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Speaker 1 (00:00:11):
Hello. Hello everyone. It’s Dr. Towfigh. Welcome to Hernia Talk Live. You’re joining me on a Tuesday. My name is Dr. Shirin Towfigh, your hernia and laparoscopic surgery specialist. Thanks for joining me. Today is yet another great session. Many of you’re following me as a Facebook Live or on Zoom. Welcome, thanks to everyone who continues to watch me interact on both Instagram and ex Twitter at hernia doc. As you know, we’ve been archiving all of our Hernia Talk Live sessions on my YouTube channel at Hernia Doc, and as you probably also have heard, because we have, I’ve heard over 500 downloads already, we have a podcast, so if you prefer to watch me as a podcast or I would say listen to me as a podcast, do go to wherever you listen to your podcast and download Hernia Talk Live, and we’re there. We’re slowly uploading.
Speaker 1 (00:01:11):
We’ve uploaded a little bit more than a third of our podcasts already, so if you want to catch up on some of the earlier ones and hear what I’ve been discussing with many of my colleagues and friends back during the pandemic times, those topics really don’t get old and I’ve been listening to some of them myself and they’ve actually been pretty good, but it’s also kind of interesting to watch how I’ve grown in this forum and how amazing it’s been to do this as both alive and now as a podcast. So I’m super excited. Okay, so many of you have asked, especially on herniatalk.com, which is the free patient discussion form, you can all go visit. Many of you have asked to have a discussion on actual surgical technique. And so because of that discussion and that request every so often, maybe every two or three months, I’ll throw in a session like today where we’re only going to be talking about surgical techniques.
Speaker 1 (00:02:17):
The last time we did one was about TEP versus TAPP. I don’t know, did we do a Shouldice one? I think we did. And today’s going to be on component separation. Those of you who have had big hernias or are talking to doctors about getting your abdominal hernia, we’re talking about not the groin anymore. We’re talking about ventral hernias, abdominal wall hernias, oftentimes incisional hernias. So you’ve had an incision before and that broke down for whatever reason, and you need now a much more complicated hernia repair. Anyone who’s had a hernia repair more than just a maybe hands breath has probably had a doctor talk to them about what’s called component separation. So what does that mean? First of all, you need to know that your abdominal wall has multiple layers to it at the muscle level. So it’s not just one muscle. You have your rectus muscle, which is your six pack in the middle. You have your obliques on the side, which are three different layers on the side, and each of them has the muscle layer. And then they also have these somewhat thicker, sometimes stronger sandwich layer called fascia. And so that’s what we refer to as the different components because you have fascia layers, you have muscle layers, and you have multiple muscle layers and fascia layers, all of which interact with themselves with each other.
Speaker 1 (00:03:54):
Some surgeons in the past have come up with really innovative ways to close the abdominal wall by manipulating these components so that the hole, which is your hernia can be closed. Now, think of your hole as like a tear in the seam of your clothing, for example. So let’s say I have a blazer on and that blazer doesn’t button up anymore because that’s the hernia, right? So if I lose weight, maybe I’ll be able to close that blazer, but if I don’t lose weight, there’s no way that blazer can be closed without it being too small. I’m sorry, too tight and then busting open, right? So as a tailor, let’s say who’s dealing with me and my very tight blazer, how are they going to close my blazer? One is they can add extra fabric to the middle, to the size, whatever. That would be the Mesh analogy.
Speaker 1 (00:04:59):
But another way is to manipulate the components of the blazer to encourage the middle part to close. So let’s say we have some inseams on the side because a tailored blazer, you can open up those inseams and make it a wider blazer that that can actually be closed in the front. That’s kind of the component separation portion of it. You can undo the lining and separate the lining of your blazer, your jacket with the front part, and then use that as a way to loosen things up. And closing the lining is often tighter than the actual jacket, so that’s why it falls better on you. So you can kind of undo the lining. That would be your transversesalis fascia to bring it together, or you can undo the seams of the actual jacket, and that would be more of an anterior component separation. So I don’t know if I lost you on that analogy.
Speaker 1 (00:06:03):
I hope I didn’t lose you on that analogy, but that’s kind of how we also handle hernia repairs with when people kind of need little extra help to close the fascial defect. So most people who have hernias of the abdominal wall, not the groin, again, we’re not talking about inguinal hernias, we’re talking about ventral or abdominal wall front hernias. Most people do not need a component separation because most hernias are not large. They tend to be 1, 2, 3, 4 centimeters, and most of those hernias do not need a component separation. And by centimeters I mean width a hernia and there’s about two and a half centimeters to an inch. So one to two inches wide. Most people don’t need a component separation for that. You can lose a little bit of weight or there’s techniques we can use to still close that defect with or without Mesh. However, once you hit that four centimeter cutoff, you start needing to manipulate the tissues to be able to close them together. The abdominal wall is very tight.
Speaker 1 (00:07:23):
How should I explain this? When you bend or you, for example, when you bend, you may feel that there’s some tightness to your abdominal wall. It’s not completely, it can’t just expand too much. If you, okay, here’s another good example. If you eat a big meal, you’re going to feel the pressure because your abdominal wall can only expand so much to accommodate for a large meal. Let’s say that you’re adding, and everyone’s a little bit different as to how distensible or flexible their abdominal wall is. So in order to be able to close that abdominal wall after it’s about four centimeters on average, your surgeon needs to manipulate the different tissue layers to make the abdominal wall more pliable so it can be closed. The most simple, straightforward and very effective way is to do what’s called a Rives Stoppa. A Rives Stoppa or Rives, some people call it is a technique by Dr.
Speaker 1 (00:08:31):
Rives and Dr. Stoppa, both French who came up with this idea, which is to separate the components only of the rectus muscles. So your six pack, the muscle and the fascia, that thicker lining behind it are disconnected and that allows a little bit more looseness of the back and the front to be able to be closed. And that’s usually adequate for like a four to six, sometimes even eight centimeter wide hernia. So that gives us a lot of good leeway. That’s called a Rives Stoppa. It’s not considered a very complicated component separation, but we are separating some components and in doing so, we need to add Mesh to support that undoing of the abdominal wall. What I’d want to talk today about is what most people call component separation, which is one step beyond a Rives Stoppa. So the Rives Stoppa is a first step of most component separations.
Speaker 1 (00:09:35):
It’s the very first step. There are multiple steps to the average component separation operation. So one is to release the rectus muscle, right, your six pack from the fascial layer behind it. But there are other ways you can separate, you can release the edges, right? Didn’t I say for your, going back to the blazer analogy that if you release those seams, then you can close the jacket. That would be called an anterior component separation. So it’s one of the three layers is separated and one of the three layers is separated, allowing two layers on the sides and therefore more laxity to close. So you’re taking your three layers of obliques, and so you’re saving two of those layers and then that third top layer is being released to allow for the closure. That’s an anterior component separation. So it’s done through the open. It’s almost always an open fashion.
Speaker 1 (00:10:42):
The newer concept and a plastic surgeon actually came up with this, his name is Professor Ramirez, and he started publishing this as a non mesh alternative to closing the abdominal wall. What he found though is it’s not a perfect repair without mesh. So there’s a recurrence rate of about a third to a quarter of patients have recurrences if you don’t use Mesh and just release it. So it is a tissue repair option, but it’s kind of unfortunate to do that tissue release and have a quarter to a third of patients recur. So Mesh has been added to reduce that recurrence to about 10 or 11%, which is much more reasonable. So that’s the Ramirez or anterior component separation and other iterations of it have been developed to kind of add to that. The posterior component separations, more of it’s like a newer procedure. It’s also called a TAR, that’s an acronym for transverse abdominis release.
Speaker 1 (00:11:56):
So again, it starts like a rives stoppa, and then after the rives stoppa proportion is performed, you still stay in that layer where you release the rectus muscle from the layer behind it, the fascia behind it, the posterior rectus fascia, and then you take an additional step and now release the posterior one. So the transverses abdominis, let’s go back to anterior rectus fascia. There’s three oblique muscles that come to the sides that attach to your rectus muscles, your six pack. Those three muscles are the external oblique, internal oblique and the transverses abdominis for the anterior component separation. The anterior component or the external oblique is the one that’s cut for the posterior component separation. The posterior component of those three oblique muscles is cut, and that’s a transverse abdominis. You may have heard me talk about transverse abdominis before. It is sometimes referred to as the internal girdle.
Speaker 1 (00:13:02):
It’s a girdle that holds everything tight. So if you want to loosen it, you take off that girdle and you cut through the transverses abdominis and that can give you even more ability and laxity to the abdominal wall than the anterior component separations. What you cannot do is to do both. So once you’ve committed to one, it’s really you really cannot do both because then you’re the abdominal wall. There are nerves that run through all these muscles, and if you get rid of the nerve that’s going to one of those muscles, which is the middle one, the internal oblique, then your whole abdominal wall is going to be very lax and not a good outcome. Maybe only in salvage situations. So many of us have moved to the posterior component separation because it can also be done laparoscopically and really robotically, not so much laparoscopically robotically, though some people do it laparoscopically. It’s very uncommon. And because it can be done robotically and therefore more minimally invasively, there’s less wound infection rate, less scarring and less Mesh infections and a shorter recovery time, less hospitalization, less pain than the typical open and anterior component separation. So not everyone’s the same, not everyone gets the same operation, but those are the main different ways of doing a component separation.
Speaker 1 (00:14:37):
And here’s a question that says the rectus fascia. You mentioned in the Rives Stoppa, is it scarpa’s camper’s, fascia, or does it have another name and is it the posterior fascia? So it is not scarpa’s or campers fascia. Those are soft tissue fascia layers within the fat. They’re very, very weak and we almost never use that as a component of any hernia repair. What I’m referring to is actual rectus fascia. So your rectus muscle has an anterior fascia and a posterior fascia. So the rectus muscle is sandwiched with a fascia on top, the anterior fascia and a fascia on bottom, the posterior fascia. And I’m specifically talking about releasing the rectus muscle from its posterior fascia, which is a thickened fascia that runs through about two thirds or three fourths of the abdominal wall in most patients. So I hope that clarifies it and thanks for your comment, Tracy.
Speaker 1 (00:15:43):
Always great information. Thanks for watching. Okay, so please send me your questions as we’re going through all of this. I will say that I’ve already had some questions submitted, so I’m going to go through some of the questions submitted and also if you have questions, please get back, type them in for me either on Zoom or Facebook Live and we’ll answer those as well. But here I’m going to show you one of the questions that was submitted earlier, which is are there surgical alternatives for patients who need to have their hernia repair by using a component separation technique? So yes, the component separation technique, I personally do not use it. I do appreciate that releasing the abdominal wall components does imply a change in your abdominal wall dynamics and a change in your abdominal wall anatomy. There are some reports that have looked at abdominal wall function and they say you can do all of that and the patient will still have excellent abdominal wall function fine.
Speaker 1 (00:16:58):
It’s just not logical to then take that and say, therefore everyone should get a component separation because it’s a better hernia repair. No, I strongly believe, as you know, in tailoring. And so what I do recommend is that people be considered for that if they’re a good candidate. And I’m very much against using the component separation technique for the majority of hernias, which some people do because it’s kind of like if you give everyone a boxy jacket or big jean jacket, they’re always going to fit into it. But some people deserve to have more of a tailored jacket or like a designer jacket or everyone’s body type and needs and lifestyles are different and the size of their hernias are different. So I don’t believe in using component separation liberally. I use the minimum amount of manipulation of the abdominal as possible to give you the results.
Speaker 1 (00:18:02):
Alright, here’s another question. Do you do blood dissection in this posterior rectus fascia or do you have to cut it? Good question. So initially you have to disconnect the posterior rectus fascia from everything else in the middle in the midline because that is part of the components separation. So it’s connected in the middle, you have to undo that connection in the middle. Now that connection is often already undone because you have a hernia, but you have to complete that connection and then you have to cut that posterior rectus fascia away from the muscle itself. But the rest of it is blunt dissection and you don’t need to cut and you try and preserve as much posterior rectus fascia as you can as part of the hernia repair because that is what gives you the strength in the posterior layer or the back layer of the repair and what also provides you with a little bit of a cinch in the abdominal wall. So I hope that makes it clear the posterior rectus fascia is not cut in the body of it, just in its connection in the middle. And then the next question is, is there another name for posterior rectus fascia such as the intimate fascia? No, it’s just called posterior rectus fascia. Okay, so let’s go to the next question.
Speaker 1 (00:19:32):
What are the different types of components, separation techniques? So we talked about starting with a Rives Stoppa and then moving on to either an anterior or posterior component separation after that, and some people call the anterior component separation a Ramirez repair, and because Dr. Ramirez was who described it first, the posterior component separation was described by Dr. Novitsky and his team and we refer to it as a TAR transverse abdominis release. So how do these differ in their complexity is the question, how are they different in complexity, risk of complications and scope of application between open and minimally invasive surgery? Good question. So in general, in general, anterior and posterior component separations are both complicated. They should only be done by people who understand their anatomy because in both situations anterior and posterior, you can mess someone up by being in the wrong space, taking out too much components and denervating the abdominal wall or causing hernias that are lateral. So if you don’t know what you’re doing, you really should not be just dabbling. In other words, don’t go to a surgeon who’s never done it before, don’t force your surgeon to do this operation if they’ve never done it before they’ve seen it or heard about it in a conference.
Speaker 1 (00:21:13):
We have courses both in the US and elsewhere, especially in Europe, where we teach component separation operations on in labs in both inanimate labs and what we call wet labs. So there’s no excuse not to go to these courses and learn if that’s what you want to do, but there’s a lot of responsibility that comes with repairing complex abdominal walls. You have to have the thinking of a plastic surgeon because you’re reconstructing the abdominal wall. You have to have the thinking of a general surgeon because you are entering a revisional reoperative space, which also includes bowel in the area and so on. You don’t want to injure any nerves and you need to appreciate that these are usually in patients where prior surgery has failed. Most people don’t come to you with a 10 centimeter abdominal wall hernia. They’ve had failures in the past, so they may have had Mesh before, they have may have had an infection, they may have had a fistula.
Speaker 1 (00:22:23):
These are complex patients. There may be multiple meshes and sutures in the area, so they may have had a colostomy or ileostomy that has failed. They may have really complex hernias from a prior liver surgery or pancreatic surgery or a kidney transplant or something like that. So these are all patients that are not straightforward healthy patients usually. And so dabbling in component separations is a big no-no. You can really mess someone up if you don’t do this correctly, which is why it’s so important that you know your anatomy and you take some courses in addition and you should be mastering as a surgeon, I should say, you should be mastering hernia surgery before you start dabbling in the advanced level, which is the component separation question. Can you please clarify why the Mesh is necessary in a Rives Stoppa surgery? Yes, so Rives Stoppa surgery and all other operations of ventral hernias without Mesh have a very high recurrence rate, at least 25% usually in the 30, 40, 50% range. So when you add Mesh, you can bring that down to about 10 to percent recurrence rate depending on the situation. It’s really not appropriate to do a complete abdominal wall disconnection and then have it fail half the time and now you’re really messed up. You have burned a lot of bridges. So the Mesh is necessary to allow for those components that are separated to be sewn together without falling apart because the sowing itself is not adequate to hold that closure together. By definition, they have failed multiple sowing attempts.
Speaker 1 (00:24:22):
All right, so going back to the prior question, we talked about complexity. So both anterior and posterior component separations are complex. Some people think the posterior component separation or the tar is more complex. I’m not so sure that’s true. I would say if you’re planning on doing it robotically, that’s definitely requires much more skill because you’re basically doing open operation, plus you have to add the skills of the robot. The risk of complications are different. So people who have anterior component separations, the risks are mostly seromas weaknesses in the lateral abdominal wall causing a bulging on the sides, and also a lot of wound complications and necrosis of the wound because of blood flow to the skin is affected once you try and get access to the anterior component separation space for the tar, the complications can include things like posterior disruption and like a hernia on the inside that you, because that back layer gets torn.
Speaker 1 (00:25:39):
You can have the sides get torn and have hernias on the sides. You’re dealing with a lot of thin tissues and of course because you’re very close to the intestine, you can have bowel injuries, but you don’t have the risk usually of a lot of skin problems and wound infections and you don’t have, which are very much more common with the anterior component separation. And you don’t usually have the problems with seromas or fluid collections because you’re not doing a lot of skin surgery in terms of whether you can do these open or minimally invasively. The anterior component separation tends to be done open. The posterior component separation can be done open or robotically or in some cases laparoscopically. There was a time when a laparoscopic kind of option was offered for anterior component separation and that was to minimize the complication I mentioned earlier about the skin problems, but it kind of fell out of favor. I would say mostly because you can just do a posterior component separation, not have those issues, but there are still some people that offer kind of a hybrid anterior component separation operation with laparoscopic components release and then you either do an open or a laparoscopic hernia repair. It’s kind of, I dunno how explain it, but I don’t do that. I never did because I saw that the seroma wrist were not worth it to do these laparoscopic components operations.
Speaker 1 (00:27:23):
And there are other techniques to use besides doing it that way, but it is definitely an option and it’s part of the toolbox that we have. Alright, let’s go to the next question. What are the advantages of a robotic tar versus a open tar and other components separation techniques? Okay, so let’s talk about this. So the TAR is a transversus abdominis release. We also call it posterior component separation. It can be done open, laparoscopic or robotic. It’s one of the beauties of this operation and it depends on the need of the patient and the skill of the surgeon. In all cases, you really need to understand your anatomy and not cause abnormal injury, worsen the patient’s outcome by causing let’s say, deprivation injury or be the wrong plane and cause another her laterally, which is very difficult to repair. That said, we tend to do these robotically if we can because of the lower risk of wound complications and infections with the robotic approach.
Speaker 1 (00:28:42):
However, in certain situations you really cannot. One is complete loss of domain where the hernia is so huge there’s really no room for the robot to manipulate tissues. The second is if you have a really ugly midline scar, I don’t see the benefit in going robotically because I like to give you a nice cosmetic closure to match your beautiful hernia repair. And so I cosmetically remove that skin and ugly scar. I gave you a newer scar. Those are the two main reasons. The third is if the patient has a lot of scarring on the inside and it’ll be very difficult to do it robotically without injuring the bowel. This would be someone who’s had, let’s say a lot of infection or multiple operations in the abdominal wall and really is not a good candidate, I must say. There’s one thing that I haven’t talked about and that’s the eTEP.
Speaker 1 (00:29:44):
ETEP is kind of like an extended eTEP or totally extra peritoneal approach. It’s technically not exploit. It’s kind of like doing a Rives Stoppa or a tar without going inside the abdomen. It’s can include a component separation. It doesn’t have to include a component separation. It could be just a simple hernia repair. There’s a lot you can do with an eTEP. It’s tricky because you’re kind of going inside laparoscopically or robotically without really going inside. So you’re going into the abdominal wall and you’re doing all the surgery within the abdominal wall and you’re ignoring everything that’s happening inside with the intestines. So it’s a good option if most of your hernia has fat in it or if it’s a very well circumscribed hernia because you don’t want to accidentally injure intestine while you’re doing a good job doing a hernia repair. So we don’t really consider those component separations, but if you really want to be picky about it, you are separating some components.
Speaker 1 (00:30:52):
Let’s say. Let’s see, is component separation ever necessary for diastasis recti or just big incisional hernias? So let’s discuss this. Good question. Very insightful. Diastasis recti is a separation of the muscles with a thinning of that layer in between. A true diastasis recti is in someone who’s never had surgery before and either has a genetic disposition to getting kind of a rounded abdominal wall, which you see in men or more likely in women that they’ve had multiple pregnancies, usually two or more where the abdominal wall has really stretched out and never really goes back into normal position either way, it gives you a rounded abdominal wall look and results in a thinning in the middle of the abdominal wall, which kind of pooches out sometimes. So to fix a hernia within a diastasis, when we’ve discussed this in some of the prior Hernia Talk Live sessions, so if you have that diastasis, which is a thinning or separation between the two rectus muscles in the middle and you have a hernia within it, most of us believe that it’s a better hernia repair if you address the diastasis at the same time as the hernia repair.
Speaker 1 (00:32:17):
You don’t have to do a component separation to address a diastasis. In fact, you want to kind of keep that space unaddressed and not separated really. We just deal with a component separation in patients with really, really wide hernias, usually eight centimeters or greater for sure, 10 or greater.
Speaker 1 (00:32:42):
If you talk to plastic surgeons, some of them do treat patients with really wide diastasis such as a 10 centimeter diastasis, six centimeter diastasis with a Rives Stoppa, and they sometimes use Mesh. So they’re really doing a hernia repair using the Rives Stoppa technique, but it’s to address and close the gap from the diastasis. I’m not a plastic surgeon. I do work with many and I learn from them and there are a handful of plastic surgeons, many of whom I’ve already interviewed on hernia talk that do a lot of abdominal wall reconstruction, really big hernias, really big diastasis, and they bring in that kind of open surgical technique and apply it to diastasis, which is often something that a plastic surgeon addresses.
Speaker 1 (00:33:49):
Alright, is Mesh always needed as a complement to a component separation technique for patients who react to Mesh? Are there any techniques to achieve an acceptable recurrence risk without using permanent Mesh? So yes, that’s a very, very good point. I’ve done this before, which is every so often there’s a patient who cannot have Mesh or does not want Mesh and legitimately should not have Mesh and those patients you can consider a component separation as their definitive hernia repair only if you’re using the component separation to reduce tension on the repair. So here’s an example, a one centimeter hernia, one centimeter. We’re always talking about width of defects. We don’t care about the length. A one centimeter hernia can be closed with minimal tension with a good result without Mesh. Once you had two centimeters and you try and close that gap, then really what we’re dealing with is much more tension.
Speaker 1 (00:34:59):
And so not using Mesh in a two centimeter hernia will result a lot of tears and breakdowns and recurrences because the Mesh is not there to help offload the tension on that repair. A three centimeter hernia is certainly not a good idea to use suture alone because try to close a three centimeter gap implies that you’re going to cinch that in really tight is going to tear at about 30, 40, 50% of the time depending on other risk factors that’s going to cause chronic pain because you’re tearing and it’s going to recur and when it recurs, it’ll be now bigger than three centimeters because you’re tearing. So the use of Mesh and the introduction of Mesh is used for ventral hernias is used to offload the tension from the primary repair. We always want to close it primarily, but we know it’s going to bust open, so we add an extra layer.
Speaker 1 (00:36:08):
It’s kind of like adding a lining to your jacket. If you buy a cheap jacket, it has no lining. It also will start tearing at the seams and not last very long, but a tailored jacket. If you go to Ralph Lauren or some designer Chanel and you buy a blazer, a jacket, they will always be lined. That lining takes the pressure off of the outer clothing. It makes it look better, right? It fall on you better. It also makes that garment last much longer. Same with lining of pants makes that garment last much longer because it’s taking the tension off of the seams of the main jacket and many of you have maybe had jackets or pants with linings. The linings tear, right? But the pants or the jacket are still perfectly fine. So the purpose of lining and the purpose of Mesh is to take the load off of the primary repair to allow the primary repair or the hernia repair to be long lasting.
Speaker 1 (00:37:09):
So that is why we use the Mesh. Now in the situation where you cannot or should not or don’t want to use Mesh and the patient has a ventral hernia repair, if you close the hole primarily it’s going to bust open after you hit about two centimeters width, width and the wider it is, the more likely you are that that will fail. However, you can close it primarily and then do releases on the side. Lateral releases, what are we talking about? The blazer, right? I can close my blazer jacket if I just have the tailored take out the seams on the sides, it’ll make it look like a boxier jacket, but at least I can close a jacket in the front. The same is true for the abdominal wall. If you don’t want to use Mesh, you just want to close the midline of your wound, then you can release the sides, and that’s part of the component separation technique.
Speaker 1 (00:38:07):
It only works if you can release so much that the tension on the primary repair is minimal. It doesn’t work if you want to have an actual, like a tight cinched in repair. A cinched in repair can only be done if you add Mesh. If you want a very floppy repair, you want the patient to lose a lot of weight, so you have a floppy abdominal wall, maintain that weight loss and then do component separation to take the tension off the repair. And that’s the only way you can successfully get a crack at fixing a hernia without using Mesh. I don’t recommend it, but it is possible to do.
Speaker 1 (00:38:55):
Looks like at least one of you liked my analogy. Thank you. I tried. Okay, let’s go back to your questions. Is a lateral incision or releases similar to McVay relaxing incision? So yes, very good. So both for Shouldice, McVay, and Bassini, all of these tissue repairs that are named repairs for the inguinal or groin region, it is too tight of a repair. And in order to take the tension off that repair and provided for more long lasting tissue repair, you do a fascial release above it. You don’t have to always do it because not everyone has a too tight of a repair. But in the cases of direct hernias and femoral hernias where the McVay is really the technique for femoral hernia, those are highly tensile, high tension repairs. And so fascial release is included. So yes, good analogy. The analogy is true for both ventral and inguinal hernias, which is why I always say as a surgeon, especially hernia surgeon, you need to understand phasix.
Speaker 1 (00:40:10):
If you don’t understand phasix and maybe even be like an engineer, you really can’t be a good hernia surgeon. And so this idea that I can just cinch your clothes and oh, it looked really good, or I have surgeons say sometimes, yeah, I did a nice tight closure and I just freak out tight is not good, tight will tear. It’s like saying, yeah, I gave her a nice tight dress. Unless you’re a model and just want to look good while you’re standing, tight dresses will tear. You can’t bend down, you can’t sit down. It’ll make everywhere pop. So it really drives me nuts when people think tightness is good, it’s not good. Next question is component separation only for the midline? I was going to talk about this. This is what a great question. Okay, good job person. Is component separation only for midline, incisional and umbilical hernias or can it be used to repair other kinds of abdominal wall hernias? I would totally going to talk about this right now. Okay, so most of what I’ve been talking about has been about midline or down the middle of your abdomen hernias. Those are the most common hernias. Umbilical hernia, ventral hernia, epigastric hernia. These are all types of hernias. However, there are some atypical hernias is what we call them, and they can be challenging to repair.
Speaker 1 (00:41:32):
And when you an atypical hernia, the best option is to, well, you have to know your anatomy and know what’s nearby and why it’s an atypical or complex hernia. Let’s say you had a C-section and you have a hernia from your C-section. That would be a supra pubic or lower abdominal hernia. What’s there, bladder and your pubic bone. Those are two things you can’t put Mesh onto. So there are ways to get around it and sometimes a component separation is necessary down there, not commonly because the lower abdomen, the lower abdomen has a lot of bone associated with it and there’s not that much release you can do if everything’s attached to bone already. So for the lower pelvis, we can’t do that much components upper you can do a little bit, not too much. Now let’s go to the upper abdomen. Let’s say you had a heart surgery, right, and your scar went down and caused a hernia right below your xiphoid process or that kind of lower chest bone.
Speaker 1 (00:42:48):
Or let’s say you had a liver transplant and you have this big incision underneath your rib cages. Those hernias are very complex and the muscles tend to be attached to again, bone, your rib cage, your xiphoid process. However, unlike the lower abdomen, you don’t have a bladder there. You’d have the heart, I mean you don’t want to get into the heart or lung space, but you do have this one layer of muscle that transverses abdominis, which can be released to allow for closure of those hernias. So a tar or post or posterior component separation, which again is the posterior transversesalis fascia transverses abdominus release that can be done for some of the upper abdominal hernias. And then there’s the flank ones. The flank ones are on the side. So let’s say you had a colostomy or ileostomy or you have a urostomy. These are all hernias that can occur on the sides of the abdominal walls. So those can be repaired by including usually a posterior component separation. And then lastly, they’re the big flank ones on the sides. Those sometimes you can do what’s called a unilateral or one-sided tar. It’s very complicated, not very easy to do, but yes, those are all possible.
Speaker 1 (00:44:18):
Okay. The posterior rectus fascia is cut or dissected with the Myers Vincera repair sometimes all the way to the belly bind in order to mobilize a rectus muscle for a vertical or downward mobilization in order to help repair the inguinal floor and adjust forces around the pubic bone. Is that similar to component separation and does it make sense to you and does it explain why some professional athletes develop hernias after their careers are over? So there is no posterior rectus fascia in the lower abdomen, so there’s just transversalis fascia. It’s very, very thinned. So I don’t believe that the posterior rectus fascia is cut as part of a sport hernia repair by Dr. Meyers and the Vincera Institute, however, do they release the posterior rectus fascia up top to allow for the closure of the rectus down onto the bone as part of the sports repair? It’s possible, that is usually an anterior rectus fascia release. I don’t think they do a posterior rectus fascial release. If they do, I don’t see how that helps because the posterior rectus fascia stops at what’s called the arcuate line, which is about two inches below the belly button, so it wouldn’t help. It’s most likely they closed. They’re cutting the anterior rectus fascia. Don’t quote me on this. I will have Dr. Myers hopefully on one day. That will be great. And if so, maybe we can run that question by him then. So stay tuned.
Speaker 1 (00:46:07):
Okay, next question, component separation. Oops, excuse me. Does component separation irreversibly change the abdominal wall anatomy in particular, is the thickness of the abdominal wall reduced after component separation hernia period? Yes. If yes, what are the implications for a patient’s recurrence risk and quality of life? Okay, very good question. So the point of a component separation is to manipulate the abdominal wall components. So the hernia can be closed. By definition, you’re moving tissue around, and so you’re not going to be as thick as when the tissue was exactly where it was supposed to be. Now, anterior component separation is different than posterior component separation. With an anterior component separation, you are releasing the anterior component, which is the external oblique muscle, and that takes a portion of your lateral or side abdominal wall to go from three layers to two layers. As a result, some patients get bulging on the sides. Most patients have body weight, have no idea that they’re bulging on other sides. However, really thin patients who have very little fat and skin on top of this muscle layer may notice a slight bulging of their abdominal wall on the sides that they didn’t have before surgery.
Speaker 1 (00:47:51):
This is why when I do an anterior component separation, especially in someone who is somewhat thin, I do place anterior Mesh that will attach to the two release edges to prevent them from getting too far out and for that space to get too thinned. That could be absorbable Mesh or non-absorbable Mesh. Usually non-absorbable like lightweight Mesh. It’s one of the weaknesses of an anterior component separation. Now for the posterior component separation, the transversesalis fascia is not really that thick in most patients. The transverse abdominis, I should say that third layer is usually the thinner of the layers in most patients. So cutting it doesn’t usually result in a bulging. However, what I say about the transverse ado muscle, it’s called the internal girdle. So you’re kind of releasing the internal girdle. So whereas you may have had a cinched abdominal wall, if that inner girdle is released, let’s say you opened up the let’s you wore a girdle and you open it up, then you’re kind of going to release out the flaps of your girdle basically. So your girdle’s going to flap out. Let’s say you wore a nice dress females and you wore one of those old fashioned girdles and you popped open the girdle. That dress is not going to look very nice on you. In fact, you’re going to see the flopping of the girl edges. The same may be true in really thin patients. Again, they tend to have a more of a square abdominal wall as opposed to a rounded cinched in abdominal wall.
Speaker 1 (00:49:42):
I’ll go back to what I said earlier in the hour. Component separation should not be done religiously on most patients or liberally on most patients. And when performed, it should be done in people who would benefit from the component separation, understanding the risks of the operation. Part of the risk of the operation is a change in the abdominal wall contour. If your normal weight or overweight, you’re not going to understand that, but if you’re thinner, you will notice a change in the contour of your abdominal wall. Same with tummy tucks. If you ever seen people have tummy tucks, their bellies don’t really look like cinched in, they kind of lose waistline. It’s just different surgeons have to do extra work with faking a liposuction in certain areas to give you the illusion that you’re looking cinched in. But most people get tummy tucks, to be honest. They kind of look square or boxy.
Speaker 1 (00:50:48):
So that’s what happens when you manipulate nature. So yeah, your question is very, very astute because yes, in fact what happens is there is a change in the abdominal wall anatomy and there’s a thinning where there’s a component separation. And even though that we do have studies to support that abdominal function is not impaired, you can still do sit-ups, you can still pick up your children, you can exercise and go and play in sports. The reality is you’re not like you were before. I mean obviously not because you had a hernia, and therefore if you’re really thin, you may notice an abnormal contour to your abdominal wall. The last part of the question is what are the implications for a patient’s recurrence risk and quality of life if you’re changing their abdominal wall anatomy, we don’t believe there’s that much consequences. Like I said, studies show that you can still play sports, pick up your kids, go grocery shopping, do your sit-ups and yoga. However, oh, sorry. And people who have hernias often cannot do that. They often lack their support of the abdominal wall. They lack their core strength and core stability. And the whole purpose of doing these manipulations of the abdominal wall is to close the hole and not just keep the hole open and bridge it, which is what we used to do. We tend not to bridge anymore. And that’s why there are all these new techniques to try and close the hole instead of just taking a Mesh and slapping it on as a bridge.
Speaker 1 (00:52:32):
So in doing so, we are hopefully regaining core stability and core function in patients. But what I say before, these are highly complex operations that require you to really understand your anatomy. And as a surgeon, if you don’t understand that you can really hurt a patient by dabbling in doing these components operations because everyone’s talking about it at every meeting and you think you should be one doing it too, and you offer it to your patients, not understanding anatomy, you could really mess someone up if you are doing a component separation and not understanding the minutiae, the details, the reasons why these techniques are described and so on. I’ll give you an example.
Speaker 1 (00:53:22):
I had a patient, not a patient, I had a friend call me who’s never done a component separation before, wants to learn and didn’t understand why you can’t do an anterior and a posterior component separation. And I’m like, no, that’s like saying I’m going to cut up your jacket on the inside and on the outside, and it is just going to be totally okay. You can just wear a jacket with holes it on both sides. Can’t do that. You’ll completely denervate the abdominal wall. But the fact that that question had to be asked means that that surgeon didn’t even understand the anatomy of the abdominal wall. And I’m glad that surgeon asked me otherwise. They would be doing this on a patient and it would be a disaster. But the thought was if an anterior component is not enough to be able to close the abdominal wall, then I can just go ahead and do a posterior component too in the same patient and add extra laxity. Not a good idea.
Speaker 1 (00:54:31):
All right. Here’s a question on denervation, which is what I was just discussing, which is are muscle denervation and wound complications significant risks of component separation hernias? If yes, how do you minimize these risks? Yeah, so there are definitely major risks with these operations. Denervation is one, derivation ultimately occurs because you’re in the wrong space. You think you’re in a space, but you’re not. You think you’re in one space, but you’re in two spaces. You think you cut one component, you cut two components, you think you, so that’s the problem. And that could easily happen if you don’t know your anatomy, haven’t done enough of these. And possibly in patients where they’ve had so many different operations, hernia repair, Mesh removed, Mesh, put back in components, separation, blah, blah, blah. It’s possible they’ve had so many operations that you don’t know where you are. You’re there.
Speaker 1 (00:55:32):
You’re like, okay, this should be the external oblique, but there’s so much scar, I can’t tell which layer I’m in as a surgeon, it can be complicated, especially since most of the patients that undergo component separation have already failed a prior hernia repair in the past, or at least have had a prior surgery in the past. And so yes, denervation is definitely a risk with component separations. It should not be done lightly. If you can do it safely and you’ve done it under supervision with other surgeons, you’ve taken courses, that’s great, but don’t dabble in it. There seems to be a big interest in component separations. Frankly, there aren’t that many people with hernias that big that require it. But I feel like everywhere you go in these meetings, everyone’s giving talks on how they did a TAR, did a roboTAR, they call it roboTAR, robotic tar. They call it roboTAR. It’s kind of cute.
Speaker 1 (00:56:36):
And everyone’s talking about doing robotar. And some surgeons can go to these meetings and think like every ventral hernia should be repaired robotically with a posterior component separation or a TAR. That’s just not true, which is also why I try and push that. There’s multiple tools. Tools in our toolbox. There’s multiple techniques we just talked about. The Rives Stoppa, you can stop right there and not advance from a Rives Stoppa to an anterior or posterior component separation. There’s laparoscopic repairs, IPOM repairs, totally okay, depending on the patient’s risk factor and their surgical needs and their lifestyle and they’re risks. So if you have a patient with a history of stroke and on blood thinners, don’t do a TAR. That’s a big operation that may kill the patient even. It’s just not worth dabbling in risky operations if it’s not going to help the patient.
Speaker 1 (00:57:44):
Sorry. Sometimes I start talking to myself and I feel like I’m talking to surgeons, but I’m talking to patients. Maybe you can take my message out there. Okay, next question. Personal question, if appropriate. Are you ever intimidated by the complexity of any case, and are you always confident? Huh? Okay, I will answer that even though it is a personal question, I’m totally okay with it. I would like to say that I have confidence in my knowledge base and my knowledge base of anatomy and phasix. When I was a resident, by the time I graduated, I felt like I was king of the world. I can do anything. And it’s because I got really excellent training and my first job was at a county hospital, and basically whatever came my way, I was the surgeon on and just whatever came through the door, we took care of, usually people were dying and we tried to save patients’ lives. And I learned that most residents who graduate don’t have that feeling of confidence that they can attack anything.
Speaker 1 (00:59:03):
In fact, with my first job, there were rumors that, oh, female surgeon can’t believe we hired her and she was trained at U C L A. They’re treated with kids’ gloves, not true. So at my first job, I was kind of approached with, oh, she’s not going to survive in this county system. We have sick patients and people are dying left. So I proved them wrong. Within the first month, there were some really sick dying patients, and I saved our lives, and I opened up some chest chess on the ward. That was kind of like a ballsy thing to do, and I earned my stripes very quickly.
Speaker 1 (00:59:52):
And it occurred to me that many of, not just my own co-residents, but especially residents nowadays, once they graduate, they really don’t have the confidence to do a lot of operations on their own. I kind of did. But that said, it’s not good to be an overly confident surgeon. I always ask for help. So if I have operations where I know the bladder’s involved, listen, if I get into the bladder, I can repair it. Bladder repair is not that complicated. If I get into a vascular vessel, I can repair it. Most likely. It’s not that complicated to repair a hole in a vessel, but I understand that the reality is I have not done a vascular repair in decades. I have not done a bladder repair in decades. It’s just not something that I do on a regular basis, and therefore I know that the patient’s best served by someone who does that for a living.
Speaker 1 (01:00:56):
So if I know that, let’s say Mesh is ingrown into someone’s bladder, or if there’s, I dunno, stomach involved or something like that, then I always call in a specialist to do that because it’s just not fair for me to say, oh, I used to do this all the time, but that was back in 2002 over 20 years ago. It’s just not fair to say that for patient care. And then if you have a complication from it, am I really the best person to handle a complication from the organ system or operation that I don’t typically do? And I think it’s not cool to do an operation that you don’t do a lot of. And then once you get into trouble or have a complication, then call the specialist. The specialist would’ve been like, why don’t you call me in the first place? So yeah, I plan a lot.
Speaker 1 (01:01:52):
I think about my patients all the time, and I hope that answered your question because I don’t like the word intimidation. I’m not easily intimidated. I don’t have fear, but I’m very cautious at the same time because I dunno how to explain it. That’s kind of it’s okay. On that note, ladies and gentlemen, we’ve kind of actually gone a little bit over our time. I love to talk about hernias and I know you all have unending questions. So on that note, I will end today’s session. It was great. I shared a little bit of my theories about life. Thanks everyone for joining me on Hernia Talk Live, go on Twitter X and Instagram. Follow me at Dr. Towfigh. I’m on Facebook at, I’m sorry, at Herniadoc. I’m on Facebook at Dr. Towfigh. Don’t forget to subscribe on my YouTube channel at Hernia Doc. And I would love it if you would subscribe and download my podcast at Hernia Talk Live, and I’ll see you next week. See you guys.
