Complex Abdominal Wall Reconstruction with Transversus Abdominis Release (TAR)
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This video demonstrates a case involving an open complex abdominal wall reconstruction with transversus abdominis release. The case involves an obese patient with a multiply recurrent incarcerated incisional hernia. The CT scan shows a complex defect involving the midline, right linea semilunaris, and inter-rectus hernia. The use of a retromuscular procedure with a posterior component separation will be highlighted and its advantages of allowing wide mesh overlap without creation of subcutaneous tissue flaps to repair defects with these challenging characteristics.
Complex abdominal wall reconstruction; incisional hernia; TAR.
This video shows the repair of a large complex incisional hernia after multiple prior failed repairs and lateral and midline defects.
51-year-old female with BMI of 43 Kg/m2. She has had four prior hernia operations including laparoscopic ventral hernia repair with mesh and an attempted robotic repair that was complicated by a missed enterotomy, end colostomy, open abdomen, and healed by secondary intention. She underwent takedown of her stoma, small bowel resection with primary anastomosis, and primary ventral hernia repair 10 months prior to this procedure. She currently has an intact functioning GI tract with a large complex incisional hernia. The hernia involves her right linea semilunaris, right rectus muscle, and her midline incision.
Obese patient with large defects both in the midline and lateral abdomen. She has a large midline scar that requires revision.
The CT scan will be reviewed in the video. It highlights the anatomic location of the defects and the inherent challenges of repairing these defects with retromuscular surgery.
There are not many options to repair these types of large defects. One consideration is the need for preoperative optimization. This patient is morbidly obese with diabetes. While there is not an ideal cutoff for preoperative weight loss, it should be considered in all patients. In this specific case, this patient was enrolled in a randomized controlled trial evaluating the benefits of preoperative weight management versus upfront surgery for patients with BMI between 40 to 55 kg/m2. She was randomized to upfront surgery and did not lose any weight prior to surgery. Her obesity does provide several challenges in gaining exposure, retraction, dealing with the soft tissue, and hernia sac.
Given the large defect, loss of domain, and wide scar, in my opinion, there are no minimally-invasive options. Given her obesity, an anterior component separation is not ideal, as the large skin flaps will significantly increase wound morbidity. While an open IPOM (Intraperitoneal Onlay Mesh) repair is something to consider, it still requires skin flaps and the lateral defects will make that more challenging. Our approach involves a posterior component separation with synthetic mesh to provide wide coverage without raising skin flaps.
This approach will allow for repair of the hernia and improving of the patient’s quality of life. In addition, it will reduce the risks of requiring emergency surgery while this obese patient waits for preoperative optimization.
The most important aspect to consider in this type of case is the experience of the surgeon performing the operation. As will be demonstrated in this case, the challenges of reoperative abdomens, adhesions, altered abdominal wall anatomy can all make this case extremely complex.
The operation begins by making a generous midline incision and excising the prior scar. Entering the reoperative abdomen can be challenging and it is important to have a systematic approach. We do this by opening the fascia in the upper abdomen and getting into the preperitoneal space without making any effort to enter the peritoneal cavity. Then we placed two Kocher clamps and with upward retraction of the Kocher clamps and downward retraction with a DeBakey forceps, we were able to identify the line of the abdominal wall that we can continue to dissect. We carefully dissected the line, and it is important to point out that we are not dissecting the bowel, we are simply dissecting that line. We stay within the midline and do not drift out laterally as that can result in worse exposure and potential enterotomies. We sequentially go down the abdominal wall until we have opened the full midline. Then we dissect each lateral abdominal wall with four Kocher clamps pulling up and getting a wide exposure trying to work around laterally to the area of concern. In this case, we reduce the right side and both the lateral defects manually and with blunt dissection are also able to identify the line of the hernia sac to reduce everything out. It is optional whether or not to lyse all intraloop adhesions and is certainly something that I do prefer to do because of the risk of postoperative obstructions and perhaps not lysing a key adhesion. After the adhesiolysis is completed and any intra-abdominal procedures were performed, we placed a blue towel that is wet over the viscera to protect it during abdominal wall reconstruction.
The abdominal wall reconstruction was begun on the right side initially by taking down the posterior rectus sheath identifying the muscle belly. It is important that you identify muscle because if you see fat you are anterior to the linea alba and if you only see the white sheen to the posterior sheath, you are within the preperitoneal space. Once we identify the muscle, we extend superiorly and inferiorly and then encircle both the defect in the right rectus muscle and in the right linea semilunaris. One of the keys to dissection and a retromuscular operation is to encircle the more difficult part of the operation. As you will see, I dissect superiorly and inferiorly to get around the area of concern and eventually take those down and close up the resultant defects in the peritoneum to protect the viscera from the mesh. We continue this dissection in the lateral abdominal wall to identify the psoas and divide the round ligament going the space of Retzius and down to the central tendon the diaphragm under the costal margin. Similar dissection was performed on the left side to create a nice wide pocket to allow a tension-free closure of the posterior sheath as well as adequate mesh overlap in all directions. Once we closed the posterior sheath completely securing the mesh from interacting with the bowel, I closed the lateral fascial defects from inside with #1 PDS sutures. It is optional whether or not to put a drain in those areas but is certainly something that should be considered if the hernia sac is too large. I then placed an adequately sized piece of mesh which in this operation was a 30x30-cm piece of heavyweight polypropylene mesh. Based on prior randomized control trials, we no longer put transfascial sutures as long as adequate overlap is obtained. Two drains were placed in the mesh, and the midline was closed with #1 PDS figure-of-eight sutures. Often in obese patients we will place a drain in the subcutaneous pocket. And then the skin is closed in layers. The patient made an uneventful recovery and was discharged home on postoperative day 4 with all drains removed and was seen in 30-day follow-up and is back to full activity with no wound complications and feeling great.
This operation can be performed with minimal equipment and a fairly inexpensive uncoated polypropylene mesh.
ACHQC Salary support.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
- Krpata DM, Petro CC, Prabhu AS, et al. Effect of hernia mesh weights on postoperative patient-related and clinical outcomes after open ventral hernia repair: a randomized clinical trial. JAMA Surg. 2021 Dec 1;156(12):1085-1092. doi:10.1001/jamasurg.2021.4309.
- Krpata DM, Blatnik JA, Novitsky YW, Rosen MJ. Posterior and open anterior components separations: a comparative analysis. Am J Surg. 2012 Mar;203(3):318-22; discussion 322. doi:10.1016/j.amjsurg.2011.10.009.
- Zolin SJ, Krpata DM, Petro CC, et al. Long-term clinical and patient-reported outcomes after transversus abdominis release with permanent synthetic mesh: a single center analysis of 1203 patients. Ann Surg. 2023 Apr 1;277(4):e900-e906. doi:10.1097/SLA.0000000000005443.
- Miller BT, Ellis RC, Petro CC, et al. Quantitative tension on the abdominal wall in posterior components separation with transversus abdominis release. JAMA Surg. 2023 Dec 1;158(12):1321-1326. doi:10.1001/jamasurg.2023.4847.
- Ellis RC, Petro CC, Krpata DM. Transfascial fixation vs no fixation for open retromuscular ventral hernia repairs: a randomized clinical trial. JAMA Surg. 2023 Aug 1;158(8):789-795. doi:10.1001/jamasurg.2023.1786. Erratum in: JAMA Surg. 2023 Aug 1;158(8):892. doi:10.1001/jamasurg.2023.3576.
Cite this article
Rosen MJ. Complex abdominal wall reconstruction with transversus abdominis release (TAR). J Med Insight. 2025;2025(469). doi:10.24296/jomi/469.
Procedure Outline
Table of Contents
- 1. Introduction
- 2. Incision and Entry into the Abdomen Along the Midline
- 3. Dissection Laterally to Remove Bowel from Defects from Known to Unknown
- 4. Running the Bowel
- 5. Measuring the Defect and Protecting the Bowel
- 6. Right Posterior Rectus Sheath Incision and Development of Posterior Rectus Space
- 7. Transversus Abdominis Release (TAR) on the Right
- 8. Closure of Lateral Defects on the Right
- 9. Left Posterior Rectus Sheath Incision and Development of Posterior Rectus Space
- 10. TAR on the Left
- 11. Further Cephalad Dissection Around Diaphragm
- 12. Closure of any Remaining Defects
- 13. Posterior Rectus Sheath Closure
- 14. Mesh Placement
- 15. Drain Placement
- 16. Skin Excision
- 17. Anterior Rectus Sheath Closure
- 18. Closure
- Placement of Additional Drain
Transcription
CHAPTER 1
Hello everybody. My name's Michael Rosen. I am a professor of surgery at Lerner College of Medicine, at the Cleveland Clinic. I'm the director of our Cleveland Clinic Center for Abdominal Core Health. In that role, I perform a lot of complex abdominal wall reconstruction, and today I'm gonna talk about a case that we're gonna do later on, which I think kind of meets the criteria for a complex, challenging abdominal wall reconstruction case, and we'll go through a bit of the patient's history and kind of what we look for in these folks. Okay, so today we're gonna talk about a case that is a challenging abdominal wall reconstruction case. This is a 51-year-old patient with a BMI of 43. She has a complex past surgical history that started with a lap ventral hernia repair, ultimately recurred, and she's had three hernia operations since then. Back in 2017 she had a robotic attempted repair where there was a missed bowel injury that ultimately required an emergency re-exploration, a colostomy, open abdomen, eventually healed by secondary intention. And I saw her about a year and a half ago. And importantly, in these patients that have stomas, large hernias, we discuss both the single-staged and a multi-staged operation, and given how complex this hernia operation was going to be, we elected to perform a multi-staged repair. So about 10 months ago, she underwent, by one of my colorectal partners, take down of her stoma, reanastomosis, and a primary repair of all of her hernias. She healed from all of that. She did also have a small bowel resection during that operation with a primary anastomosis. So she healed everything and now presents for her definitive abdominal wall reconstruction. One of the challenges is her obesity, and you'll see that in the operation and kind of some of the tips and tricks that we use to deal with that. With her BMI of 43, she's actually in one of our studies right now whether six months of preoperative optimization versus upfront surgery, what's best, and she was randomized to upfront surgery so that's part of the reason we're going in and operating at her current state. And so just to take a few minutes and look at her CT scan. So this was a CT scan from about a month ago and importantly this was after her stoma take down, and you can see as we start down from the top, you can see she has a fairly thick abdominal wall and then you can see her hernias will start in her upper abdomen. She's got a midline component, interestingly, and I think we'll see this in the operating room, and at the right lateral abdominal wall at the linea semilunaris, she has a full-thickness defect with her external oblique separated off the internal and transversus abdominis, which is going to create some challenging intra-abdominal issues for us to deal with this defect on the side. I think this was during the cut-down port for the robot. Otherwise this is a common look that we see in patients that have had a prior component separation where there's perhaps been some misidentification, but you can see the challenge here is this is right at the linea semilunaris on the right side, and then as we come down, again, more of a midline defect, and you'll see this is her old stoma site within the rectus. She has a hernia here as well with quite a bit of small bowel outside of it, and then her hernia continues down in her lower abdomen around her umbilicus and then her pelvis is fairly intact. So again, you know, this CT scan highlights some unique challenges, and I always like to point out, you know, there's a lot of excitement about doing TAR procedures and abdominal wall reconstruction, but I think this case highlights the type of case that these operations should be performed in, not for the routine small hernias 'cause these are large dissections and hopefully we'll be able to demonstrate in the operating room. There's a lot of opportunity to get lost. There's a lot of complications that can occur from attempting these operations, so we really do save these for large complex defects as you can see here. And again the challenges of large defects off the side within the rectus muscle and then particularly defects in the lateral abdominal wall. Not to mention the challenges of obesity that goes into hernia repair. So with that, we're gonna take this patient to the operating room, plan on a formal abdominal wall reconstruction. And to me, the steps of that will be a midline incision, getting in, taking down all the scar tissue across your entire anterior abdominal wall. I typically plan to lyse all the adhesions, but that can be a game time decision. I prefer to make sure that there's no undissected area that could potentially cause a bowel obstruction in the future, particularly when I'm placing large pieces of mesh. And then a lot of this will be setting up the exposure of the abdominal wall with the basic premise of working around lateral defects from known to unknown and trying to encircle the enemy and not going right at where defects will be the hardest. Another key thing that I typically do in these type of cases, the lateral defects, I typically will not resect the hernia sac. I'll just close from below. And while there might be a chance of a seroma, to get out that hernia sac is very difficult through these small incisions. And then another key thing, particularly when operating on obese diabetic patients is, and I think you'll see in the operating room, hopefully, I do not raise any skin flaps, and I think that's a really key point of doing complex cases because when you're operating on these patients, we'll be using synthetic mesh. If you try and make the skin perfect in one operation, you really risk more wound morbidity 'cause that often involves undermining the skin, tends to cause an ischemia. For me, I tell all these patients, we're gonna close up your skin the best we can. A year later, if you're unhappy with that, you can always have a revision with plastic surgery. But for me, really key, particularly when operating on obese diabetic patients and smokers, no skin flaps if at all possible.
CHAPTER 2
Okay, so first of all, we're gonna excise the old incision. We always- Oh is our Bovie...? We're gonna excise the old incision, and I think one of the things about doing complex hernias is you must make a big enough incision to do the operation. And this is also where people can make an enterotomy 'cause they end up getting in the hernia sacs, as you see like we're constantly pulling up and staying right under that skin. This is where a lot of people kind of go deep with the Bovie and then they end up getting in that hernia sac in an uncontrolled manner. And then the other piece of this is just operate on a lot of diabetics. I'm a big fan of cut, leave the white, as you see it's not bleeding too much and then take the white with the cut and then everything else with the coag and that way you avoid torching the skin. All right, let's let that be. Try and get up here if we can. And lift up. There's my hernia sac coming in the field so I wanna be above that. And now you can see there's the fascia. So take the fascia right up to my hernia sac right there. And then, with just lifting up, this is kind of an important way of just getting into a reoperative belly and if you watch, I'm gonna see the fat right underneath me. That's falciform. and I think this is where a lot of people make a mistake, Kochlers. What they try and do is get into that falciform. Particularly in heavy patients like this, that's almost impossible. So he's gonna hold up, I'll take DeBakes Metz. And then again, there'll be a line here if you just take a second. I'm not even gonna worry about getting in. And once I take it down a little bit, and here's where people also get in trouble is this hernia sac right here. There could be bowel coming right over here, so you gotta be really careful not to catch the lip of the bowel when you're coming down here. So just as far as I can see and feel. And then we'll just, one stays on, grabs, centimeter away from the hole, opens up, and then I'm gonna keep going down my line. And again, it really, if you watch and this is a good way to get into any reoperative belly, see I'm gonna see this line so that hernia stuff must come out, and all I do is I stay on my line and I don't worry about the bowel one bit. This is just a dissection of that line. So there, right here is the line. And again, all I need to do is stay on that line and now we're gonna start getting in. As you can see, right, there's hernia. But again like I don't even need to be concerned with that. For me, as long as I see my line, I'm safe. And now we're gonna be in the hernia. And same rules apply, the centimeter away from the V, I'll go here, he'll go there. And again, if you just watch, there will constantly be a line for me. So that's my line. That line is always there. If there's mess, there's a line, it doesn't matter. So to me, no care at all at this moment about bowel, as long as I see the line, I'm good. Yeah, DeBakey, and this was kind of just a little bit getting off the line, price you pay for that. Tonsil, and 2-0 tie. So now we're in the hernia, but again, as you notice, like no effort to get in the belly at all. This is just about getting the midline open. Catch that right there. And again, same deal, just staying right on my line. And the other little trick to this is not getting distracted by going to the side. That's where a lot of people, another spot you make enerotomies is trying to get to the side 'cause we don't have the exposure yet for that. So we just need to kind of stick with our original plan and just get the midline down. Okay, and then again, I like to avoid, that's why I stopped taking down the skin, doing too much past here until I know I'm safe underneath. As soon as I get in the hole, switch. Pull that back, yep. Uh huh. And lift up with all you got. And I think you'll see here we're just about to get to now we're actually clearly in the belly. I got more hernia stuff here. And this is all hernia stuff. So now I'm safe, but you see right here where we're doing the skin, if you start buzzing through here, you are gonna get into the bowel. Clean my tip off for a second. Pull. All right, I got some bowel right here. No bowel right there. And I actually think for video purposes, I think getting into a reoperative belly in hernia surgery might be one of the most underappreciated skills. But if you make a bunch of enerotomies, you're really limited in what you can offer, so being able to take down adhesions is really critical and just safely getting in. All right, that all looks good And you can see how thin it is. That's why I stopped taking off that skin. We'll see the CT scan later, but I knew it was gonna be thin. I didn't want to risk making an enterotomy going in. The other key aspect I think of this, particularly in open surgery, which is underappreciated, is using the table to your advantage. So you'll see I'll switch it multiple times. Could we go T-Berg? So I'll use the table position to help me. That's good, thanks, table up. And here we got a little bit of bowel left. That's good, thank you. Can I see a 15 blade, please? Sometimes when it's really stuck I find it just easier to use a knife. You gotta use the fat part of the blade, and again, I follow that line. I'm not thinking about this bowel, I'm thinking about this line. If I can see that line, I can cut. If I cannot see that line, I cannot cut. So again, to me, the bowel doesn't mean anything. I either see a line and I cut or I stop and I reposition my retraction. Nope, nope. Hold on a second. And again to me, right, there's bowel right there, but I'm not concerned about that bowel because I can see this line, so it's safe to cut. Mhm. And again a lot of people here would be kind of fixated. Can I see a DeBakey? On the bowel. It's irrelevant to me. Yeah. Can I get a DeBakey? All right and just hold that there. Knife back. Now that I've made a little bit of progress, I'm gonna go ahead and open down to it. And all of this is mostly for me about fighting for perfect exposure, not making any moves kind of out of frustration. Can I see another Kocher please? Right there. I'll take the 15 blade back, please. Yep, then again by moving it down right, I got my line and all I do is I walk that line with this hand giving me exposure. And that way I don't get lost in fat planes, I just work the line. And here we got a little knuckle of bowel. And then just as another little tip, if you start taking down the hernia sac, this gets impossibly complicated. So you really wanna fight to be in the right plane, not the easy plane. And most people as I watch do this, the biggest trouble they have is they don't provide enough retraction 'cause they're afraid of ripping something. Grab right up here. But I'm watching the bowel, right? I'm looking, making sure I'm okay, pull a little harder, and I'm safe. And again I go right back to my line, right? Knife back, so we got, our hernia kind of ends here so we'll definitely need to open all this up. You can let go of those guys, thank you. Now another important thing, this lady has a high BMI. She's involved in the study where we either randomized people to medical weight loss for six months or upfront surgery if your BMI is from 40 to 55 and she got randomized to upfront surgery, so she's BMI of 43 I think or so. So a couple little tricks for dealing with heavier patients. You'll see I'm gonna take this down to the bottom of her hernia here. But all this extra fat right here, I'm not gonna extend my incision and at all costs, I'm not gonna extend into the crease 'cause that's where you get the wound healing issues. Yeah, lemme just open this guy up and we should be good. Okay, so now I've accomplished step one, which is get the midline down. Now we're gonna move over. You hold this guy there. If you could take this one here.
CHAPTER 3
So now I'm gonna work my way out to the side by getting the midline down first, and so line one was the midline, line two... So this is that hernia off to the side. You'll see later. This is at our old stoma site. Got a lot of bowel stuck up there. I'm probably gonna need that knife again. So again here, I don't want to veer off. If I can't see my line, I stop. No, okay, that's fine. Yeah. Right, so again, I always go back to, I can always find a line. For me, I'll change my retraction, not ever just cut, right? So I don't like that. I'm good there, I'll cut. And by the way, this is a good example of hernias. Big hernias within hernias can still obstruct. You can see this is probably where she was having all her symptoms. So even though she has a gigantic hernia, she has a little hernia within that hernia and that can still get you in trouble. You can see she had some fluid up there, probably intermittently incarcerating. So again, right, like I'm gonna keep going for that line. There's always a line. If I could teach any general surgeons one thing, it's fight harder for that line. Don't give up, another Kocher? So again, right, like I don't have great exposure, I don't have good traction. So what I'll do is I'll move this retractor down. Yep, you can take that guy this way. And I'll keep fighting for every little step so that I can see the line. There's my line. And again, you know a lot of people right now would be like, ooh the bowel's right there. But that bowel doesn't mean anything to me 'cause as long as I see my line I'm safe, and here I can't quite see it, so... Lift up. I feel like she had another hernia. Yeah, more lateral. Or was that the one we just dealt with? We'll see. That's the external, the one that goes through this. I think that that must be up there. We'll switch table positions. You think that's it? No, I don't think so. I think that was her old stoma site. All righty. And another very important aspect right here is to not take the bait and go in the retroperitoneum. So when you're doing this dissection, you've gotta make sure that you stay out of the retroperitoneum 'cause that's subsequently where we need to be for the TAR. A lot of times in colorectal, the teaching is leave some abdominal wall on the hernia but that won't work - or on the bowel - that won't work for us. Can we go reverse T-Berg now please? Can we do reverse T-Berg? Absolutely. Thanks guys. Yeah, actually there's another hernia way out here. Oh dear. Oh, it's way out. That's good, table down. Table down. Another thing people always ask me is should you use the Bovie or the knife? And it doesn't really matter as long as you're working the line. So like right here, right? Like there's a temptation, just go through all this. But I won't take that. I'm gonna go find my line and I stay true to my line. And see, that's muscle, so that cannot be the line, but right back here it is. All right. Now what do I got left? We got this whole hernia way out here past the linea semilunaris, which looks like that's gonna be a tough one. A lot of times there's like a little rim around hernias, and if you can just get through that, you can get it all down. Yep, hand in there. Uh huh. Again, I'm gonna try to stay true on that line if I can see it. Yeah. And there's this little kind of rind right around the edges. Uh huh, lift up, lift up, there you go. And again, I still won't cheat, I want my line. So if you look out here, let's let go of this. So this is what will make this a challenging hernia, right? Is you've got liver, this defect way out here. This is at the old stoma site. I don't really understand why she has a defect here to be honest. She has no incisions. I don't know what this, she hasn't had an open coley. This is a bit of a weird one. Something happened there during one of her surgeries. We'll talk about all the surgeries she's had later, but something happened. So we'll figure that out later. All right, now we'll go ahead and take down the other side. Go ahead. Buzz. You could just check and see if it slides at all. I think you see how this is a good example. See, he's doing it wrong 'cause he can't see a line, so the line is over there. See, you're willing to buzz through stuff without seeing the line. It just makes it like a little less clean. That's your line there? Pull, pull, see you're not pulling hard enough. That's why you can't see the line. Okay. Looks pretty good actually. All the way around there, I'm liking it.
CHAPTER 4
Okay, and then for me, particularly anything complicated, I'll typically run the bowel. So this is her stoma take down where she has an ileo to transverse colon anastomosis. All that bowel looks good. I don't know the answer whether or not you need to lyse all adhesions, but you know when I'm putting a big piece of mesh in here and stuff, it is my preference to do that. You often can find stuff. I won't go crazy on it but like you know this is a good example. If you don't look at this, you just won't know, so... That should just be garbage to the retroperitoneum. And again, if you're gonna do anything complex ab wall stuff, it's critical - there can be no, and this is, she had a small bowel resection as well during one of her hernias, so that's that. Oh no I'm sorry I just went backwards. Yeah. To me, if you're doing complex ab wall stuff, you gotta be a hundred percent certain. This is her old anastomosis right here. Yep, that the bowel is okay. There can be no doubt. If there's a doubt, you must stop 'cause you only get one shot at these, so really gotta be a good GI surgeon first. And we're gonna put the blue towel in in just a second. But that goes in, signifying that there is no issue with the ab wall. I mean with the bowel. Or I would not put it in. This is that spot where she was probably obstructed. A little something there. Do you have 3-0 Pops? And I'll do every little serosal, anything. So you see we got a little something there. And for me, anytime I close a serosal thing - another stitch - I start at one end, I get that corner. Oop. I get the next corner. So this is kind of like an anastomosis. It's all lined up. Another stitch. Maybe two more. One more. Okay, you just take the corner, right? Then I take, I'll give you everything else as it comes. Five throws in this, okay? Okay. We'll cut 'em all at the end. Mhm, I'll teach you a little trick about cutting these. You'll be right every time if you just slide down, turn 90 degrees. It'll be just the right... It's hard from your angle being away from the field. I think that was just... To get it just right. Metz. Uh huh. Make sure we're okay. Yep, there's a ligament Treitz. Okay. All righty. Can we see - how about a tonsil real quick? Can I get a 2-0 tie? Let's do this, one more tonsil. Put a tonsil right there. 2-0 ties. All right, now we get to see if we got it. Mhm, you gotta slide down, yep. You gotta turn the other way. We'll take six Kochers next. Nope, you were right, coming that way, turn. Yep. That's what we got into a little bit.
CHAPTER 5
Okay, a bunch of Kochers please. Uh huh. All right, here. I'll get these two, you get that one. We'll take another Kocher please. You're gonna take the bottom two. Another Kocher. One more. And a wet blue towel please. All right and that guy's gonna, oh boy. Just, oop, no, you're good. Okay. And this is important to get everything out of the field so that we're safe. We're operating on the... And this by the way, for whatever reason, this is something that people just cannot replicate. So if you notice I'm putting my thumb back here and pushing it in with my fingers so I don't just move the whole towel over. It's a small thing but if this towel's not in there right, then there's bowel poking around the field and it just makes it dangerous, so you really want to take a second. Okay, now, oh you're okay, let's switch it. You can come off with that, switch it right here. Yeah. Okay, I'll take a ruler please. We measure from the widest point, which will be, lift up some, should be this guy way out here. No, come, lift up, its way out here. So there. That'll be 15. 22 by 28. Okay. He'll take the Bookwalter post, I'll take all your Laheys.
CHAPTER 6
Could we go T-berg please? This kind of shows you like the basic struggles of we have a hernia through the rectus muscle. We have a hernia at the linea semilunaris. So these are gonna be all kind of inherent struggles with retromuscular surgery, with lateral incisions and whatnot. So basic principles, number one, I'm gonna start away from that. And here I gotta make sure I'm in the retromuscular space, so I cannot progress until I see muscle. So you see that right there? That's a must. I have to see the rectus muscle. You cannot, a lot of times people will be like oh, oh, and these graspers must be at the edge. A lot of times people put the graspers in the hernia sac and what ends up happening is they don't see muscle and they think that they're in all this fat 'cause they're up in the hernia sac. So you know, everybody's got a rectus muscle unless it's gone. So a lot of times people say, oh it wasn't there. More often than not you're probably just in the wrong place. So I'm gonna come up and I'm gonna just follow this line, right? This is my linea alba, and I'm just gonna stay right on it and go from a known to unknown. Lemme wipe that tip off. And again, you see I gotta stay true to my plane and I'll just work around this little spot. This would be the same thing by the way, if there was a stoma right here, this is how we do it. I think later this week we're gonna do one but, and again you see I'm staying right up on my line here 'cause I need all this to close. You can see here I got a little hole but it's no big deal. I'll just address that later. And I'm staying very true to this line. A lot of people right here start to drift down. I don't wanna do that yet 'cause I need all this particularly in case I get in a bad hole situation out lateral. That's my posterior sheath, comes down. More Kochers. We'll take all the Kochers you got. So now I got my tracks and counter tracks. That's all I get. Again, kind of importantly, this hand's keeping everything nice and splayed out, and I'm just gonna stop at this little spot. And you'll see here comes the epigastric, coming right here, and I know that my linea semilunaris is just about one centimeter past that, so if you just engage right here and lift up. You can see right there's the epigastric, right here. And here comes the nerves right there, yeah. Right under there. And there's the nerve. Right, see, right here, and this little guy right there. So I'm gonna work around myself here. There's my nerve right there. I can nicely see it. And I am right up next to this guy. So now I'll come up to the top. And if you notice just kind of my principles of ab wall reconstruction is encircle the enemy, right? Like surgery 101 type stuff. So I'm not gonna obsess about the one hard area. I'm gonna do everything else first and I'll come back to that later. Can we flatten the table, please? Flatten the table? Yep. Okay, yep, no sweat. How about a little reverse T-Berg then? And here I'm gonna look for two other landmarks. It's gonna be the ribs and the superior epigastric. So here comes, the rib is right here. Just past, that's a nerve. That's probably T7 right here, and super epigastric is right there. I'll show it to you better once we change our retraction. And I want to be, another aspect of ab wall stuff, I gotta be as lateral as I can be without cutting nerves 'cause that's how you make fewer holes. So here's probably that other hernia. Here's my nerves right here. You gotta see that, hopefully. This is a nerve to the transverse abdominis. I'm gonna take him. But these are nerves to the rectus, which I want us to keep. So now I kind of got that down. So here, a lot of times people try and resect all this hernia sac. I don't think it's worth doing that 'cause you can always close this. So what I'll do is I'll just make a hole. Do you have two 3-0 Vicryl non-pops? And if there was a stoma right here, like this is how we do parastomals, right? Just make a hole and see it and work around it, and then just connect my planes. There goes my nerve, right? So you see there's my nerve, there's my inferior epigastric. Hold that up right there. Now hold up here. See this is a landmark, right? This is triangle, inferior epigastric, probably T11 maybe. And then linea semilunaris is right there And that's it.
CHAPTER 7
So here, can you hold this guy there? Yeah. I'm gonna keep these guys, and here's all my landmarks. This right here. This is my arcuate line. So I know if I start just above my arcuate line, there's my inferior epigastric and my intercostals are right here. Linea semilunaris is right there. I wanna be right in front of it, and I know I'll take down here posterior lamella and the transverse abdominis fascia, and then below the arcuate line, it's just transversalis fascia. And you'll see, I'll take that here. And then as I move up you'll start to get the muscle belly and again, importantly, I'm staying on a line as close to the lateral aspect as I can. And you'll see once I see the muscle belly, I'll stop. And there is your muscle belly, so posterior lamella is right here. This is probably the hernia right there. And once I got that, then I can head out and then there'll be two planes here we like to talk about, and a lot of this is just predicated on good tension. So if you look right back here is the plane that most people want to go, but all this fat. Can I see a Kittner? All this fat, that plane's gonna take you behind the psoas. So if I come here and there's a small difference, but this plane right here, leaves all that fat, gets right on the peritoneum, and then it will take me right to the psoas right there. And that avoids all of that fat and everything that goes along with all of that. So again, we can kind of head up. I am gonna work my way behind that lateral hernia. I'll take a lap pad and I'll give myself a landing zone. Okay, so now I got the whole bottom third done. I'll close that in a second. Can we go reverse T-Berg? Now I'm gonna come up and try and encircle this spot. So just as one quick little review, my hernia, as I said, it's right there, okay? So I'm right up next to it there. Now I'm gonna come on up to the top part. Can you fix the lights? And here we take posterior lamella of the internal oblique, and that's important 'cause that's gonna get us, you'll see the advancement it gets on the posterior stuff too. And that's the hernia. I'll just go ahead and drop posterior lamella. And then, we call this little area of the fat pad of pabu. It's always there. There's a little fatty area right in front of the rib, which is right here. And if you stay right on that... Then you can drop right down. And this will be diaphragm right here. So right there is diaphragm under the rib, and I'm gonna come back on that spot. And again, if I could really summarize what we've done over here, it's encircle the enemy, right? Like it's just surgery 101 to not be so worried about this one spot here that's gonna be hard and we're gonna come at it from all sides. And then there's kind of two planes here. Either one's acceptable. You can be in the pretransversalis or the preperitoneal. If it's thin, I'll go pretransversalis. I think it's a little bit more bloody if you do that. But if it's not, I'll just stay preperitoneal. Now I'm gonna work my way back behind everything and if I did it just right, should be able to come back here and be where my sponge was and now I can just come back up on the part that's hard with my fingers around, 'cause one of the issues people get into, what we see a lot of is, right here, 'cause people are worried about making holes. They go this way and they get into the lateral abdominal wall and kind of worsen these defects. And again, I don't worry too much about the hole, I just accept it. There's the hole. I try and limit it, but there's gonna be a hole there and I don't try and pull all the hernia sac out. I find that almost impossible. People get seromas. That's just kind of part of it. I'll close this later on. And now you can kind of see nicely. In our preperitoneal plane, we'll have mesh well behind this lateral defect, and actually this is kind of a nice shot. That's your external oblique. Can we get our suction on? I'm not gonna be able to fix that, not really, huh. Maybe I'll just catch it in this. Yep, that's our external oblique, kind of transverse abdominis. So somebody did something back here and got pretty lost. And that's it, there's your diaphragm. Gonna have excellent coverage, You can see the psoas right here. Somethin' bleeding? I don't think so. All right, now we're gonna look down here real quick. Yeah, okay. Not quite how far down we really are to be honest. Here we'll do a little bit in the pelvis just to fit our mesh. Wipe that tip off for me. And here comes her round ligament. We'll take big clips. Lemme get 'em to see it first. There's your round ligament. Go ahead, yep. One more clip. So inferior epigastric, round ligament. Okay, that's pretty good. Oh yep, I got it, let it go for a second. I clip that, or...? I dunno if it's clippable to be honest. It's like right in the ab wall. Like that.
CHAPTER 8
Okay, can I see some of those number one and a long Kocher. Actually I think I'm gonna do it with a long Kocher here. I'll keep my hand there. I'm gonna get external oblique, and this, I think we're gonna close this this way. You take that that way, I'll take the number ones. So we're gonna close all these defects out here laterally. These are just number one PDSs. Yep, snap that. I'll take another stitch. And go out the corner now. Just take that to you that way. Mhm. Okay, you can come off with that. Yep, you can cut that needle. Go ahead and tie that one. You can start from the bottom, yep. I'll take local next. Tight, tight. Scissors. Scissors? Do you have 3-0 non-pops? Go ahead and take one of those guys. Lemme just see what we got here. Hold that guy there for me. Now we're just gonna close this up with a 3-0 Vicryl. You gotta push that. Yep, just keep your hands out. I'll take a DeBakey. Oops. And this is probably the most important part of this operation, but this has got to be safe, otherwise you gotta do something else. And this is why I think it's important to understand how to do a TAR, 'cause the TAR is what really allows this to come together without tension. Okay, bring your hand out. Yeah, you can cut that, needle back, another 3-0. Scissors. Mhm, go ahead and follow me. Tie it up. I'll take the local. Okay, lemme just get him. Then we do a little TAP block, which probably doesn't do anything but appease anesthesia. Needle back. I think it was right here actually. I just injected a bunch of epi into it. Oh, hold on a second. That's probably okay. Let's come off here now. Can I see some more of those number ones? Just leave it, oops. And a Bonney. We'll close this guy too. Must be the old stoma site. Another stitch. Okay. Needle back, you start from the bottom. Get these guys closed and then get on the other side. Scissors. Okay.
CHAPTER 9
All righty, so just a few things here. Looking now I can immediately tell something happened down here, probably during one of her colectomies or something, people kind of damaged the abdominal wall, so I won't start there. Can I go reverse T-Berg? Of course, reverse T. And then this side, there's obviously no stoma, so it should be just a little bit easier to show everybody. I'll take a Bonney please. So again, these retractors have to be on the edge of the hernia, not in the hernia sac. Now I'm just gonna start somewhere where I think I got it, and right now I must see muscle. So as you see, I won't stop until I see and I fully confirm it. If I see fat, I'm in the hernia sac, I must go lower. If I see white, I'm on the posterior sheath and I'm not there yet. So now I'm gonna head up. This is another little trick a lot of people struggle with is this falci, particularly in heavier people. What I do, I just take it all down and then I'm actually gonna be above it all so I don't have to deal with it. So you see, I just leave it alone. It's out of the way of my closure. It'll be outta the way of our mesh. And I also like to kind of, you know, listen, I mean we can probably, one of the discussion points is you know, BMI cutoffs and whatnot. And obviously this is part of this study, we don't know the answer. But, you know, if you look here like this woman's not particularly obese right here and we're not raising any skin flaps. So, you know, if you're doing the operation this way, not raising a skin flap and just operating in the retromuscular space, you know the wound morbidity is, I'm not sure it's as big of a deal as we all think it is. Lemme get rid of this, a little bit of momentum left. And again, if you watch I just ride. Oh nope, that's wrong. Yep, that's right. I just ride this line. And here's where something happened before. There's something wrong over here. So I'll just kind of make sure that I stay true to the plane. Do you have a Kocher? Go ahead, I'm gonna have you grab that. There's a stitch right there. Grab that. Heavy scis? Oh, try it again. Right there, twist it out. Another important aspect I think is to get all these old stitches outta here. Yeah, there's more here. I'm gonna get you exposure though. Get this guy right there. See that? I'm a big advocate of getting all the old stuff out. And again, I'm just gonna work that line from my known to my unknown. A bunch of Kochers please. So now I'm gonna head out here again, try and find my nerves. And here it comes. Most of these nerves give a little back branch to the transversus abdominis. You can take that, and then they come up. It'll get you a little bit more lateral. Like that's a back branch. And then my landmark, when I know I'm far enough will be the rib, which will be right there. And there's my superior epigastric and there's probably T7 right here. I want all that exposed. That's probably, yeah, there's the nerve penetrating right there. Can we do a little T-Berg please? And again, if you really kind of listened to this, the whole case, I've been moving the table around constantly. That's another way to really help yourself with heavier folks. Just let gravity work for you. So again, I'll go back down to my landmarks. So here comes my, go ahead and grab that. Here comes, here's my arcuate line. He's gonna, nope, grab the inferior epigastric, lift it up. He's gonna lift that up, and I know, here it is, this is one of my triangles. There's inferior epigastric, right there is probably T11, L1, and that will be my linear semilunaris. That means I'm as lateral as I need to be to start my TAR. Just real quick, let me... It'll be easier to expose for the... Oh, something bleeding a bit there. And then sometimes I can just get around as long as I'm on the pubis, I can work my way around, come up here, and I just connect the two dots. And now I'm all the way to the pubis without extending my incision all the way down there, which is important for healing perspective. Something's going right over here. Hold on. Wait a minute. Yep, there it is. Do you have a small clip? See this guy here? Go ahead and you get it with the small clip. Yep, gimme one on the other side. Yep. Go one under it. Yeah. I'll take one more clip for me. Lemme come at it this way. Okay, we'll take the Riches now.
CHAPTER 10
So here's my inferior epigastric right up here and here comes my intercostals. Let's mark your line. Can I wipe that tip off real good? Thank you. So if I start right at the arcuate line. And I have good depth control with my Bovie. And I just skim off those nerves, that's why I want to be all the way to the edge of them. And you'll see in a second. And here comes transverse abdominis muscle. Usually once I get there I stop. And I'll come on down here and I know my anatomy so I know that right now all I got to transversalis fascia. And again with good tension. And I want to be on the, hold on a second. I'll take a Kittner please. I don't want to be up here on this line. I want to be on this line because that's gonna take me right over to the psoas and avoid fighting, and there's my psoas right there, avoid fighting all of this retroperitoneal fat. And I'm just gonna take that up a little and then we'll just, while we're down here, we will just take care of this real quick. This will be my round ligament. I could fix an inguinal hernia if she had one. There it is. And there's your round ligament, yep. And I know that 'cause I see my inferior epigastric right here. It's going just lateral to it. Okay, so that takes care of my bottom part. Can we go reverse T-Berg now? Reverse T coming up. Then up here, I don't really need to do a whole ton. This is more about just getting the perineum closed. I want to cheat the mesh over to my other side. So posterior lamella, internal oblique. Then we got our transverse abdominis. Wanna be as lateral as I can be. And this confuses a lot of people. This right here is diaphragm that I'm pulling really hard, right? That's rib. I need to be not here. I need to be under that muscle. There could be no muscle down. If you see, if I extend it over right, that's her diaphragm. That must go up. Now I can see, right? I did the bottom third. It's gotta connect now, these two dots, this will be transverse abdominis. I'm gonna take, now I've already taken posterior lamella, internal oblique. And - just a little bit more out here. And then I can just connect the two. Yep, Bovie. Okay, and that's it. I'll get my whole side out there. Up under there if I need a little, see if anything's gushing, something's bleeding right there, Bovie. All righty. We'll take the local. Do our little TAP block over here. Okay, can we do a little T-Berg real quick? Actually, you know what? Nope, you're fine. All right, we're gonna swing this guy around real quick.
CHAPTER 11
So now I got posterior sheath, posterior sheath. I'm just gonna take the posterior sheath insertion off. Join up with our TAR over here. No matter what you do, there's always a little bit more diaphragm right here. And you see this right here? This is that little extra diaphragm that if I don't take this, I'm creating a Morgagni hernia basically. Yeah, probably, can I see the dry lap? Lemme see, I might have gotten it already. And it's important this diaphragm, 'cause there's the rib, must go up. So it's this retraction that is allowing this to be safe. Same thing over here. There's that little bit of diaphragm left and it's always there. Oop, oh, making a hole, shoot. He'll take a 3-0 pop. And now here's the cinch 10 of the diaphragm. Right. All the diaphragm is up. Hold on there. And that little white right there, that's your cinch 10 in the diaphragm. We could tuck our mesh. There's costal margin. Costal margin. Little bit more there. Hold on, something's going up here. Right there. You might need a DeBakey. Grab, just grab that. Yep. That looks a little better. Lemme just see here. I don't wanna go too, I don't really need that much more to be honest. What about, hold on a second, let's make sure we're not bleeding up here. He'll take it, one second. Okay.
CHAPTER 12
Alright, he'll take the 3-0. Let's get you here, hold on a second. You got two drains, 30 by 30. Okay. I'm gonna use it here. I don't want to - although, again, so that's pretty - it might be a 40 by, I don't think it's a 50 by 50, you know. And I think the truth is that left side over here, there's nothing, we'll be fine on the midline, so like I might just edge it over to this side just a bit. I think we'll be okay. We'll make sure the wings are like a little higher, you know? So I'll trim off the top part. And I'll take a 2-0 for me.
CHAPTER 13
So now we got kind of the whole visceral sac. Let's get rid of all this guys. I don't think there was anything on your side I don't think. Is there? Okay. Looks pretty white too. And - nothing else back there. And then, most important thing, right? You know you didn't do a TAR if this doesn't come together easy, Bonney, and a 2-0? That's the real advantage. I mean that's what the TAR is really for, which is important is for the posterior sheath closure. Go ahead and tie that up. And this is the Achilles heel of this operation. If this isn't a good closure and this breaks down, you get in big trouble. Okay, we should do our count. Pull back up. I think we might need some 3-0 Pops on some of this over here. We'll see. Yep, I'll take a Bonney and another 2-0. And then we should be good for a bit. And a Bonney? Nope, got it. Yep, tie 'em up. Another trick is if you leave this blue towel in to the bitter end, you don't risk catching the bowel. Yep. And then those Kochers. Remind me to take out this towel. You needed a 2-0, right? One 2. And this really should always be closing without tension. If you're finding it too much tension, you didn't really do a TAR and you gotta make an adjustment. Yep, tie them up. Yep, right there, two needles back. Can I see a 3-0 pop when you get a second too? I feel like I need a little something right here. I think that might do it. Yeah, that looks pretty good. Okay. You wanna turn the other way actually? Turn this way? Yeah, yep. Oh the bottom two. Hold on, two needles back there. Can I see another two Kochers please? And the mesh. Can you take the bottom two? And don't put it down on the skin actually there, yeah.
CHAPTER 14
Okay, this will be a 30 by 30 piece of mesh. I'll take scissors. And I'm gonna trim it off just a little bit to cheat it up to catch this one in the top. So you'll see by getting this corner off, what I'll do is I'll be able to hit it down in the diaphragm more - you take top two. And I'll let it wing out hopefully to appropriately catch. And we don't use any transfascial sutures anymore. We did a big randomized control trial that shows you don't need it. I think the key though is you do need a lot of overlap. So you know we got pretty extreme overlap here, which is why we feel like you don't need them. Yeah, that's good, it's right there, we got plenty of coverage.
CHAPTER 15
Okay, can we go reverse T-Berg? Yep, there is... Two drains. You wanna sub-q on this one? I dunno. Maybe, let's see how it looks. You hold that guy right there. Yep, right there. Sharpie back, another drain please. Just lemme look at that, I was kind of blind. I think I'm okay. And we put two drains out in the gutters. Again, push down. I want to see kind of right over there. Cut. Sharpie. Okay, can we go T-Berg? I'll take your number ones. All your snaps. There's a Sharpie back. Yep.
CHAPTER 16
We might be cutting more, we'll see. Maybe not. Okay, we'll take all your snaps please. And I'll take the number ones.
CHAPTER 17
We got it. Cut right there. And I'll take the not so small needle driver please. It'll be with the next stitch, hold on just a second. Yeah, I'll switch up after this stitch. She doing okay? Yeah, she's doing good. And then I like to close these incisions with figure of eights. Certainly many people run 'em. I don't think it has anything to do with hernia recurrence, but I think if you do it right and you put them, don't travel. Yep, go, cut. As soon as he snaps down, cut. If you don't travel in between, another stitch. Yeah, be ready with the next one, okay? That should be cut and ready to go, so we can just kind of, oh, you got it, perfect. I'm gonna need four more so you can go ahead and load up the next one. I like to not travel in between, only travel within these stitches. And that way if there's a little issue with the wound or anything, it protects the mesh. Versus a running. Things get loose pretty quick. You've got a little early wound, but can we level table please? Level? Yep. And what other medical stuff does she have? Hypertension, lipidemia, she's diabetic, poorly controlled. Okay. Okay. Yeah, I'll take a peek, we're almost done. Cool. What time did we cut skin? Do we know? 10:05. What time is it? 11:55. Yeah, two hours. Another stitch, needle back. Does she smoke? I don't believe I saw that. No. Okay. At least she don't do that. Okay, can we see one extra drain when you got a minute too? Let's do it. I think we need one more sub-q, I like it. Needle back. And then the advantage to me of this Is when you pull 'em up like this, if you do it just right and we let go of everything, it all stays where it should. You start from the top, I'll do the bottom. Get ready to cut for us. Can I get another scissor? That's fine. Yes there is. And scissors up here, yeah. There you go. I think one of the important things is you see us kind of doing these large complex hernia repairs on obese patients. There is no skin flap here. And we don't create skin flaps, so I think that doesn't apply if whatever operation you're doing involves a large skin flap. And I think that, you know, often we talk about hernia repair, we don't kind of break it down to the technique that's been done and that has a huge impact on wound morbidity. All right, I might say, I might not cut anything out to be honest, but I might give her like a nice innie, you know, give her this with your 3-0. You know if you need to cut some of that? I would not, to be honest with you. I'd leave it with her belly button. It's okay, 'cause this, she know she doesn't have much of a flap here, so you're just gonna put more tension on it. Do you have a drain?
CHAPTER 18
Like, you see, she doesn't have like that thin skinned hernia sac stuff, so I wouldn't do it. What I would do is we're gonna put a drain kind of right here and then tuck her belly button down to kind of do it. Do you have a 2-0 Vicryl? Let's go like this. I'll take a 2-0 Prolene. Sharpie back. And then why don't you cut this guy right there. There's one thing we are kind of experimenting with leaving drains in obese people. He'll take one, too. You can cut this, needle back. Do you have one more 2-0 of prolene too? Yes. Okay. And cut, another Prolene. Oh, thank you. Needle back. I think we can put her on the pathway too. You know, there wasn't a whole lot of bowel stuff. The one thing I would just say that's a little controversial here, cut, is should we have drained this stuff. I mean I just accept a seroma to be honest with you. Like it's a pain if you try and put it from below, then where we're stitching, you can catch it. Most of the time, she wears a binder, it'll go away. Okay, sweet.
CHAPTER 19
Okay, so hopefully you guys enjoyed the case. I think it presented a lot of the unique challenges that we thought we were gonna see. I think for me, kind of key highlights that I like everybody to learn when watching us do complex abdominal reconstruction is number one, getting in safely. So take the time to watch that video and how we track the line of the abdominal wall and how we don't try early to get in through the falciform ligament into the peritoneal cavity, and we just ride that line, taking the midline down, and then working laterally. 'cause for me, a lot of these abdominal wall reconstruction cases are about setting up lines, the midline, the lateral line, and then the cut lines. And if you can set it up that way and you truly see the lines of dissection, it makes it a lot less bloody and a lot more dissecting in potential planes. That's number one. Number two is some of the tricks about working around the abdominal wall, particularly when there are lateral defects. And while there's going to be holes in the abdominal wall, those holes can be limited and typically easily closed. And then also importantly, we didn't talk about it before, but we've done a lot of work on how a TAR actually works, and I think it's really important for any surgeons operating in the retromuscular space to understand why you're making the releases and what they're achieving. And the posterior rectus sheath release is to allow the midline to come back together. It does nothing for the posterior sheath. The posterior sheath advancement comes from the posterior lamella and the internal oblique, and the transversus abdominis muscle. In that dissection, and then carrying that out in the retroperitoneum, as you can see for a fairly large defect, I think what most people would agree is loss of domain. We're able to close the posterior sheath with very little tension and a much safer operation. So that's another key point is if you're doing these operations and the posterior sheath is closing with excessive tension, it is almost always because you did not do the transversus abdominis release and you're lost in the abdominal wall. And then finally, wide coverage, large pieces of mesh. We don't typically use transfascial fixation sutures anymore, as long as we're not in a bridging situation, which we weren't in this case. And then managing the skin and sub-q, we did put a drain in. That's something that we're studying right now. But certainly operating on thicker patients can be quite a bit more challenging. And then finally, just expectations for these patients. Most of them are in the hospital about three days or so. Typically the drains come out before they leave. Sometimes the sub-q drain won't. We'll put them on a liquid diet tonight, a regular diet if they're tolerating it tomorrow. And as I said, home on the third day for most patients. And that's it. Just a couple highlights of some of the studies that we talked about and kind of how it relates to surgery and whatnot. So first of all, a published study that we did, Ryan Ellis is the first author. Gita Pabu was the primary investigator. She's the senior author on this. And this was looking at about 325 open complex abdominal wall reconstruction cases where we did not bridge the fascia, where the anterior fascia was closed and all of them had synthetic mesh. Half of them got transfascial fixation sutures and half did not. I used to be a big advocate for placing those sutures, but in fact there was no difference at all. Interestingly, there was no difference in pain either. So if you feel like you need them, there's no harm in putting them. But for the past couple years, as long as I can close the anterior fascia, we do not put transfascial sutures. The second study is an ongoing study. We're about a third of the way done right now, and this patient was enrolled in it, and this is kind of asking the question about preoperative optimization. And I want, this is a very nuanced conversation, 'cause to be clear, all of us should want to, and in being a good doctor, having patients quit smoking, get their diabetes under control, and get their BMI down, and I'm not here to argue that point, but we have become so hardened and made such strict cutoffs that our group has questioned, are we denying surgery to a group of patients that might benefit from that operation due to some perceived risk that is so prohibitively high that it's not safe to operate on them? And we don't really know that answer. I think we know with reasonable certainty that operating on obese diabetic smokers, there's going to be some early higher rates of wound morbidity. But the question is does that wound morbidity result in mesh infections and hernia recurrences, or is it just minor problems that we treat through? And I think as I said before, and as you see in the video, during the operation, we're not raising skin flaps. So the wound morbidity for many of these patients is much, much less, and the mesh is behind the muscles. So the point of this study is to figure out at one year after being either randomized to six months of ideal medical weight loss, dieting, exercises, and potentially drugs versus just going ahead and operating on these patients and weathering the storm, what are the best outcomes? And we'll be able to determine how many people show up for an emergency operation while waiting for optimization. And if we just operate on people and they get better, do they go on to go ahead and lose weight, exercise, and regain their health? And the other piece of this that a lot of folks haven't thought about is that by denying surgery to obese diabetic smokers, we know that the healthcare disparities in that group are much greater. And we know that the majority of folks in that group tend to come from lower socioeconomic status or they're doing manual labor and they need to get back to work and they might have insurance issues. So when you continually deny folks the chance for an operation, you might be inadvertently worsening healthcare disparities. So understanding the risks and also what risks matter. I would argue a seroma, it's not meaningful enough. I would argue a superficial surgical site infection that doesn't involve the mesh is not enough to deny surgery. Mesh infections, mesh removals, chronic problems, that's real. Higher hernia recurrence rate, that's real. So that's what we're looking at with these studies. And again, you know, we'll see what we see.