1. Ventral Hernia: Challenges and Choices George S. Ferzli MD, FACS Professor of Surgery, State University of New York

3. Is the Abdomen a Weakness in the Human Race ?

7. Wound complications related to stitch length Effect of Stitch Length on Wound Complications After Closure of Midline Incisions; A Randomized Controlled Study, Millbourn, D MD; Cengiz, Y MD, PhD; Israelsson, L MD, PhD Arch Surg/vol 144 (No. 11), Nov 2009 www.archsurg.com Stitch length a Fisher exact test. Complication Long Short P Value a Wound dehiscence, No. (%) of patients 1/381 (0.3) 0/356 .99 Surgical site infection No. (%) 35/343 (10.2) 17/326 (5.2) .02 Incisional hernia No. (%) 49/272 (18.0) 14/250 (5.6) .001

8. Significant predictors of surgical site infection and incisional hernia a Effect of Stitch Length on Wound Complications After Closure of Midline Incisions; A Randomized Controlled Study, Millbourn, D MD; Cengiz, Y MD, PhD; Israelsson, L MD, PhD Arch Surg/vol 144 (No. 11), Nov 2009 www.archsurg.com Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); CI, confidence interval; OR odds ratio; SL, suture length; WL wound length A Results of logistic regression analysis. All recorded variables were included in the model and removed by a backward reduction strategy if nonsignificant. Predictor Regression Coefficient (SE) OR (95%CI) Surgical site infection Wound contamination 1.03 (0.48) 2.81 (1.09-7.25) Being diabetic 1.01 (0.38) 2.73 (1.30-5.72) Long stitch length 0.77 (0.31) 2.15 (1.17-3.96) Incisional hernia Male sex 0.76 (0.34) 2.14 (1.10-4.15) Higher BMI 0.05 (0.02) 1.05 (1.01-1.10) Longer operation time 0.005 (0.002) 1.01 (1.002-1.01) Surgical site infection 1.16 (0.40) 3.18 (1.44-7.02) SL to WL ratio <4 1.32 (0.52) 3.73 (1.36-10.26) Long stitch length 1.44 (0.34) 4.24 (2.19-8.23)

9. Conclusions Effect of Stitch Length on Wound Complications After Closure of Midline Incisions; A Randomized Controlled Study, Millbourn, D MD; Cengiz, Y MD, PhD; Israelsson, L MD, PhD Arch Surg/vol 144 (No. 11), Nov 2009 www.archsurg.com When a long stitch length is used, the suture cuts through or compresses soft tissue included in the stitch. This increases the amount of devitalized tissue in the wound and may explain the correlation with infection. This also causes slackening of the suture, which allows the wound edges to separate and increases the risk of incisional hernia. • Surgeons should place stitches 5-8 mm from the wound edge, with minimal tension applied to the suture. • Midline incisions should be closed with a single layer, running monofilament suture and the SL to WL ratio should be at least 4. This ratio should be achieved with several small stitches that incorporate aponeurosis only.

10. Ventral Hernia: Anatomy

11. In humans the intra-abdominal pressure ranges from 0,2kPa (resting) to 20 kPa (maximum). Pressure

13. Ventral Hernia Mesh Positioning: Onlay l

14. Ventral Hernia Mesh Positioning: Inlay l

15. Ventral Hernia Mesh Positioning: Underlay

16. Ventral Hernia Mesh Positioning: Intraperitoneal

30. Properties of Absorbable Barrier-Coated Meshes

31. Ventral hernia repair - Mesh portfolio Open Open/Lap Hiatal Parastomal Covidien PCO OS PCO PPC PCO2H Coming soon Bard Ventralex (umbilical) Kugel composix Composix E/X Composix L/P Crurasoft Bard CK Ethicon Proceed Gore Dual mesh Atrium C-Qur

56. Competition Evaluation Covidien Pariextex Composite Bard Composix E/X Bard Ventralex Ethicon Proceed Atrium C-Qur Gore Dualmesh Genzyme Sepramesh IP Adhesion prevention +++ + + + ? + ++ Tissue integration ++ + + + + - ++ Shrinkage + + + + + - + Elasticity ++ - - + ? - + Ease of fixation ++ + ++ + + - + Protected edge Y Y Y N N N N

58. Biomeshes

59. Level of Complexity Grade 1 Low risk of infection Low risk of complications Grade 2 Smoker Immunosuppressed Obese Diabetic Grade 4 Active infection Infected mesh Grade 3 Contamination risk Stoma present Violation of bowel wall Previous Wound infection Grade 5 Traumatic fascia loss Extensive fascia loss Percent Performed Open Patients with co-morbid conditions have up to 4x increase in wound-infection rates Open incisional hernias are 10x more likely to have infection than a clean surgical case Infected mesh commonly results in a 2 nd procedure for removal Synthetic Biologic

60. Massive Incisional Hernias

78. FlexHD Musculo-Skeletal Foundation (MTF) Acellular dermal matrix from Human allograft skin . Alliance between Ethicon and Musculoskeletal transplant Foundation (MTF). Prehydrated with no need for refrigeration .

80. Permacol Supplied sterile, hydrated & ready-to-use Flexible and strong Flat, continuous collagen sheet Easily cut to desired shape

81. Patented Process used to Manufacture Permacol Porcine dermis Extraction of Cells, RNA, DNA Collagen structure maintained Crosslinking for durability Extraction of fat Permacol

90. Components Separation

91. Grevious MA. Cohen M. Shah SR. Rodriguez P. Structural and functional anatomy of the abdominal wall. Clinics in Plastic Surgery. 33(2):169-79, v, 2006 Apr. External oblique Internal oblique Transversus abdominis Rectus abdominis Components Separation

93. Case Report

95. Abdominal Wall Reconstruction: Lessons Learned From 200 “Components Separation” Procedures Jason H. Ko, MD; Edward C. Wang, PhD; David M. Salvay, MS; Benjamin C. Paul, BA; Gregory A. Dumanian, MD Abdominal Wall Reconstruction: Lessons Learned From 200 “Components Separation” Procedures. Ko, J, MD; Wang, E, PhD; Salvay, D, MS; Paul. B, BA; Dumanian, G, MD ArchSurg/vol 144 (No. 11), Nov 2009 www.archsurg.com Large complex hernias can be reliably repaired using the components separation technique despite the presence of open wounds, the need for bowel surgery and numerous co-morbidities . The long-term strength of the hernia repair is not augmented by acellular cadaveric dermis but seems to be improved with soft polypropylene mesh.

96. Abdominal Wall Reconstruction: Lessons Learned From 200 “Components Separation” Procedures. Ko, J, MD; Wang, E, PhD; Salvay, D, MS; Paul. B, BA; Dumanian, G, MD ArchSurg /vol 144 (No. 11), Nov 2009 www.archsurg.com Figure 1. Modified “components separation” technique using bilateral transverse subcostal incisions to access the external oblique muscle and fascia . A, Using a narrow Deaver retractor and a Bovie cautery with and extender, the external oblique muscle and fascia are divided superiorly (above the rib cage) and inferiorly. B, At the caudal aspect of the midline incision, the cut edge of the external oblique muscle and fascia is delivered using manual traction for complete release.

97. Abdominal Wall Reconstruction: Lessons Learned From 200 “Components Separation” Procedures. Ko, J, MD; Wang, E, PhD; Salvay, D, MS; Paul. B, BA; Dumanian, G, MD ArchSurg /vol 144 (No. 11), Nov 2009 www.archsurg.com • Senior author Gregory Dumanian adapted his surgical technique to perform the external oblique releases through bilateral transverse subcostal incisions to avoid wide undermining, an evolution of the technique of “periumbilical perforator preservation .” Releases take only 15-20 minutes to perform and avoid the setup of endoscopic equipment.

98. Abdominal Wall Reconstruction: Lessons Learned From 200 “Components Separation” Procedures. Ko, J, MD; Wang, E, PhD; Salvay, D, MS; Paul. B, BA; Dumanian, G, MD ArchSurg/vol 144 (No. 11), Nov 2009 www.archsurg.com Figure 2 “Components separation” technique with midline approximation of the rectus abdominus muscles. A, No mesh. B, Acellular cadaveric dermis underlay. C, Soft polypropylene mesh underlay.

99. Abdominal Wall Reconstruction: Lessons Learned From 200 “Components Separation” Procedures. Ko, J, MD; Wang, E, PhD; Salvay, D, MS; Paul. B, BA; Dumanian, G, MD ArchSurg/vol 144 (No. 11), Nov 2009 www.archsurg.com Figure 3 A 41-year old man with a history of a perforated appendix treated through a midline incision who later developed an incisional hernia. A, Preoperative oblique view after a hernia repair with polypropylene mesh by another surgeon. B, Preoperative computed tomography scan demonstrating the small bowel herniating to the right of the polypropylene mesh, with wide displacement of the rectus abdominus muscles. C, Six-month postoperative oblique view demonstrates restoration of abdominal wall continuity. D, Postoperative anterior view demonstates stable midline closure and bilateral transverse subcostal incision scars.

100. Abdominal Wall Reconstruction: Lessons Learned From 200 “Components Separation” Procedures. Ko, J, MD; Wang, E, PhD; Salvay, D, MS; Paul. B, BA; Dumanian, G, MD ArchSurg/vol 144 (No. 11), Nov 2009 www.archsurg.com Figure 4. Predictors of hernia recurrence and major and minor complications using logistic regression controlling for mesh type and follow-up duration. Error bars represent 95% confidence intervals. BMI indicates body mass index.

101. Abbreviation: NA, not applicable. a Includes patients in whom components separation was performed concurrently with panniculectomy or parastomal hernia repair. a Major complications include hematoma, infection that requires incision and drainage, repeated operation for any complication, myocardial infarction, pulmonary embolus and death. c Minor complications include cellulitis, seroma that requires aspiration, skin sloughing and wound breakdown. d Fisher exact test for categorical variables and the F text for continuous variables. e Statistically significant. Abdominal Wall Reconstruction: Lessons Learned From 200 “Components Separation” Procedures. Ko, J, MD; Wang, E, PhD; Salvay, D, MS; Paul. B, BA; Dumanian, G, MD ArchSurg/vol 144 (No. 11), Nov 2009 www.archsurg.com Rates of Recurrence and Complications Based on Type of “Component Separation” Repair a Type of Repairs Patients No. Follow-up Mean mo Recurrence No. (%) Time to Recurrence Mean mo Major ComplicationsNo. (%) b Minor Complications No. (%) c No mesh 158 9.6 36 (22.8 ) 14.3 40 (25.3) 30 (19.0) Poly propylene 6 5.4 1 (16.7) 9.9 1 916.7) 2 (33.3) Cadaveric dermis 18 14.7 6 (33.3) 17.8 4 (22.2) 3 (16.7) Soft polypropylene 18 13.8 0 NA 3 (16.7) 3 (16.76) Total 200 10.3 43 (21.5) 14.8 48 (24.0) 38 (19.0) P value d 0.20 0.04 e 0.92 0.92 0.80

102. The components separation technique many be an ideal hernia repair for large defects because it weakens or loosens the contracted sides of the abdominal wall to augment the midline repair. Increased lateral wall compliance may reverse the lateral abdominal wall disuse atrophy and fibrosis seen in animal incisional hernia models. Abdominal Wall Reconstruction: Lessons Learned From 200 “Components Separation” Procedures. Ko, J, MD; Wang, E, PhD; Salvay, D, MS; Paul. B, BA; Dumanian, G, MD ArchSurg/vol 144 (No. 11), Nov 2009 www.archsurg.com Observations

103. The midline movement of tissue with the components separation technique permits the excision of all scarred and inflamed tissues. Abdominal Wall Reconstruction: Lessons Learned From 200 “Components Separation” Procedures. Ko, J, MD; Wang, E, PhD; Salvay, D, MS; Paul. B, BA; Dumanian, G, MD ArchSurg/vol 144 (No. 11), Nov 2009 www.archsurg.com Observations

104. • The hernia recurrence rate with a cadaveric dermis underlay was even higher than that for primary closure. At the time of repeated operation the cadaveric dermis was often difficult to find and when present, large holes in the material itself, were often noted . • Cadaveric dermis alone does not provide long-lasting or durable results in abdominal wall reconstruction and should therefore, be reserved for contaminated wounds, where a prosthetic mesh is best avoided. Abdominal Wall Reconstruction: Lessons Learned From 200 “Components Separation” Procedures. Ko, J, MD; Wang, E, PhD; Salvay, D, MS; Paul. B, BA; Dumanian, G, MD ArchSurg/vol 144 (No. 11), Nov 2009 www.archsurg.com Observations

105. Abdominal Wall Reconstruction: Lessons Learned From 200 “Components Separation” Procedures. Ko, J, MD; Wang, E, PhD; Salvay, D, MS; Paul. B, BA; Dumanian, G, MD ArchSurg/vol 144 (No. 11), Nov 2009 www.archsurg.com Conclusions: • A major lesson learned over the years is that handling of the skin is important, especially in patients with an elevated BMI. Wide undermining of the skin to release the oblique musculature disrupts the perforator blood flow to the midline abdominal skin, thereby contributing to wound complications in these patients.

106. Abdominal Wall Reconstruction: Lessons Learned From 200 “Components Separation” Procedures. Ko, J, MD; Wang, E, PhD; Salvay, D, MS; Paul. B, BA; Dumanian, G, MD ArchSurg/vol 144 (No. 11), Nov 2009 www.archsurg.com Conclusions : • Another skin-handling technique is to perform a panniculotomy at the time of the components separation for morbidly obese patients with infraumbilical hernias (repairs of hernias that extend above the umbilicus are generally performed using vertical midline incisions). A third improvement for skin handling is the use of short-term subatomospheric pressure dressings as immediate postoperative dressings in patients with an elevated BMI, gross contamination and large suprapubic dead spaces . This “semi-closed” technique for skin management had led to decreased seroma formation and infections in addition to allowing access to the midline fascial closure in the immediate postoperative period.

114. Questions???