1. Tough Situations In Ventral Hernia Repair: A Community Perspective
Rodrick McKinlay, MD, FACS
Rocky Mountain Associated Physicians
Minimally Invasive Surgery Symposium
Salt Lake City, Utah
February 23, 2011

2. Disclosure
Consulting agreements with Ethicon Endo-surgery and Covidien

3. Goals Identify difficult situations in ventral hernia repair
Discuss strategies to manage, prevent, or avoid difficult situations
Discuss economic viability of a hernia practice

4. A snake in every gulch Enterotomy Loss of abdominal domain
No (or “undesirable”) mesh available
Unusual hernia locations

5. Enterotomy Most ventral hernias require at least some adhesiolysis
May be severe in recurrent vhr with previous use of mesh or multiply operated abdomen

6. Pre-op VH Discussion Discuss possibility of enterotomy
Plan if enterotomy occurs:
Repair and proceed if no spillage
Repair and postpone if spillage, especially if mesh required

7. Avoiding enterotomy intra-op
Make first access site away from scar/hernia
Use cautery/harmonic scalpel sparingly
Permissive bleeding
Work on known to unknown
Leave mesh on bowel instead of vice versa

8. Managing Enterotomy Options Open and repair
Repair and proceed if no (minimal??) spillage
Repair and close if moderate or more spillage, or when in doubt, and return for staged repair
Repair but use biologic instead of synthetic

9. Loss of Abdominal Domain
How many would tackle this hernia?
Difficult to do laparoscopically
Favor open component separation technique
Prepare for long case (2-3 hours+)

10. Intra-op Dissection Creation of flaps widely Deliberate adhesiolysis
Identify musculo-fascial planes

11. Component separation
Incise fascia just lateral to rectus sheath through external oblique aponeurosis
Rib cage to anterior superior iliac spine
Gain 5-6 cm on each side

12. Place biologic implant
Underlay technique, 5 cm
Interrupted permanent suture
Re-approximate fascia

13. Still Can’t Reach
Despite all the mobilization, bridging defect in upper abdomen
Options
Leave a bridge
Place synthetic over biologic

14. Completion
Two days on ventilator, one week in ICU, one week on wards, post-op rehab

15. Mesh availability
Certain mesh products are on contract, discounted rates to hospital
Other mesh products purchased by hospital but not on contract because of frequent use
Others “on consignment”, hospital pays as product brought in
Hospital may apply pressure to use mesh that is on contract

16. What to do if desired mesh not available?
How many have experienced this?
Best to avoid by checking two days before, but not always practical
Use less desired product
Call rep and wait for desired product (how long?)
Cancel case
Do not use mesh at all

17. Unusual hernia locations
Epigastric
Use transfascial sutures inferior to ribs, tacks above ribs; caution around pericardium
Suprapubic
Mobilize bladder if necessary
Generous use of transfascial sutures as low as possible

18. Economics of VH Repair: Component Separation
Codes:
15734 Abdomino-fascial flap, bill R and L separately
15330 Biologic
49560/5 Ventral hernia repair/recurrent
49568 Mesh implant
Reimbursement:
Insured patients: $
Medicare: $1900
Medicaid: $1850

19. Economics of VH Repair: Standard Lap and Open Repair
Lap repair reimbursement
Insured patients: $700-$1200
Medicare patients: $600
Medicaid patients: $500
Open repair reimbursement
Insured: $
Medicare: $700
Medicaid: $600

20. Ventral Hernia from community perspective, bariatric practice
Large, complicated hernias seen
Lap hernia repair offered with good success, but they are often interested in “skin removal”
Movement toward increasing use of component separation technique
Favorable economics for component separation technique, less so for “standard”

21. Questions