Questions: Component Separation Self Check (Part 5) Questions: Component Separation When learner completes the surgery Dr. B asks a few questions, that also show up on the screen with multiple choice answers:] [Correct answers are in bold and underlined.] Ventral Hernia Repair 1 Component Separation

Component Separation Learning Objectives After completing this section, you will be able to: State the purpose for using the component separation technique in ventral hernia repair procedures Select the appropriate surgical instrument and perform each step of component separation Name the surgical instruments being used in the surgery Evaluate whether or not additional advancement of component separation is necessary Suggest two methods of additional advancement List the steps required to perform each method of component separation additional advancement [Learning Objectives – as Dr. Beokay states them, they should also appear on the screen] Voice Over (Dr. Beokay): First, let’s discuss the key learning objectives you should focus on while learning about component separation for this surgery. After performing the component separation yourself, you should be able to: State the purpose for using the component separation technique in ventral hernia repair procedures Select the appropriate surgical instrument and perform each step of component separation Name the surgical instruments being used in the surgery Evaluate whether or not additional advancement of component separation is necessary Suggest two methods of additional advancement List the steps required to perform each method of component separation additional advancement Ventral Hernia Repair 2 Component Separation

Self Check: Question 1 What is the purpose for performing a component separation in ventral hernia procedures? Select all that apply. It speeds up the hernia repair surgery It provides stronger tissues with which to attach the mesh It enables the rectus abdominal muscles to reach each other so they can be sutured together to cover the defect Post-surgical abdominal function is maintained – most patients are able to rotate their body after healing VO Dr. B: What is the purpose for performing a component separation in ventral hernia procedures? Select all that apply. It speeds up the hernia repair surgery It provides stronger tissues with which to attach the mesh It enables the rectus abdominal muscles to reach each other so they can be sutured together to cover the defect Post-surgical abdominal function is maintained – most patients are able to rotate their body after healing Ventral Hernia Repair 3 Component Separation

Self Check: Question 2 Which surgical instruments are used in the component separation when the external oblique muscle is being separated from the internal oblique muscle? Select all that apply. Kocher clamps are being used to pull the tissue tautly Electrocautery is being used to dissect the tissues from each other A Right-Angle clamp is being used to guide the electrocautery Surgical scissors are used to snip and separate the tissues from each other 2. VO Dr. B: Which surgical instruments are used in the component separation when the external oblique muscle is being separated from the internal oblique muscle? Select all that apply. Kocher clamps are being used to pull the tissue tautly Electrocautery is being used to dissect the tissues from each other [A Right Angle clamp is being used to guide the electrocautery] Surgical scissors are used to snip and separate the tissues from each other Ventral Hernia Repair 4 Component Separation

Self Check: Question 3 What are the two methods used for additional advancement of component separation if the two rectus abdominis muscles do not reach each other? Select all that apply. Posterior Sheath Elevation Anterior Sheath Elevation External Oblique Muscle Elevation Internal Oblique Muscle Elevation 3. VO Dr. B: What are the two methods used for additional advancement of component separation if the two rectus abdominis muscles do not reach each other? Select all that apply. Posterior Sheath Elevation Anterior Sheath Elevation External Oblique Muscle Elevation Internal Oblique Muscle Elevation Ventral Hernia Repair 5 Component Separation

Self Check: Question 4 When is it necessary to use additional advancement techniques for component separation? Select only one answer. When about one or two more centimeters will enable the rectus abdominis fasciae to meet comfortably When the rectus abdominis fasciae meet comfortably When the external oblique muscle can’t be separated from the internal oblique muscle When the defect is smaller than one to two centimeters 4. VO Dr. B: When is it necessary to use additional advancement techniques for component separation? Select only one answer. When about one or two more centimeters will enable the rectus abdominis fasciae to meet comfortably When the rectus abdominis fasciae meet comfortably When the external oblique muscle can’t be separated from the internal oblique muscle When the defect is smaller than one to two centimeters Ventral Hernia Repair 6 Component Separation

Self Check: Question 5 Which procedure provides the most advancement after performing the component separation? Select only one answer. Separating the external oblique muscle from the abdominal wall Making an incision in the middle of the rectus abdominis sheath Separating the anterior sheath from the rectus abdominis muscle laterally Separate the posterior sheath from the rectus abdominis muscle medially VO Dr. B: Which procedure provides the most advancement after performing the component separation? Select only one answer. Separating the external oblique muscle from the abdominal wall Making an incision in the middle of the rectus abdominis sheath Separating the anterior sheath from the rectus abdominis muscle laterally Separate the posterior sheath from the rectus abdominis muscle medially [Note: Need to determine what should happen in response to correct and incorrect answers] [Note: End of component separation] Ventral Hernia Repair 7 Component Separation

Self Check: Results [questions component separation] Ventral Hernia Repair 8 Component Separation

Questions: Onlay Position Self Check (Part 5) Questions: Onlay Position When learner completes the procedure Dr. B asks a few questions, that also show up on the screen with multiple choice answers:] [Correct answers are in bold and underlined.] Ventral Hernia Repair 9 Onlay Position

Onlay Position Learning Objectives After completing this section, you will be able to: Perform the steps to implant the Strattice® Tissue Matrix using the Onlay (Overlay) position Identify the appropriate surgical condition in which Strattice® Tissue Matrix can be positioned in the Onlay position Explain how to prepare the Strattice® Tissue Matrix before proceeding with the implant Explain how the Strattice® Tissue Matrix will be sutured and to which tissues Name advantages of using the Onlay position [Learning Objectives – as Dr. Beokay states them, they should also appear on the screen] Voice Over (Dr. Beokay): First, let’s discuss the key learning objectives you should focus on while learning how to implant the Strattice® Tissue Matrix in the Onlay position to reinforce the repair. After completing this section, you should be able to: • Perform the steps to implant the Strattice® Tissue Matrix using the Onlay (Overlay) position • Identify the appropriate surgical condition in which Strattice® Tissue Matrix can be positioned in the Onlay position • Explain how to prepare the Strattice® Tissue Matrix before proceeding with the implant • Explain how the Strattice® Tissue Matrix will be sutured and to which tissues • Name advantages of using the Onlay position Ventral Hernia Repair 10 Onlay Position

Self Check: Question 1 What is the other term to used to describe implantation of the Strattice® Tissue Matrix in the Onlay position? Select only one answer. Underlay Inlay Sublay Overlay [Learner begins the Onlay procedure. When learner completes the surgery Dr. B asks a few questions, that also show up on the screen with multiple choice answers:] [Correct answers are in bold and underlined .] 1. VO Dr. B: What is the other term to used to describe implantation of the Strattice® Tissue Matrix in the Onlay position? Select only one answer. Underlay Inlay Sublay Overlay Ventral Hernia Repair 11 Onlay Position

Self Check: Question 2 Which surgical condition is necessary in order to place the Strattice® Tissue Matrix in the onlay position? Select only one answer. Before the rectus abdominis fasciae has been closed with sutures After the rectus abdominis fasciae has been closed with sutures When the hernia defect is so large, that the rectus abdominis fasciae cannot be sutured together Only if the patient has an infection around the site of the hernia 2. VO Dr. B: Which surgical condition is necessary in order to place the Strattice® Tissue Matrix in the onlay position? Select only one answer. Before the rectus abdominis fasciae has been closed with sutures After the rectus abdominis fasciae has been closed with sutures When the hernia defect is so large, that the rectus abdominis fasciae cannot be sutured together Only if the patient has an infection around the site of the hernia Ventral Hernia Repair 12 Onlay Position

Self Check: Question 3 Which statements are true when preparing Strattice® Tissue Matrix for implantation? Select all that apply. The mesh must soak in either sterile saline solution or sterile Lactated Ringer’s solution prior to implantation The mesh must soak in either sterile saline solution or dextrose 5% solution prior to implantation The mesh must soak in the solution at room temperature for 4 hours prior to implantation The mesh must soak in the solution at room temperature for 2 minutes prior to implantation VO Dr. B: Which statements are true when preparing Strattice® Tissue Matrix for implantation? Select all that apply. The mesh must soak in either sterile saline solution or sterile Lactated Ringer’s solution prior to implantation The mesh must soak in either sterile saline solution or dextrose 5% solution prior to implantation The mesh must soak in the solution at room temperature for 4 hours prior to implantation The mesh must soak in the solution at room temperature for 2 minutes prior to implantation Ventral Hernia Repair 13 Onlay Position

Self Check: Question 4 What is the purpose of using quilting stitches after the Strattice® Tissue Matrix has been sutured on the sides, top and bottom? Select all that apply. The quilting stitches secure the mesh to the rectus abdominis fascia, thereby reducing tension on the closure It is less likely that fluid that gets between the mesh and the rectus abdominis fasciae will lift the mesh upwards Fewer stitches on the sides are needed The risk of infection is reduced VO Dr. B: What is the purpose of using quilting stitches after the Strattice® Tissue Matrix has been sutured on the sides, top and bottom? Select all that apply. The quilting stitches secure the mesh to the rectus abdominis fascia, thereby reducing tension on the closure It is less likely that fluid that gets between the mesh and the rectus abdominis fasciae will lift the mesh upwards Fewer stitches on the sides are needed The risk of infection is reduced Ventral Hernia Repair 14 Onlay Position

Self Check: Question 5 Sometimes a mesh is not used in hernia repair. Which of the following are advantages for using a mesh in repairing hernias? Select all that apply. The mesh provides added support of the closure, thereby helping to reduce tension on the sutures holding the fasciae together The mesh reinforces the weakness that was created when the external oblique fascia were divided The risk of incisional hernia recurrence secondary to hernia surgery may be reduced The implanted mesh may enhance the function of the external oblique muscles on both sides by pulling the muscles toward the midline VO Dr. B: Sometimes a mesh is not used in hernia repair. Which of the following are advantages for using a mesh in repairing hernias? Select all that apply. The mesh provides added support of the closure, thereby helping to reduce tension on the sutures holding the fasciae together The mesh reinforces the weakness that was created when the external oblique fascia were divided The risk of incisional hernia recurrence secondary to hernia surgery may be reduced The implanted mesh may enhance the function of the external oblique muscles on both sides by pulling the muscles toward the midline [Note: Need to determine what should happen in response to correct and incorrect answers] [Note: End of Onlay procedure] Ventral Hernia Repair 15 Onlay Position

Self Check: Results [onlay procedure] Ventral Hernia Repair 16 Onlay Position

Questions: Retrorectus Underlay Procedure Self Check (Part 5) Questions: Retrorectus Underlay Procedure When learner completes the surgery Dr. B asks a few questions, that also show up on the screen with multiple choice answers:] [Correct answers are in bold and underlined.] Ventral Hernia Repair 17 Retrorectus Underlay/Sublay Position

Retrorectus Underlay/Sublay Position Learning Objectives After completing this section, you will be able to: Perform the steps to implant the Strattice® Tissue Matrix using the retrorectus underlay (sublay) position Identify the appropriate surgical condition in which Strattice® Tissue Matrix can be positioned in the retrorectus underlay position Identify the two types of sutures that can be used when stitching the mesh laterally to the anterior rectus sheath Name the advantage of implanting the Strattice® Tissue Matrix the retrorectus underlay position [Learning Objectives – as Dr. Beokay states them, they should also appear on the screen] Voice Over (Dr. Beokay): First, let’s discuss the key learning objectives you should focus on while learning how to implant the Strattice® Tissue Matrix in the retrorectus underlay (sublay) position to reinforce the repair. After completing this section, you should be able to: • Perform the steps to implant the Strattice® Tissue Matrix using the retrorectus underlay position • Identify the appropriate surgical condition in which Strattice® Tissue Matrix can be positioned in the retrorectus underlay position • Identify the two types of sutures that can be used when stitching the mesh laterally to the anterior rectus sheath • Name the advantage of implanting the Strattice® Tissue Matrix the retrorectus underlay position Ventral Hernia Repair 18 Onlay Position

Self Check: Question 1: Retrorectus Underlay Procedure What is the other term to used to describe implantation of the Strattice® Tissue Matrix in the underlay position? Select only one answer. Onlay Inlay Sublay Overlay [Learner begins the retrorectus underlay procedure. When learner completes the surgery Dr. B asks a few questions, that also show up on the screen with multiple choice answers:] [Correct answers are in bold and underlined .] 1. VO Dr. B: What is the other term to used to describe implantation of the Strattice® Tissue Matrix in the underlay position? Select only one answer. Onlay Inlay Sublay Overlay Ventral Hernia Repair 19 Retrorectus Underlay/Sublay Position

Self Check: Question 2: Retrorectus Underlay Procedure Which surgical condition is necessary in order to place the Strattice® Tissue Matrix in the retrorectus underlay position? Select all that apply. After the rectus abdominis fasciae has been closed with sutures When the hernia defect is so large, that the rectus abdominis fasciae cannot be sutured together When the rectus fasciae meet comfortably at the midline Before the rectus abdominis fasciae has been closed with sutures 2. VO Dr. B: Which surgical condition is necessary in order to place the Strattice® Tissue Matrix in the retrorectus underlay position? Select only one answer. After the rectus abdominis fasciae has been closed with sutures When the hernia defect is so large, that the rectus abdominis fasciae cannot be sutured together When the rectus fasciae meet comfortably at the midline Before the rectus abdominis fasciae has been closed with sutures Ventral Hernia Repair 20 Retrorectus Underlay/Sublay Position

Self Check: Question 3: Retrorectus Underlay Procedure What two types of sutures can be used when stitching the mesh laterally to the anterior rectus sheath? Select all that apply. Apex suture Quilting suture Running horizontal mattress suture Interrupted figure of eight suture VO Dr. B: What two types of sutures can be used when stitching the mesh laterally to the anterior rectus sheath? Select all that apply. Apex suture Quilting suture Running horizontal mattress suture Interrupted figure of eight suture Ventral Hernia Repair 21 Retrorectus Underlay/Sublay Position

Self Check: Question 4: Retrorectus Underlay Procedure What is the advantage of using the retrorectus underlay position for implanting the mesh in repairing hernias? Select one answer. The procedure takes less time because there is less suturing involved Less mesh is required There’s an additional layer of closure : the mesh can be positioned between the sutured posterior retrorectus fasciae and the sutured anterior rectus sheath There’s less chance of infection VO Dr. B: What is the advantage of using the retrorectus underlay position for implanting the mesh in repairing hernias? Select one answer. The procedure takes less time because there is less suturing involved Less mesh is required There’s an additional layer of closure : the mesh can be positioned between the sutured posterior retrorectus fasciae and the sutured anterior rectus sheath There’s less chance of infection [Note: Need to determine what should happen in response to correct and incorrect answers] [Note: End of retrorectus underlay procedure] Ventral Hernia Repair 22 Retrorectus Underlay/Sublay Position

Self Check: Results [Retrorectus Underlay Procedure ] Ventral Hernia Repair 23 Onlay Position

Self Check (Part 5) Questions: Underlay Technique in the Intraperitoneal Position Procedure When learner completes the surgery Dr. B asks a few questions, that also shows up on the screen with multiple choice answers:] [Correct answers are in bold and underlined.] Ventral Hernia Repair 24 Strattice® Underlay Technique in the Intraperitoneal Position

Underlay Technique in the Intraperitoneal Position Learning Objectives After completing this section, you will be able to: Perform the steps to implant the Strattice® Tissue Matrix using the underlay procedure in the intraperitoneal position Identify the appropriate surgical condition in which Strattice® Tissue Matrix would be implanted using the underlay technique in the intraperitoneal position State the number of centimeters the edges of the abdominis muscles should overlap with the mesh Calculate the size of the mesh to be measured, given the width of the defect Identify the two types of suture techniques that can be used when securing the mesh as a bridge in the intraperitoneal position [Learning Objectives – as Dr. Beokay states them, they should also appear on the screen] Voice Over (Dr. Beokay): First, let’s discuss the key learning objectives you should focus on while learning how to implant the Strattice® Tissue Matrix in the retrorectus underlay (sublay) position to reinforce the repair. After completing this section, you should be able to: Perform the steps to implant the Strattice® Tissue Matrix using the underlay procedure in the intraperitoneal position Identify the appropriate surgical condition in which Strattice® Tissue Matrix would be implanted using the underlay technique in the intraperitoneal position State the number of centimeters the mesh should overlap with the edges of the abdominis muscles Calculate the size of the mesh to be measured, given the width of the defect. Identify the two types of sutures can be used when securing the mesh as a bridge in the intraperitoneal position Ventral Hernia Repair 25 Strattice® Underlay Technique in the Intraperitoneal Position

Self Check: Question 1: Underlay Technique in the Self Check: Question 1: Underlay Technique in the Intraperitoneal Position Procedure When would it be necessary to perform a ventral hernia surgery using the underlay technique in the intraperitoneal position? Select only one answer. When the rectus abdominis muscles meet comfortably at the midline After the rectus abdominis muscles have been sutured together When the rectus abdominis muscles don’t meet comfortably at the midline When the defect is small [Learner begins the underlay intraperitoneal procedure. When learner completes the surgery Dr. B asks a few questions, that also show up on the screen with multiple choice answers:] [Correct answers are in bold and underlined .] 1. VO Dr. B: When would it be necessary to perform a ventral hernia surgery using the underlay technique in the intraperitoneal position? Select only one answer. When the rectus abdominis muscles meet comfortably at the midline After the rectus abdominis muscles have been sutured together When the rectus abdominis muscles don’t meet comfortably at the midline When the defect is small Ventral Hernia Repair 26 Strattice® Underlay Technique in the Intraperitoneal Position

Self Check: Question 2: Underlay Technique in the Self Check: Question 2: Underlay Technique in the Intraperitoneal Position Procedure How many centimeters (cm) should the edges of the rectus abdominis muscles overlap with the Strattice® mesh? Select only one answer. 1-2 cm 3-5 cm 6-10 cm More than 10 cm [Learner begins the underlay intraperitoneal procedure. When learner completes the surgery Dr. B asks a few questions, that also show up on the screen with multiple choice answers:] [Correct answers are in bold and underlined .] 2. VO Dr. B: How many centimeters (cm) should the edges of the rectus abdominis muscles overlap with the Strattice® mesh? Select only one answer. 1-2 cm 3-5 cm 16-20 cm More than 10 cm Ventral Hernia Repair 27 Strattice® Underlay Technique in the Intraperitoneal Position

Self Check: Question 3: Underlay Technique in the Self Check: Question 3: Underlay Technique in the Intraperitoneal Position Procedure How wide should the Strattice® mesh be cut if the size of the defect is 10 cm wide? Select only one answer. 10 cm 13-15 cm 16-20 cm 30-50 cm [Learner begins the underlay intraperitoneal procedure. When learner completes the surgery Dr. B asks a few questions, that also show up on the screen with multiple choice answers:] [Correct answers are in bold and underlined .] 3. VO Dr. B: How wide should the Strattice® mesh be cut if the size of the defect is 10 cm wide? Select only one answer. 10 cm 13-15 cm 16-20 cm 30-50 cm Ventral Hernia Repair 28 Strattice® Underlay Technique in the Intraperitoneal Position

Self Check: Question 4: Underlay Technique in the Self Check: Question 4: Underlay Technique in the Intraperitoneal Position Procedure Which of the following statements is/are true when implanting the mesh in the underlay intraperitoneal position? Select all that apply. The mesh can be implanted using interrupted figure-of-eight sutures all around or with running horizontal mattress sutures laterally The mesh lays flush against the peritoneum The mesh is positioned between the posterior retrorectus fascia and the anterior rectus sheath The mesh can act as a bridge if the rectus abdominal muscles don’t meet each other comfortably at the midline [Learner begins the underlay intraperitoneal procedure. When learner completes the surgery Dr. B asks a few questions, that also show up on the screen with multiple choice answers:] [Correct answers are in bold and underlined .] 4. VO Dr. B: Which of the following statements is/are true when implanting the mesh in the underlay intraperitoneal position? Select all that apply. The mesh can be implanted using interrupted figure-of-eight sutures all around or with running horizontal mattress sutures laterally The mesh lays flush against the peritoneum The mesh is positioned between the posterior retrorectus fascia and the anterior rectus sheath The mesh can act as a bridge if the rectus abdominal muscles don’t meet each other comfortably at the midline Ventral Hernia Repair 29 Strattice® Underlay Technique in the Intraperitoneal Position

Self Check: Results [Underlay Technique in the Self Check: Results [Underlay Technique in the Intraperitoneal Position Procedure] Ventral Hernia Repair 30 Strattice® Underlay Technique in the Intraperitoneal Position