery over here and because of the two hernias that I showed you over on her left abdomen again, the scarring. And I think the fact that she's 82 years old. Um And doesn't have the strongest tissue in the in the world are causing us to struggle. Is this the the layer is so paper paper thin are thinner than love paper that be like having Kevlar. Yeah. Mhm. But it's like one cell layer thick and we're where she's making us work pretty hard. Try and do this and we're still not sure if we can do it. But we're trying and like what we were talking about earlier is just sort of reacting to the situation in doing what's best and making decisions about what's best for the patient and safest and etcetera etcetera. We're still working through that. And even though it's a struggle but you may perceive because every pace of the operation is like clogged down. We're taking our time. And we're mostly dr fisher is doing all the heavy lifting right now. Trying to create this flat back here. Yeah. Well these were trying to create is trying to create a flap if you will. And what we're holding up what Tony and I are holding up would be her abdominal wall. The midline fashion. The strength player, the rectus muscle. So the muscles of her abdominal wall and what dr fisher is trying to push down and get through all the scar tissue is a couple of different layers but the inside lining of the abdominal wall called the peritoneum which you've heard about Bobby, it's on 20 Yeah fine. And another layer of the abdominal wall. I've got the four. All right girl. Made a lot of yeah, bearing peritoneum. Yeah. Almost. Yeah. Sean just passed. Mhm. This is giant hall. This is giant hole here. Yes sir. Yeah. That's the that is the whole yeah. I just got to take this down. It's down. Yeah. Let's um bom please. So far dr fisher's working really hard but he's being successful and if we can do it safely it's much better for the patient. Which is why we're doing this. Yeah there, yeah. Face. Mhm. Hold on Michael. Mhm. Six. I don't think it will. Yeah. Yeah. Mhm. Yeah. Yeah. Yeah. Mhm. Welcome. Mhm. All right, fatality rate B I think Close zero less than 1%. There's there's always a risk in any patient I guess. Even though she's 82 and age does have something to do with it. It's more than just a number. Um There's risks to any surgery. Just saying there's no no small surgeries. Whenever you get anesthesia. Something could happen. You could have a heart attack. You could um aspirating all kinds of things can happen. The sort of and you know she could have a problem in the postoperative. Just because we get her out of the operating room upstairs to the floor. Doesn't mean that bad things can't happen but that's why she's here. We watch out for those things. Ah The risk that this hernia could come back after we do this depends upon how we fix it. I know. Swiss cheese. Right. No, I know. I'm with you. Let me get a match now. You weren't here. I probably would have given up. Listen. So we're remember we're giving her the the beamer. We're trying to give her the beamer repair. I would guess the recurrence rate would be around somewhere between three and like 7%. Like maybe one out of 20 chances not zero. And then as we Mhm. Give her lesser repairs, the recurrence rate goes up a little bit. So, if we were to just like mm hmm. So, so stuff up and not use mesh. Mhm. Mhm. The recurrence rate would be, Yeah, Probably over 50%. Thanks sometimes. Yeah, that's all you can do, like. Okay, sponge, stick to me please. Okay. Oh yeah. Oh yeah. And it acre of mesh in that symbol. Okay, thank you. Bye bye. Okay, I'm gonna put several sponges in here for the moment. We need a lot of give me a couple of valuables. Uh Thank you. All right. So, we're gonna have so we have one towel and now I have a note. This one at two. three sponges. Left abdominal wall back here for the moment. Let's see if this is a salvageable. I don't know. Yeah, I just dropped one Bobi sorry. Uh X. I don't think 44 sponges in, guys. Let me get a malleable please. Morning, get it off only. Mhm. Let's we're asking a lot. Yeah. Right. I mean like you think about thank you this close this. Well, that could also close the problem. These ones I don't know if they so thin. I don't. No. Okay. Yes. What we do that? What are the other guys seriously online? That's our other option. Yeah, stuck inside of wrong. Are you over here? Yeah. Closed their sheep. Uh huh. Everything thanks to give it perhaps that's what their fossil. You know what Right now? You know, literally there's literally no way we care that could close. But this been to prepare. Wait, I had a giant one back here. Yeah. I think the problem is they're all propagating. No. And I think we just scrap it. No. So scarred. Check this space rain this your towels coming back up to three. Mhm. Uh huh. Mm. Mhm. Yeah. Okay. Scholars crap. Mm mm. So you saw might have been pretty guys. But we were struggling to create that space and we kind of just made the decision that that space that we were struggling to create would not be um salvageable to close because there's so many holes in it. So I think we're going to actually probably go down to option number two be what to do what is called an on leg meaning will close all the strength layers and um then put a mesh on top which is nothing. The mesh will be sewn on. Will help buttress the hernia repair. No it's on top on the outside of the tire if you will. It's better than no mesh. Um Yeah if we want to look at the silver lining we did do a bowel resection on the inside. So it makes me as a general surgeon feel a little better that I'm not putting mesh on the inside where it could potentially be infected even though that's a small concern right now. Um. Mhm. So that's what I'm planning to do I think. Um And then close everything up and get her off of the O. R. Table. How so? Yeah. Do you have any questions for me? Um Yeah. Yeah. Well we don't really do push ups or I'll do like warm up exercises. We do maybe one of these Sometimes two sometimes even more a week. Um And so he and I have done I don't know probably Around 200 of these in the last few years. Um So it's pretty routine and pretty straightforward. We know what we're gonna do. We know what our options are going into it and we know what we want to achieve. Um. Right. Right. Uh I think they will with the increase in minimally invasive surgery and robotic surgery that the main source of these her knees are previous surgery incisions. So perhaps they will. Yeah we haven't played. We're we have well over an hour to go. Um Yeah okay there's good luck. Ah Certainly it shout me if you have any questions or anything. I think you can get my email address through. Envision um and have a great day all. Created by Related Presenters Sean Harbison, MD Professor of Clinical Surgery Gastrointestinal Surgery
