Chapters Transcript Ventral TAPP Course: NYU Langone 2nd Annual Hernia Symposia: The Alphabet Soup of Ventral Hernia Repair Yeah, you know, I noticed uh Xavier made fun of me in the beginning, but he also forgot to thank Flavio and David for uh allowing me to present. So thank you guys. I'm gonna be talking about transabdominal prepaoneal ventral hernia repair. I have no financial disclosures, but I would like to disclose that I do not believe IPum is evil, and I especially don't think it's fair to compare a poorly performed IPump to an expertly performed tap. And, you know, I think. A lot of recurrences and problems with iPod meshes lifting off and, you know, ball adhesions can possibly be and miss hernias, you know, especially in the epigastric region, can be traced to improperly performed taps, or excuse me, IPO. So just as an outline, you know, why tap, tap for ventral hernia versus IPO, uh, some operative technique, some troubleshooting, and just as a um um. Forward, you know, in my practice, I use ventral tap for similar, uh, similar ideas that Xavier mentioned for, uh, ventral ipos. These are for small primary umbilical or epigastric hernias, typically less than 4 centimeters. Um, these are Patients without large or without symptomatic diastasis. Um, I use these for port site hernias sometimes in the midline, but even those can be kind of challenging. And I do use these, uh, the tap approach for lateral and flying hernias, but that's, uh, beyond the scope of this discussion. So why do we need tap? I think actually saw this picture in the last uh talk, you know, you go onto Greer's website or Bard's website, you could find a billion pictures of these beautiful peritonealized um uh intraperineoneal meshes. Another example, I think this is the 3rd time we're seeing this picture, but not always the case, you know, dense ball adhesions, potentially enter prosthetic uh fistula, you know, chronic mesh infections, and other potential problems related to Intraperitoneal mesh. So, you know, in terms of the data, this was a uh a really nice uh meta-analysis from 2022 that looked at tap, um, versus other MIS techniques for ventral hernias. 9 studies, mostly retrospective, mostly 12 year data, some robots, some lap, um, seroma, hematoma, recurrence, uh, had no difference between IPO and tap, but a little bit into the nittier grittier stuff, um, tap. Does take longer than IPO in the literature, but if we look at studies that comprised the majority of the patients in these meta-analysis, actually tap was significantly faster than IPO, which has the suggestion that as you do more cases, you get faster at doing tap, and maybe the lack of needing fixation, the lack of needing to uh suture circumferentially, you can actually do a faster procedure despite doing a preperitoneal mesh location. Surgical site infection was less with tap, although pretty low um in both tap and IPO. Pain was less was significantly less in both studies that looked at pain. This is acute pain as measured by VAS, um, and that's, you know, almost definitely due to the lack of need for um, uh, a ton of fixation. Chronic pain, however, in both these studies that took it out a little bit longer, was equivalent between tap and IPO. Cost. Keeping your robotic versus laparoscopic modality equal cost was significantly less with ventral tap, um, and that's probably due to the lack of need for composite mesh, as well as the um uh lack of need for tackers. So I'm gonna present a case from a uh much more skilled surgeon than me, so you should be thankful for that. And this is a 50 year old male, small umbilical hernia, mild uh but completely asymptomatic super umbilical diastasis. Um, I'll mention a similar setup that Xavier did for IPO, and I find that, you know, if your ports are set up correctly for a ventral tap, your ports are also set up correctly for an IPO. Um, getting that. ASIS aligned with the flex of the bed, and just remember to check that the flex of your bed is correct before you get the patient on the bed. I've made that mistake before, and, uh, transferring an intubated patient to another bed is, is kind of an annoying thing to do. I always insufflate the abdomen with a virus, uh, before placing my ports. That really lets me get the, uh, camera port and my right hand port, if I'm Docked on the left as lateral as possible. Yes, you want to be at least 10 centimeters away from your mesh edge, which is gonna be your ipsilateral peritoneal edge, but really, you know, 15 centimeters lateral is better. You can cheat this but I'm sure it's not projecting, but um you could cheat this bottom left or up and in um to avoid collisions with the thigh and with the ASIS. So this is, I think, you know, better than any textbook that you could buy, um, this is from uh um. Uh, Doctor Nichole's, uh, YouTube channel, it's just, I think, an incredible textbook on MIS surgery. You know, I used to start these ventral ventral flaps, um, these tap flaps as a kind of a horizontal line through the difficult, hold on, how do I? Through just kind of the difficult area of the peritoneum and I've actually found that if I round the mesh and start more in the fatty area and then curve back towards myself, it makes the subsequent dissection a lot easier because the um the fat is gonna be really where the, the area is um easy to dissect and excuse me, and easy to get into the pre-paroneal space and if you curve out here, you're gonna make your harder dissection uh just. A little bit easier. That, um, shimmying the closed jaws in the preperitoneal plane, um, you know, helps develop the plane and then cutting and burning helps, um, uh, keep your flat nice and dry. So as we get to the middle, um, then we start curving back to the, uh, to the coad area where again there's gonna be a preponderance of preperitoneal fat that's gonna make the dissection easier. Once I um get this preperitoneal. Flap, um, kind of started. I really try and hug the under surface of the line alba, you know, uh, dissection you're familiar with if you're doing. Anything from IPO to ETEP, um, you really wanna get all the extra peritoneal fat off the linea alba, that's gonna help you identify any, um, any more occult defects that you may not even see on transperitoneal view, and it's gonna help keep your flap as robust as possible and is gonna help you reduce bleeding. So I don't really attack this middle section until I've developed, you know, basically to the contralateral fat above and below the defect. Um, in the, in the lower abdomen, the infra umbilical abdomen, you're gonna encounter a lot of uh ligaments that, um, uh, Fareed, uh, talked to us about earlier. And I think it's important to kind of keep all those ligaments down. Um, it's easy to get lost in the fat when you have these, um, you know, obliterated vessels going above and below you. So if you just really stay and hug the, uh, abdominal wall, you're gonna make your dissection a lot easier. Um, now that the top and bottom have been dissected, you can see how easy it is to deal with the harder part. Um, it really just gets that onto a pedicle, um. Again, getting those those ligaments down, you could see climbing above all those ligaments, exposing the inferior the under surface of the linea alba. Um, if you end up going below the arcuate line, I then try and transition back into the true pre preperitoneal plane in order to keep some transversalis fascia up against the muscle, um, and maybe prevent some injury to the inferior epigastrics. In primary hernias, you can see, even though this patient on exam only had an umbilical hernia, um, we found in a cold, or Doctor Nicole and found in a cold, uh, epigastric hernia, and um sac reduction is uh extremely straightforward in primary hernias. And even port site hernias, the sac reduction can sometimes be not um not as easy as you might think based on the preoperative look of the patient. Now that we're getting to the contralateral under surface of the mid rectus, the peritoneum is gonna be getting very sticky, and this is the kind of other place you can make a lot of holes. So, here's where it's important to learn how to um recruit layers of the transversalis fascia, um, in order to keep your flap as robust as possible. Some other tips are, um, Burning on the wall instead of the flap. You could see here on the left of the On the left of the screen, the peritonea. On the left of the screen, the peritoneum is very thin, and, you know, there's probably some impending holes here, but um if we can get some of those layers of transversalis fascia down, it really um it really uh makes the peritoneum more robust. Again, burning on the, on the, um, posterior sheath instead of burning on the peritoneum and pushing up on the abdominal wall instead of uh pushing down on the peritoneum, I think are are keys to making a successful uh uh large flap. This is just complete the dissection. Um, I'm usually aiming for a 15 centimeter, um, a 15 centimeter wide and long mesh, um, you know, sometimes an 11 centimeter for really small ones, but I'm usually shooting for 15 centimeters. For umbilical defects, I typically Close them transversely, um, unless the patient has a lot of diastasis. I don't love, uh, you know, putting a lot of sutures through distatic linealba to be a formal fascial closure. Since this had two defects, I think closing it longitudinally, uh, made a lot more sense, um. I always like to lay in the sutures before um I start tightening them. I think that's good practice also for the residents to uh get used to closing bigger defects. You can always practice um how you would close a bigger defect by closing smaller defects. And then I do like to run these back and the rest of the video is mesh postman and um uh uh you know, minimal fixation. I actually typically just use glue and maybe a cardinal suture in the middle, um, and I marked the center of the mesh. So in terms of troubleshooting, cause that patient obviously had very favorable pyridium, that patient had no prior surgeries, um, you know, I think patient selection for tap is really important to reduce frustration, um. The patients where I anticipate I'm gonna have a lot of difficulty with tap, uh, patients who've had prior gynecologic procedures, uh, lots of the gynecologists and maybe even general surgeons too, you know, after fat and steel incisions don't necessarily close the peritoneum. If you go in for a transabdominal view and you see bear rectus below the umbilicus, I would not even recommend. And uh trying a, uh, ventral tap, that's something I would probably eye palm. Um, hernias within midline laparotomy incisions. Sometimes it's tempting. You see a focal hernia within a midline laparotomy incision. You think, oh, you know, I'm gonna treat it like a primary umbilical and try and tap that and, um, tap that and um. Uh, you know, those are really difficult. It's really difficult to recruit a large enough peritoneal flap in somebody that's had a laparotomy. Elderly patients, I've noticed tend to have thinner peritoneum and it's a little more difficult to work with. And if you go in on transperitoneal view and you see a very narrow, um, uh, section of central preperitoneal fat, that's gonna be pretty difficult too. So, in terms of the bill. Xavier mentioned this also, you know, converting to an iPump, there's uh there's really no shame in converting to an intraperitoneal repair. I think it's much better to have a um uh an intraperitoneal repair with adequate overlap than to have this narrow strip of uncoded mesh just so you could say you could do something fancy. And if you watch some videos online. And you can see some, um, you know, what looks like pretty undersized meshes to try and do something extraperitoneal. Um, I've used extraperitoneal fat, I've used hernia sac, I've used, I've used tons of momentum to interpose uh small holes in the uh peritoneal flap. You can use a composite mesh in the extraperitoneal space, um, but I would be careful about, um, You know, leaving a bunch of holes in peritoneum um on the anterior abdominal wall that could be a source of internal hernia in the future. Um, you know, I'll put as a question converting to a retrorectus repair. You know, if I'm considering a retrorectus repair, I'm usually not considering a tap or an eye palm as my plan A. So, just think about the dynamics of the hernia. Think about whether that patient actually needs, you know, an abdominal wall reconstruction, cut dividing of the posterior sheaths, risking semilunar line injury and deinnervation, and burning the retromuscular space for what might be a 2 to 3 centimeter umbilical hernia. I'm not saying, you know, never convert to it. I'm just saying think about, um, you know, what you're trying to treat. Um, this is not actually a tap, but this was part of a, um, an EAP, uh, uh, an ETE with a unilateral tar for a subcostal hernia, and I had this giant gap in the posterior sheath. I harvested this pathetic piece of hernia sac, and my resident is like laughing at me while I'm starting to uh suture this circumferentially, but this video is really just to show. that even a little bit of herniassac can provide a lot of coverage. Um, it's extremely stretchy. You can see that was the same piece used. There's really not a lot of tension here, and I was actually able to use just that sliver of hernia sac to, uh, completely, uh, cover the posterior elements. So, you know, uh, sometimes you do have to be creative and Now, I'll show you a much better surgeon than me, which is Flavio, and this is uh a ventral tap, which um we're completing the contralateral dissection and this is another difficult area. Things are extremely thin, you know, we're making innumerable holes. If this were me, I would have already cut straight down the center. That flap, and I would have done an IPO. Um, but Flavio being Flavio, you know, with incredible patience and, um, he's able to create a big flap, you know, we know we're gonna probably use some sort of composite mesh, but trying to get as lateral as possible. Here's insertion of the composite mesh, which, if anyone doesn't use these positioning systems, uh, whoever invented. It really deserves the Nobel Prize for medicine because they've uh simplified things so much and I think made IPO so much more fun and so much easier to get the mesh flat. So I have no financial disclosure with that, but I love the uh positioning systems. So, you know, it seems like it's gonna be impossible to get this mesh completely reperalized, but why not try? Um. So by uh starting the main flap closure, then Fabio very creatively realizes that he's got a lot of extra stretchy um peritoneal sack here from the um reduced hernia sack, and he's actually able to divide this, and then he's gonna suture it to cover those holes on the side, and I really, um. I think this is uh just an incredible exercise in patience and creativity that sometimes is required in order to cover a mesh. Um, you know, there is a theoretical seroma risk here, so Flabio does, um, suture some of that mesh, some of that peritoneum up against the mesh to theoretically reduce the seroma mesh from the composite mesh, and there's really no areas for potential internal herniation, and I just think that's uh an incredible video. So in conclusion, you know, I think with proper patient selection, tap is a great addition to the extraperitoneal ventral hernia repair ornamentarium. I think there's likely less pain than IPO due to the lack of fixation and the lack of typically a need for a 12 port. Um, you can reduce the cost, especially, especially as your efficiency improves. I really do think you should not violate the attendance of good ventral hernia repair just to avoid. Peritoneal mesh, and I think that's mostly wide mesh overlap. You need patience, sometimes creativity to peritonealize the mesh. And just remember, I, I still do a lot of eye palms. I still think it's important for residents to learn how to do a good IPalm, and the use of coded mesh is well established with good long term results and a good safety profile at the population level, despite horrific pictures that we show during presentations. And thank you very much. Published May 3, 2024 Created by Related Presenters Jeffrey Lipman, MD View full profile
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