 Good afternoon friends. I welcome you all. On behalf of the Department of GI Minimal Access and variatic surgery at the Manipal Hospital's Vodka, New Delhi. Today we're going to be discussing hernias hernia is a very common problem that we find in the world. One of the commonest surgery, which is done worldwide and India is no different where hernias are done all over the all over the country, whether it's a small hospital or it's a it's a government hospital or it's a tertiary care hospital like ours. Though of course, the treatment of hernia over the years has changed. We have added several dimensions to the treatment of hernia and today we are going to discuss what is the latest management of hernias, whether it is a growing hernia, 2% in in males and about 2 to 3% in females or it is a ventral hernia commonly occurring or it is complex hernias which we encounter in our clinical practice. So we'll discuss all three of these hernias and discuss at length what is presently available in the world and what we are doing here at Manipal Hospital's and to discuss with this I have two of my colleagues who would be discussing various paths and Doctor Navin Verma. He's a consultant in the team. He would be discussing the management of growing hernias or in vinyl hernias, which like I said is extremely common, particularly in the males. This would be followed by Doctor Munindra Gupta who's again a senior consultant in the team and he would be discussing the treatment for ventral hernias which again is extremely common in the ladies or in the females. This would be followed by management of complex hernias which I would be discussing. So there are. There is a certain component of ventral hernias which come to us, which are complex hernias, which cannot be treated by routine laparoscopes. How do we manage those hernias and what are our results? So we'll discuss all three. So to begin with Doctor Navin Verma and he would be discussing in vinyl hernias and the latest management. Thank you. Thank you, sir. Good afternoon, everyone. So I'm Naveen Verma in the consultant in GI mass and data cuisine Manipal Duvaka. So I'm discussing about in vinyl hernias and its management. So first of all, basically hernia is defined as abnormal proportion of viscous material or viscose from opening, which can be artificial or acquired with a covering of plutonium called as sec around it. So patiently present with this wedding in the groin area like this diagram. So symptoms of in my hernia are mainly one is groin pain, second is bulge that comes and goes with standing and walking also, third is burning sensation, then fourth is a heaviness or dragging sensation also there and sometimes swelling in the squatting also there in case of complete hernias. It's a very common symptom of in vinyl hernia. And if it is about types of in vinyl hernia, so one is light hernia, which is generally acquired by birth only. So this is generally mainly found in gang population and it's very common. Second is light hernia, which is mainly due to because of muscles which is acquired with time, then we would like heavy weight lifting also, standing also and with old days. So they are generally bilateral and if we see location wise in light hernia is generally lateral to infelipigastic vessel and light hernia is medium to epigastic vessel. Cozy of in my hernia, so any factor which increase intraabdominal pressure there is a hernia formation like chronic of constipation, hard physical work, pregnancy, weight lifting, overweight, snatching and muscle weakness. So they're very common cozy of hernia formation and the multiple connective tissue also which disorder, which also react in hernia formation. So they basically result in defective quality formation. So muscle become weak and hernia formation more likely and multiple numbers as one diagram. So completion of in light hernias generally hernias are you know basically came with basic symptoms but sometimes completion can also happen one is like in carcinoma in carcinoma of hernia. So when hernia get stuck into growing or scutum this is called in carcinoma of hernia. So it goes pain also and sometimes it causes obstruction of it and also in patient came with severe pain, vomiting and emergency. So second is strangulation of hernia. It happens when vestularity of intestine is cut off. So bowel become ganglionous and it's very life-threatening also and patient can you know die also after completion. So I will tell about anatomy of in my canal which is very complex so I will just tell you briefly. So antivore is made of generally extinoblique epineurosis. The later pore is from internal oblique muscle and posteriorly transversally faci and transversal muscle is there. Superiorly also internal oblique muscle is there. Inferiorly inguinal ligament is there. But what we see during laparoscopies and opomies totally different form anterior approach. So this is we can see this is a periscope vessel here and that this is ilioburic line is there which correspond to inguinal ligament and this is vast defences there and this is sperm vessels there and this is medial and this is lateral oblique ligament and this is lateral oblique ligament. So this contain epigastric vessels. So this is our site of hastile extinoblique from where diethaniline came and this site of ethyl ania which is lateral to epigastric vessel. This is site of femoral hernia which is only below ilioburic line and this is the angle of doom which is made from vast defences immediately sperm vessels laterally and paternum infinitely. So this contains actually like altrain pain. So this is called triangle of doom because any injury can be very fatal also in this area and this is triangle of pain which is formed by sperm vessels in the side then ilioburic line this side and then paternum. This contain multiple nerves so any fixation of tiger here cause severe pain to patient. So this is called triangle of pain and so this is again just a diagram of triangle of doom and triangle of pain. So this triangle of doom is made of vast defences and testicle vessels and paternum. This contain actually like altrain pain and one nerve also real and this is triangle of pain which contain femoral nerve and three more bunches. So this is your height of lateral hernia. This is height of lateral hernia. This is infelipigastric vessels. This will be to work out. So this is advantage of leprosopy that we can cover all the effects by putting mesh which we can't cover in open material. So you know by we can see the diagram also we are covering direct defect also here indirect defect also femoral defect also nicely. So if you see types of inguinal hernia repair so one is entered or open approach which is done from very old time and this is postive repair or we can see leprosopy also there. So in open repair one is like extend repair which tends less repair. So plug repair and other also. In postive repair I will tell about leprosopy repair only because this is now it is bore standard and it has two types. One is truss abdominal pre-pattern repair and second is totally extended repair. So this is truss abdominal pre-pattern repair. So as the name is truss abdominal means we are going into intra-abdominal cavity. This is a momentum bubble. So we are putting code into intra-abdominal cavity then pre-pattern name. It means we are doing surgery in the pre-pattern space. So we open the plutonium in this area and to surgery. So this is called tapped repair or truss abdominal pre-pattern repair. Second is TEP or totally extended repair. In this we just go beyond the rectus muscle in the pre-pattern space. So this is plutonium. We are not going into intra-pattern cavity. So basically procedure is same but techniques are different. So we prefer this technique TEP approach. So sometimes they do tap also. It depends on how comfortable they feel. This is protocol of measurement of inguinal hernia. So if any symptomatic inguinal hernia of which piston came electrically if hernia is a one-sided man then lab and open both are equally effective and we can do both technique also with same results. If it's in female then lab is preferred because due to better cosmoses and if it's hernia is bilateral then obviously lab is better than open in any case. And if it's a complete hernia or total hernia then open will be easy and open will be better than lab because in lab it's difficult to use the hernia completely. And in the after previous operation in the lower abdomen then lab become very difficult. So open is preferred. And if patient outfit for GA then also open is preferred because we can do under spinal or local also. And if recurrence is there so if recurrence is after previous open it where then lab is preferred because piston plane is vision plane. And if previous lab recurrence is there then open is preferred because the entire plane is vision mode. And if any patient came with hernia emergency like in car series and strangulation. So strangulation we never do lab because we can do better best time for the machine with open only. But in case of incarceration we can try lab also after using hernia. But still we prefer open because we can do complete job by open technique only. Or if it's about indication of laparoscopic hernia recurrence so same one is recurrence after previous open recurrence bilateral hernia. In the diagnosis confusion is there then lab is preferred because court has more small incision and if patient has driven to activities early then lab is preferred. And contradiction same like piston outfit for GA with multiple medical issues. And if recurrence is after previous lab then we can't do lab again because there are lots of origins and chance of injury will be more. And in strangulation hernia also lab we can't do. And in previous hernia in the lower domain and you can difficult. And one of the best repair is definitely less pain is there small scar so better cause message is there early recovery, less blood loss and low chance of good infections there. So lab is preferred as can be open. This is paper published in 2003 which compare laparoscopic hernia with open legacy repair. So as per this paper long term recurrence is almost same so both are equally effective but laparoscopic hernia repair cause less burn pain and less herachesia as can be to open approach. Again paper published is compare between TEP or totally extra for the repair with class abdomen people to repair both are lab techniques. So but as of this paper TEP takes slightly more time as they are to open a tonium then it goes also and even hospitals is like long with the TEP technique as can be to TEP. So this is video how we do our laparoscopic hernia repair. So this is TEP technique we are putting three ports. This port is 12 amport which is good just to blow up like us and then two small five amports. This port is lower port which is out to centimeter above the supra pubic margin and this port is put in between two ports in the midline. So starting video. So we put a laparoscopic we do dissection of the medial space with laparoscopic only. So this is our TEP plane and we can see here this is a pubic bone here. So then we come on the later side this is direct sec. So by traction and counteraction we are separating direct say from the transversal facial this is transversal facial you can see. So after using direct sec then we come on later to add the space of bogdals. So this is no indirect sec along with port structure. So again traction and counteraction carefully. So then again holding a sec with the petonium. So we are separating a petonium from your direct sec from the port structure. So be very careful because we can injure boss difference here. Tested vessels and even bigger vessels also. So we can see this is the boss difference and this is testing vessels there. So our point of dissection is up to point we have boss turns medialine. So this is R2 of boss along with the boss here. So carefully again traction and counteraction. So we generally prefer seizure because we can do SAR as well as blunt direction also that's easier. So and then later also we are separating the testing vessels from the petonium layer. This is the marginal petonium we can see earlier and this is standard vessels here. So this triangle of pain is there and actually like RT and Bain is also behind this. So you should be very careful in this area and this triangle of pain is there. So you can get multiple nerves. So you should be very careful in this area also. So we can say nice now how boss is turning medialine. So this is a point of dissection in the middle space. So after making full space and making a little space also. So we can put almost nicely then we come on the left side for the bilateral case. So again, there's no right side here. So it's a separating or direction middle space then coming laterally. This is again in light second code structure. So again traction and counteraction same technique so careful dissection and then again holding in light sec with the code structure and they're separating with seizure and we use poetry also for dissection. So this is in here because we can see right now. So any hernia middle, this is called direct hernia and hernia lateral, this is called in light India and hernia here is to mobile hernia. So we are separating sec from code structure carefully. Again with traction and counteraction along with electro poetry also which we're very very careful here also to our injury. So we can see how this is boss difference and tissue also there. So this is the angle of doom. So making good space on middle head also and make head also so that mess can come comfortably. Then again opening more space of bogras carefully and this is again a purpose regalment here and this is to be worn, you can see here. So this is again separating plutonium from the code structures carefully. So this is the angle of doom in the side. So this is boss again, we are going to boss in the middle. This is literally again making good space for the mess. Then we're putting messes. These are the preferred 3D bar messes. We are very easy to handle and we can open very nicely. So we are covering all defects. Then we fix messes with tackers carefully. So then we can be putting mess in the right side also. So we are putting mess on both side or by little hernia. And our basic rule will be our risk overlap around one to two centimeter in the middle and also to cover all defects. Then we're fixing mess with the tackers on the coppers regalment nicely. So now we can see how nicely they're covering direct defect, direct defect and tomorrow also. And this is later. So now we dissipate our abdomen. So we can see now how nicely we are putting mess and covering all defects. So thank you very much. I'm very thankful to many part of my boss Dr. Indi Vadawan and Dr. Manin Ruktha also. So now I'm starting and I'm giving Dr. Manin Ruktha will tell about mental hernia. Thank you very much. Hello friends and colleagues. Good afternoon. I'll be talking about mental hernias. So mental hernias are the hernias which arise from the defect of the anterior abdominal wall. They are known as umbilical hernia. The defect is in the umbilical scar. In seasonal hernias if the defect lies in the previous abdominal surgery. Paramylical hernias when the defect lies above below or on the side of the umbilical scar. Epigastric hernias are the hernias which arise from the linear elbow. They are fatty hernias. They occur between the zephysternum and the umbilicus. Spigilian hernia is a hernia which arises in the linear semi-neuronaris. So this is one of the patients with the large umbilical hernia. It causes her to increase intrabominal pressure, obesity, multiple pregnancies. Such hernias require complex surgical procedures. Now umbilical hernia as already explained is the herniation through the umbilical scar. It can be congenital which is presents his birth. Most of these is all without any treatment. In next two to three years however, a few of them require surgery. Acquired umbilical hernias, they occur in the adults with the, because of increased intrabominal pressure caused by obesity, pregnancies, high weight lifting, cuffing, straining. The umbilical hernias contents consist of extraperidonal fat of the anterior abdominal wall, greater momentum and occasionally as the hernia grows in size small intestine. These umbilical hernias are liable for complication of irreducibility, obstruction and strangulation because they have a very thin fibrous neck. Now this is the photo of much more common umbilical hernias in Africa. And as these people grow older, many of them continue to have umbilical hernias in adult world. Now a little bit about surgery for umbilical hernias. Hernias which are small less than two to three centimetres in size, simple primary repair known as Bayoz repair, also known as the vest over pants because the upper flap is superimposed over the lower flap. The surgery of choice for umbilical and ventral hernias is leproscopic approach. So leproscopic surgery, leproscopic umbilical hernioplasty started in late 1990s where the approach was initially entered the placement of intrapiridinial mesh. However, because of recurrences, better results were obtained with leproscopic trans-facial sutures with intrapiridinial mesh placement. Now this is another umbilical hernia. You can see there is this skin change colour. This is strangulated hernia. The contents, however, are probably momentum because there is no abdominal distension. Now I present a case of umbilical hernia strangulation. This patient presented to us in the casualty, severe pain with vomiting. On leproscopy, we find that the intestine was injured. Part of the intestine has entered the hole. The umbilical hole was very small, one to two centimetres only. But the part of the intestine, like a richer hernia, had entered into this hole and was injured. This is the hole. You can see how small it is. So we are trans-facial ligation of the opening is being done. The proline suture is introduced and with the suture passer, we pass it through and we put a figure of eight suture to close the opening. Once the opening is closed, we put in a mesh. The mesh has trans-facial sutures on all the four sides. These sutures are ligated and the mesh is fixed with tackles. You can, this is a old video, I think about 10 years old. So you can see that the tackles are metallic. They have pointed edges outside, likely to cause injury to any very interesting sutures get stuck to it. Nowadays, we are using absorbable tackles and the outside edge of the tacker is blunt. Not likely to cause an injury. So the mesh is fixed all around the tackles and a few tackles are also applied near the hernia opening, which had been closed. While applying tackles, we reduce the abdominal pressure so that the abdominal wall being slightly more relaxed, the mesh is stretched. So this is the final picture of the mesh in the repair of the ventral hernia. So now we talk about incision on hernias. Incision on hernia occur at a place where there is the abdominal wall defect because of previous surgery. Any laparotomy or any surgery of the anterior abdominal wall causes injury to the epidurosis, the muscles, and the nerves of the abdominal wall causing the formation of an incision on hernia. 10 to 20% of laparotomy patients develop incision on hernias and 50% of these recurrences occur in first two years after surgery. Recurrence is also common after primary suture. If mesh is not used, the recurrence is about 50%. When meshes are used, the recurrence is reduced to 10 to 20%. Now this is a picture of a large incision on hernia. He underwent a laparotomy followed by a hernia and the hernia was repaired twice. Please come for a third mental hernia repair. You can see that the defect is huge. It is from one side of the abdomen to the other. In addition, he has obesity. So these hernias require complex surgical procedures. Now we come to the predisposing factors for the hernias. Some of them are patient-related. The others are surgeon-related. For a patient being in old age, obesity, diabetes, wound sexes, wound bihiscence, immunosuppression, patient on steroids, patient suffering from malignancy. Then the surgeon-related incisions, the longer the incisions, more the hernias, midline incisions and longitudinal incisions cause more hernias rather than transverse incisions or oblique incisions. Then sutures, non-absorbable sutures or slowly-absorbable sutures do better. Suture length should be four times the length of the incision. And the bite should be between five millimeter to one centimeter from the edge. The shorter bite we need to cut through and a bigger bite we need to sloughing of the edge of the muscle. And then the entire abdominal pressure, MNC surgeries and wound contamination lead to a much larger incidence of incision and hernias. The open hernia repair still has a place in incision and hernias because some of them are very large. The defect is huge and also the skin is distended and big. Distended and big. But these open hernia repairs are a major surgical procedure with the wide deception of soft tissues. They lead to considerable morbidity and a high incidence of wound surfaces. Mashes in hernia are very essential. All hernias now require meshes. They are applied in four ways. One is the only, only meshes applied over a repaired hernia suture line. Inlay technique with the defect is too large. The two edges cannot be brought together. So the mesh is sutured to the margins of the eponeurosis. And the underlay technique, where the mesh is placed retro muscularly but extra painfully. And a sublay technique where the mesh is placed intra painfully. Now leproscopic hernia repair is done with the intra peritoneal mesh placement. So there is a full thickness transfacial suture and an intraperitoneal dual mesh. It has minimal postoperative morbidity. It has a shorter conveyance period and a acceptable recurrence rate. The meshes now are bi-return dual meshes. Either a bi-layer PTF or a bi-layer polypropylene mesh. Now this is a video of a patient who has had a umbilical hernia. You can see that it contains basically the extra peritoneal fat. And also a very large di-verification rectile. So this, because of the di-verification rectile right from the zephysternum up to the pubic symphysis. The abdominal is very lax. If done by an open procedure, this patient would have an incision right from the zephysternum to the lower part. So now we are denuding this central area. We are removing the umbilical fat and the ligamentum derives the median umbilical ligament from below. So the medial part of the abdominal wall is denuded of all the fat so that it can be stitched together. Now we are doing a stitching from inside the intraperitoneal stitching. When we do an open surgery, we can pull the suture with hands and give it enough force. With the prescopi, the pulling is slightly more difficult because you are pulling with the forceps. So now instead of pulling sutures, we are using V-lock sutures so that once we pull it stays. Here you can see we are having a problem with pulling because as we pull, the two edges do not come exactly in a position. So we apply the suture right from the top to the bottom and once we have applied the suture, we put additional second layer transfacial sutures so that it acts as a second line of defense. So these are the transfacial sutures being put after we have put in the intraperitoneal sutures. So these sutures have been put and then we put in the mesh. The mesh covers the whole thing and gives strength to this repair. So we are able to achieve both the repair of the divertication and also the embryo honey. So here we have put sutures in the mesh which also give it strength because they are fixed to the entire abdominal wall. And then it is fixed to the tacker. You can see these tackers are different, these are absorbable and they do not have a pointed edge at the end. So this tacking is going on and after putting the tackers all around the edge, we also put a few tackers in the center of the mesh to keep it in position. So now, is leproscopy surgery done in all cases? No, there are a few contra-educations. It cannot be done in emergency situations, especially in obstructed and strangulated hernias. It cannot be done in a hemo dynamically unrestrained patient. It cannot be done in the presence of a gangrenous bowel, massive societies, medically unfit patient for a leproscopy, massive intra-abdominal adhesions following previous open surgery and patients who have entero-cutaneous crystallized, infected meshes and intra-abdominal abscesses. So in conclusion, leproscopic intracarotronium on the mesh, ipop, repair is an effective surgical procedure for ventral honey repair. It is suited for honey and defect size of 2 to 10 centimeter. Leproscopic technique avoids extensive sub-cutaneous dissection, reduces serum of formation and reduces wound sepsis. Hence, it can be considered as a primary procedure for ventral honey repair. Thank you. Thank you, Dr. Naveen and Dr. Munindra for this lucid presentation. So like I mentioned in the initial introduction that most of the surgeries that we do are primarily of groin hernias, which Dr. Naveen discussed. Again, the others would be the, the ipoms or intra-peritoneal on-lay mesh or the ones which come with simple ventral hernias and Dr. Munindra discussed that. But then there are about 10% patients which this number is now increasing more who come with complex hernias, hernias which cannot a complex ventral hernias. These are the type of hernias which cannot be dealt in a normal way, just releasing the adhesions or putting in a mesh laparoscopically. They require a different method of treating them. They are more complex, cannot be dealt at most places only at specialized centers. So I'll just discuss these type of hernias and these are some novel procedures though they've been existing abroad for a while. But in India, they become popular in the last decade or maybe a less than decade. Let's look at, you know, how do you define or how do you classify abdominal hernias? Now you know that what is a classification for a cancer? Somebody with a cancer, if he is to come and somebody is to say that he's got a T2N0M1 or T2N2M1, everyone understands this that he's got a tumor which is second grade tumor. He's got some nodal spread and he's got some spread extra nodal as well. Now similarly, we have a classification for abdominal wall hernias as well. So if somebody is to tell us that this is a hernia which is let's say M2. So we all understand M2 means it's an epigastric hernia. So we know how to treat those hernias and therefore this classification is extremely important. And we in our department always will classify a hernia and then plan the treatment according to the classification of the hernia. So we can move from M1 to M5 depending upon where the location of the hernias are and this is in the midline. Then there are some lateral hernias which could be subcostal flank iliac or lumber. Now these again would be according to the location of the hernia. So like I said, somebody can say L2. L2 means it's a flank hernia. So we understand we are dealing with a flank hernia. Then once we've identified the location, then we know what, whether it's a recurrent hernia or it's a primary hernia. So once you say R0 means there's no recurrence or if you mentioned R1, we know there's a recurrence in that hernia. Similarly, we also measure the length and the width of the hernia and the length would be the maximum chordal to the maximum cranial distance which could be if somebody's got multiple defects, we still measure the cranial most end and the chordal most end. Similarly width, the maximum width laterally and accordingly we again decide whether it's a W1 which is a less than four centimeters or a W3 which is more than 10 centimeters. So let's say once again, somebody says it's a M2 hernia. It's a, that means it's a epigastric hernia. Then he says it's a R0. That means it's no recurrence and then he says W1. That means it's less than four centimeters. So we actually know what is the kind of treatment which would be required for this hernia and therefore this classification is extremely important. Coming to what are these complex ventral hernias? We've already dealt with the regular ventral hernias which are the, which we do laparoscopic treatment in the form of hypomes. Now the complex hernias are infected wounds. If you're doing a concomitant bowel surgeries, large defects which are more than 10 centimeters, subcostal, chevron or non-midline which are the lateral hernias and then certain hernias that sub-zephoid, paraheliac, suprapubic, parastomal hernias, these are all coming the complex hernias. Then hernias with multiple recurrences. So for people who've had multiple recurrences when they come to us, they all come in this category of complex hernias. So let's see, these are some of the patients who've come to us. Like I said, almost 10 to 15% of all our practice is complex hernias. So just have a look at this hernias. And this is a patient who's coughing and when you see that cough laterally, so it's a lateral hernia, it's a large hernia which is more than 10 centimeters in size, it's not non-midline hernia and therefore this becomes a complex hernias and obviously you can't do it laparoscopic. You need to do something different for these type of hernias. Again, have a look at the video here. Now this is a midline hernia, but then the defect size is more than 10 centimeters. See the size of the defect when the patient is coughing and this is a recurrent hernia. The patient already had had a IPOM surgery and has had a recurrence. So therefore again, this becomes a complex hernia. These are again complex hernias. Patients who've had multiple surgeries or the hernia defect is huge and it's a protuberant belly where more than 20% of the volume of the abdominal contents are actually outside. For these, they can't be taken up right away. We need to have a good preoperative planning for these patients, which means in the form of physical examination to know what is the defect size, what is the location, whether they have any stomas or draining sinuses or if they've been operated previously, whether they have an exposed mesh. Look at the skin. Find out the operative history. The cold standard investigation here is a CT scan. So CT scan is absolutely mandatory. We get to know the size, location of the hernia. We can identify if there's a mesh which has been previously placed. We can also find out what is the abdominal musculature and then plan the surgery accordingly. We need to manage the medical conditions. Most of these patients may have diabetes, obesity, they could be having some infections. So we need to treat this or contain them before we take them up for a surgery. Ideally speaking, the patient should have a smoking cessation for at least a period of four weeks. If not four weeks, at least for two weeks. Informed consent is absolutely mandatory for these patients because they can have complications. These are complex hernias. They can have recurrence. They can have mesh infection. They can have an abdominal compartment syndrome because most of the abdominal contents are outside. Once you pack them inside, they may have an abdominal compartment syndrome. They may require a most of post-operative ventilation. So you must take an informed consent that all these things may be possible. Of course, it requires training. You just can't get into doing these complex ventral hernias without adequate training. And I traveled abroad to go to the best in the business who's Dr. Yuri Novitski. We spent some time with him to get training in these complex hernias. And then we started doing this routinely in our department. So just to revise the anatomy, this is a cross-sectional of the anterior abdominal wall. We know that that's the rectus muscle there. Those are the external, internal oblique and transverse abdominis. And so above the archway line, you'll have the anterior rectus sheet. But once you reach below the archway line, which is one-third of the way between the emblicus and the pubic synthetis in symphysis, you only have the anterior rectus sheet. You do not have the posterior rectus sheet because the sheets of external, internal and transverse abdominis, they go anteriorly and they don't go posteriorly. So you actually have the rectus abdominis muscle lying on the transverse allyspration. Now this is extremely important when we are doing component separation or tackling these hernias. Again, another important line which we find is the linea semilonaris. Now that's the lateral edge, nearly the lateral edge of the rectus muscle. Now here, this is where most of the neurovascular bundle actually pierces the sheet of the internal oblique muscle. And once it pierces the posterior rectus sheet or the anterior lamina of the internal oblique and it comes out, we need to save this. There is no way we can injure these vessels. And because they cannot be injured, so therefore the repair has to be in a way done so that this neurovascular bundle has to be safeguarded. Because if there is an injury there, this can lead to a flaccid paralysis of the rectus muscle. And once that happens, you have a flabby abdomen. So this has to be preserved. You'll see in our presentation how we preserve this and yet can manage a hernia which is a defect size of more than 10 centimeters. So what we are going to discuss is the retro muscular repair. Only these days are not done. By and large, they are obsolete. We know why. IPOM we've already discussed. What I'm going to discuss is the retro muscular repair that is putting in a mesh just below the rectus muscle bilaterally. Only like I said, by and large is not done because of the wound related complication. Surgical site infections are huge. There could be seromas, hematomas. There's a huge chances of descents, not suitable for large defects. When we are talking about defects, more than 10 centimeters. Patients having multiple defects, again not an option, has a high chances of recurrence. And therefore by and large it's become obsolete. So we've come to what is called as component separation. Component separation is a technique where we're trying to bring the linear Elba in the midline, close the linear Elba without any tension and offloading the constant lateral pull of the oblique and the transverses muscular system. And therefore ensuring that you close the linear Elba in the midline and then reinforce with a mesh. So what have a look at this short video this is a patient who came to us. A young man who'd had an abdominal surgery, a defect size of more than eight centimeters in the midline had a bad scar. We obviously did not offer a laparoscopic surgery because eight centimeters cannot be closed by laparoscopy. So we offered him what is called as component separation and what is called a brief stopa repair. So this is one part of the component separation. We'll discuss two parts. This is the first part of the component separation where what we do is we first do adhesiolysis. Once we are doing, this is an adhesiolysis which is being done. Once we've done the adhesiolysis, what we'll do is that we'll form a small plane from the, we'll dissect the posterior rectus sheath just about a centimeter. That's the posterior rectus sheath which is being dissected from the rectus muscle about a centimeter from the midline. Once we dissect this, that's the posterior rectus sheath which is we are holding up the anterior rectus sheath. We've not made any subcutaneous space here. So that means no mobilization of the subcutaneous space or the skin and the subcutaneous fat and therefore lesser chances of SSI or surgical site infection. This is the posterior rectus sheath which is being mobilized. And what we can do is about eight to 12 centimeters can easily be closed without doing anything much. But here what we do is I mentioned the word linear semilonaris which would be the lateral edge of the rectus muscle. We will go up to the lateral edge of the rectus muscle and not beyond, safeguard the neurovascular bundle and ensure that we've dissected right up to the neurovascular bundle. And we have the posterior sheath which has been dissected on both the sides. It's a tension-free repair. We closed the posterior rectus sheath like we are closing now and then we'll place a mesh which would be placed a big mesh which would cover in the retro rectus space covering the on the posterior rectus sheath from one edge to the other edge safeguarding the neurovascular bundle and therefore ensuring we have a good and an excellent repair. And this is, we don't need to do anything beyond this, particularly for hernias which are anything between eight to 10 centimeters of size. So like I said, we do not offer a laparoscopic treatment here. We offer what is called as component separation. This is first part of the component separation. So like you see, we've closed the posterior rectus sheath. Once we've closed the posterior rectus sheath here, then we'll measure the size of the defect. Once we measure the size of the defect, what we'll do is we'll place a mesh here. So mesh comes very nicely. You can see the rectus muscle. Mesh has come in very nicely. And then after that, once we fix the mesh, then we close the anterior rectus sheath. No mobilization of the skin and subcutaneous tissue, hardly any chance of surgical site infection and excellent recovery for this patient. This is the same patient and then just closure after that. This is a patient in which we did the Reeve Stopa similar. You saw this video earlier. This is a video of the same patient. Recurrent hernia had already had an IPOM. IPOM is what was demonstrated to you earlier. He had an IPOM technique. He had a recurrence. We did a Reeve Stopa. This is the patient on the seventh day when he came for a clip removal. You can see we are telling him to cough. There is no, it's absolutely flat, very well repaired. The previous mesh was taken out and a Reeve Stopa repair was done. So sometimes what happens is the defect size is 10 centimeters, 12 centimeters and beyond. Once the defect size is more than 12 centimeters, a Reeve Stopa repair will not suffice because you need more mobilization of the posterior rectus sheath. You require more medialization of the posterior rectus sheath. That is when you do a more complex procedure which is known as the transversus abdominis release or the tar. In this, the first component remains the same. This is the rectus muscle. We are mobilizing the posterior rectus sheath up to the linear semilonaris, but we'll not go beyond the linear semilonaris because we obviously do not want to injure the neurovascular bundle. So what we do is we give an incision on the posterior rectus sheath just about a centimeter medial to the posterior rectus, to the linear semilonaris. Go on to the transversus abdominis muscle. We see the transversus abdominis muscle. Once we see the transversus abdominis muscle, we cut the transversus abdominis muscle and they'll go behind the transversus abdominis. So what happens is once we go behind the transversus abdominis, the internal oblique is above. The transversus abdominis with the posterior lamina of the internal oblique is above. So the neurovascular bundle is preserved and we are going behind the transversus abdominis muscle. So once we are going behind, we are safeguarding the neurovascular bundle and we can go right up to the suase major muscle. So this is technically demanding procedure, but we can go right up to the suase major muscle. Once we can go right up till there, we can mobilize 10, 12, 10 to 10 centimeters on each side and can close it. Very nicely. Once we close it again, the procedure remains the same, place a large mesh and close the skin. Again, like you've seen, we've not mobilized the skin in the subcutaneous pad. So hardly any chances of surgical site infection and lesser chances that this patient would have a recurrence. This is again a patient where we've done a bilateral tarp. So this is a patient which I showed the video earlier. This is a patient where it's a lateral hernia. It's about a 12 centimeters. It's a complex hernias. And so this we've seen. So this is the patient again, which came on the 10th day. So once this patient on the 10th day, you can see it's a well preserved. It's a midline incision that we've given. Absolutely perfect. That's the photograph right after the procedure and that's on the 10th or the 12th day. So excellent procedure, but it's more complex. It's easy to get it wrong, large dead space. So it's technically challenging, requires appropriate kind of training and experience to be doing this procedure. Postoperative care again is important. Can't be done in nursing homes. Has to be done in a tertiary care center where we can actually manage most of the other things, including the pulmonary problems, the abdominal compartment and everything else if the patient requires some amount of ventilation can be done. We give these epidural catheters, discharge the patient three to four days, sometimes with the drains and remove the drains on the fourth or the seventh day. Some evidence has come around. People have been doing endoscopy for the last few years, but in relatively easier procedures. But if we compare it with open surgery, no major difference. In fact, in endoscopy, it requires more time, lesser time in open surgeries. Recovery is by and large similar. And if you look at the guidelines which are published, you'll find no difference if you are doing a tar, open, laparoscopic, or if you're doing robotic. Excellent case. I thought I'll just share this case. This is again a unique case. This is a 26 years old female who came to me. Had a laparoscopy for twisted life to variances. She had 22 weeks pregnant at that time. She was operated, her laparotomy was done. During that time, there was an inadvertent sigmoid perforation. So she required a laparotomy again after that. During the laparotomy, they repaired the sigmoid perforation. It did an aliasmine. This was done outside. And then a closure of aliasmine was done at three months. But she presented with the eight centimeters inframilical defect. And so she required a repair, but she was 26 years. She had not even started her family. She wanted to have a family, but at the same time she wanted a repair for a hernia. So obviously she required a complex hernia, required a component separation, but at the same time, what we wanted to do was give her a repair or give her a hernia or give her a mesh, which was actually long time absorbable mesh. Something where if she has to have a pregnancy later on, she can have a pregnancy without a problem. And this mesh actually gets absorbed. So we did a unilateral tar, which I already explained how we do the tar, close the defect and put in a mesh. Now this is a quality of a mesh, which has just come around. We are the first users of this mesh in the country. Some usage has been done at other centers as well. Now this is a resorbable mesh, which takes about 18 months to get absorbed. And what it does is it gives strength to the native tissue. As a result, the native tissue becomes has enough strength to take care of the, to prevent a recurrence and the mesh completely goes away. So as a result, if the lady is to have a pregnancy after 18 months, there is not going to be any mesh, but the native tissue is going to be so much strengthened that it's going to be completely like a normal tissue. And so even if she has a cesarean later on, the gynecologist or the obstetrician there could just stitch the sheet without any problem. So these are the, they come at a cost, they are expensive, but we've started using these meshes in certain complex conditions, particularly in ladies who need to have pregnancy after, and they have a hernia and they want to still have, they want to conceive after that, we use it in those cases or in cases where there is some amount of infection where we can use these meshes. So excellent meshes, like I said, come at a cost, but we've started using them in complex hernias. So this is an algorithm that we follow in the department, less than two centimeters, we do a suture closure, anything between two to six centimeters and IPOM+, which was already described, we can do it laparoscopic or robotic, six to eight centimeters, we do a hybrid procedure, we can just give a small incision, close the sheet and then put a intraparitonally mesh, or we can do a reef stopa, which I just showed, again, it can be done robotic or laparoscopic, eight to 12 centimeters, we always and always prefer to do a reef stopa or a component separation and more than 12 centimeters is at our procedures. So this is something which we follow in our own facility and by and large, we are quite happy with this algorithm and we are able to take care of almost all vitrella hernias which come to us. So finally, my friends, the goals in the repair of a complex hernias is to increase their abdominal wall capacity, closure of the midline is extremely important, just placing a mesh will not suffice, patients are going to have a recurrence, so you need to close the midline and then to offer a mesh to ensure that there is increased dynamic muscular support, wide coverage of the mesh is extremely important and you must take care of the redundant skin so that the patient has a good cosmetically appealing scar. Thank you very much for your kind attention and take care of all of you in these COVID times. Thank you.