Chapters Transcript IPOM/LIRA Course: NYU Langone 2nd Annual Hernia Symposia: The Alphabet Soup of Ventral Hernia Repair Hey everyone, I'm uh I'm here to talk about the faithful and uh always controversial uh ipo. Um, my goal is to show you that in the world of all our new and fancy techniques, uh, IPO, uh, still has a, uh, still alive and well and still has a place. Um, much like Georgia, I have, uh, nothing to disclose. So I feel like every IPalm talk that I've ever been to kind of starts the same way. It's like this horror show of fistulas and floating bowel and these crazy adhesions, and it kind of leaves a a bad taste in your mouth and The truth is that every time I'm chipping away at one of the Jeff's eye palms, um, I always just can't help but bash him under my breath. Uh, it's very painful. Um, but that's clearly not the full story. Um, you know, I think that bad cases are, um, are highlighted and, and brought to the forefront, probably because their complications are pretty severe and, and they carry a lot of morbidity. I kind of think about it like bariatric surgery, you know, 99% of the time, um, things go very well and everyone's happy, the weight's coming off, uh, but when things go wrong, they, uh, they really go wrong. Um. But the truth is that uh most IPalms probably look more like this, um, and less like this. So why are we even having this discussion? Like, I mean, I thought we all kind of moved on from, you know, IPO to bigger and better things, you know, the ETEPs and the tars and the Milos and the the scolas of the world, but the truth is that we probably haven't moved on. I mean, if you, if you look at the uh national trends from the NISI data, just in the last decade, you, you'll see a continued increase, and even, even an inflection point in the takeover of uh MIS ventral hernia repairs. Um, and not only that, but a trend towards more complex cases, um, you know, more incisionals and more recurring incisionals, uh, being tackled, uh, with MIS. And probably robotics played a, a, a major role and also the, the growth of ABBA as a field, uh, mostly for the people on the right, uh, uh, side of the screen. But for the people on the left, you know, the surgeons just, you know, starting to embrace and adopt MIS, you know, those guys are probably starting with inguinals and, and I palms as, as the um before moving on to, you know, more complex, uh, repairs. If you look at data from the QC, which is a hernia specific database, you see a very similar uh trend of adoption of the MIS. And in fact, the QC is great because it lets you get pretty granular in terms of the data. Um, and if you look roughly at the 37,000 cases of ventral hernia cases they did last year, um, a quarter of them are still repaired with IPal mesh. Keep in mind this is, you know, this database tends to have a bias, um, to, uh, towards people that are interested in hernia or hernia practitioners. So yeah, I mean our our landscape is changing, and our field is is evolving, um, and new techniques are being introduced, but, um, clearly IPO uh still has a role. And if you don't believe me, this is one of the most controversial posts on IC like ever. Hundreds of comments and people kind of fiercely defending their side, and, and this was like two months ago. So yes, you know, we've established that iPal is alive and well, um, but why? Why do so many people still revert to? Well, it's safe, um, it has acceptable outcomes, it's fast, it's reproducible. Um, it's fairly easy to teach, um, it's cheap, it's versatile, and it's continued to evolve over time, and, and, you know, there are papers that kind of support each one of these statements, and there are papers that also go against each one of these statements, and that's why, you know, it's, it's there's still some, uh, such a source of controversy. So I think most of us will find a role for IPO within our practice. You know, I work at the Manhattan, uh uh uh the NYU, the main campus in Manhattan, but I also work down the street at the Manhattan VA and, and honestly, those two populations just couldn't be any more, uh, more different. So I think where you practice, um, you know, your population, the goals of the patients, um, I think that is gonna play a major role in, in, in, um, shape how you're gonna use IPO in within your practice. So. For me, I think smaller primary central defects without diastasis, um, you know, somewhere around 2 to 5 centimeters, um, or in cases where you're not addressing the diastasis are, are amenable to IPOM. Um, I think it's a good bailout for tap, um, like when you have very thin or unfavorable peritoneum where you're not able to fit an appropriately wide uh uh mesh in your pocket. I mean, the truth is I, I'd rather have a well performed iPalm with good overlap, um, than a poorly done ventral tap, uh, with an inadequate mesh coverage. Um, I also tend to revert to IPO in more urgent, uh, or emergent cases and especially if patients are not optimized, you know, small bowel obstruction where you're reducing the, uh, the hernia high BMI patients, I tend to revert more to, uh, to, uh, IPOM. And finally, I mean, I'm thinking of my of my VA patients, you know, um frail older patients uh who are not very active, where honestly a more extensive repairs, really not gonna be much uh uh uh very beneficial to them. So, here are some tips for a good eye pal from probably the youngest surgeon in the room. Um, position the patient at the edge of the bed, um, Where you're gonna minimize collisions with the uh side rules of the uh of the uh operating table. Uh tuck the arms. I like to really flex the bed, um, uh, to increase the in the space between the uh cost of margin and the ass. Obviously your trollar should be at least 10 centimeters from the ipsilateral side of the uh of the hernia, but obviously, um, a little more can be helpful. Um, traditional is lateral, but it, you know, you can kind of adjust your ports, um, and rotate them a little bit if you're tackling, uh, maybe an inguinal hernia, um, or you're doing this laparoscopically, you need a little bit better ergonomics. Um, and, you know, for the PAs in the room, uh, you know, really burp up ports, uh, before you go sit at the console and kind of bring them back to to maximize your, your working space. Of course, you'll reduce um the contents and take the hernia sac if possible and or at least placate it during your repair. Um, I think one of the, you know, most critical zones uh uh parts of the, of the case and I think it's been alluded to already is create a good landing zone uh for your mesh. You really have to create uh remove all that fatty tissue from the abdominal wall and sometimes this means or most times it means taking down the al form, um, or some of that uh uh fat below the umbilicus. Uh, a lot of times you may even discover additional defects that, um, you know, may, you may not have seen on initial entry. But the bottom line is you really need a good flat surface, um, to be able to fixate your mesh really well. Um, at this point you can decide to do a myofascial release, um, or a lead up. So let's talk a little bit about what that is. I think it's also been, um, alluded to. So the uh laparoscopic intracorporeal uh rectus aponeoplasty or lida was introduced in 2018 um by a Spanish surgeon, uh Salvador Morales Conde from um from Sevilla. Um, and the idea is to incise the posteriorectal sheaths just lateral to the hernia defect, um, along its entire length, usually about 3 to 5 centimeters beyond it, kind of just kind of think of where my closure is gonna start. He has kind of a Complex formula on how to determine the length, but I think this is a little bit more practical. Um, and then the medial leaflets of the posterior sheath are incorporated um into the midline closure, um, as you close. And honestly, the rest of the case is pretty much the same in terms of your mesh placement, your measurements, your fixation. Um, and, you know, there are very few papers for like 4 papers on this um uh approach, um, very little to no outcomes, just kind of initial um experience and kind of uh um explanation of the of the uh technique. Um, but, you know, there's some hypotheses that it can, uh, decrease, uh, recurrence rate because you're decreasing the tension, decreasing postoperative pain for the same reason. Um, but there's also probably some benefits, uh, benefit to mesh integration because now you have exposed rectus, which is very vascularized, as opposed to peritoneum. Um, So here we see uh where we make that incision in the uh posterior sheet at the accurate line, you don't have to start the accurate line, just happened uh that way in this case. It's kind of like the beginning of a tar, um, except that you don't really do your retroactive dissection. Um, and you can do this on one side, but most of the time it it to me it makes more sense to to do it bilaterally. Um, defect closure, um, is pretty standard. You wanna kind of incorporate the medial leaflets that you've, uh, just mobilized, um, uh, into your closure. So I usually start, uh, a little bit above and below, um, to be able to do this. Uh, and you can see that, um, you know, the, uh, media leaflets really medialize well, and by the time you're finished, uh, with your closure, um, you know, you kind of see the two recti, um, uh, kind of opposed. So needless to say, you need an appropriately sized mesh, uh, that's coated, uh, it needs to be centered over the defect. Um, I think that can be tricky when you're looking at it from the side. So I always, you know, mark my mesh or put a suture, um, or, you know, obviously the positioning systems really help with this, but, you know, the mesh needs to be centered and it needs to be lying completely flat against the abdominal wall to, um, and, and you really need to to work hard to minimize uh wrinkles and folds. That can uh end up causing a recurrence. Um, I think, uh, fixation is absolutely critical with iPons. Um, remember, the mesh just has one surface to adhere to, so as much contact with that surface as possible, um, is ideal. Um, don't use permanent mesh, I'm sorry, don't use permanent sutures, um, so that the mesh contracts, you're gonna create this sort of Cton effect and cause some small peripheral defects, which I've seen a few times, uh, when going back. Um, I usually do a running, uh, outside suture when doing it, uh, uh, robotically, um, or bigger meshes, I even do additional suture lines down the middle and transversely, um, and I even do individual viros just to really oppose that mesh to the, uh, uh, you know, in this case to the rectus, um, or to the interior abdominal wall. Of course, if you're doing this lab, this is Jeff Lipman's case. Um, you know, don't think twice about um adding additional ports on the other side to really, um, be able to, to fixate your mesh when you're kind of working, uh. Close to yourself. So to wrap this up, I think IPOM, honestly, it's rarely my plan A and honestly, you know, not commonly my plan B, um for most hernias, but, uh, when it, you know, it, it's a safe and effective approach when it's done the right way, um, in the right patient. I think it's a good entry point uh for surgeons adopting, um, uh, MIS ventral hernia repairs, and I, I think it should remain in our toolbox along with other more, you know, advanced or fancy uh uh repairs. I think each of you will kind of decide the frequency in which you use it, and I think that's gonna be based on your, you know, uh, personal preference, your practice type, your training, your, your population, your access to the robot. Um, as far as leader, I think it could be helpful with more challenging closures. I think it definitely works to help decrease tension. Um, it's pretty easy to perform, um, there's some, you know, kind of described benefits that are still, um, yet to be proven. And uh look out for it. I know there's uh some new papers coming out describing the technique in the uh extraperitoneal or in the tap um in tap repairs, so that's kind of some some pipeline. Thanks. Published May 3, 2024 Created by Related Presenters Xavier Pereira, MD View full profile
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