Abdominal Wall Reconstruction: Update Course 2017

Now I have to live up to that grand rapid. um, so these are my disclosures. I hope you'll find that they aren't relevant to this except for this one disclosure which has already been mentioned. I am not a pediatric surgeon. Um, these are my patients. Most of your patients can fit inside of the hernia sacs of my patients. So my real objective here today is just to talk about two main things, and that's the techniques that are newer in abdominal wall reconstruction. And a little bit about mesh selection and our sort of evolving thought thought process around that and then you can kind of take that and we can talk about how that may apply to pediatric surgery. So, um, I will start with a case though, and this is a case that was a gift from, uh, Todd. This is a 16 year old with, uh, he presented to me after he had a history of bowel obstruction, uh, where he went to the emergency department, uh, for a peristomal hernia. He was incarcerated, but they were able to reduce it. He has a past medical history of spina bifida. He's had a surgical history of Metrofanov and a mace, as well as then converted to a colostomy and ileal conduit. He's already undergone one pair of stoolal hernia repair with a description of a pretty extensive license of adhesion that took over 4 hours and a history of a VP shunt as well. And those are just the abdominal operations. On exam, he has a BMI of 43. He's wheelchair bound. Uh ileal conduits on the right, lostomy's on the left, and there's a softball sized peristomal hernia. So. Uh, we have a CT scan, so you can get a better look. So it's a little separated in the midline, but for the most part that's intact. Uh, you see a few loops next to the colon on that. And there's the second image. So, uh, with that being said, we've sworn in the panel, uh, and I already know what Todd's gonna do. So we're gonna give a chance to everybody else to kind of give their input on what they might do for this, uh, young gentleman. Open approaches laparoscopic. How would you go ahead and fix this? Do we have choices or no? Uh, I actually, no, I didn't put any choices, so I apologize for that. So Mark, you look like your mouth is about to open. What would you do for this patient? So I, I, I mean, I try to put a scope in, um, but although it sounds like and if it looks like his, uh, belly wall has, uh, been, you know, I don't know what it's gonna be like in there, and it may, I may be influenced by the last operation if they said it was cement, and I might just go open. But I would, I would fix the peristomal hernia and I would use a biologic mesh. To repair it. All right. Would anyone else do anything different? No? OK. All right, perfect. So, what I did was an open, uh, posterior component separation with retromuscular repair, the 30 by 30 centimeter macro porous medium weight monofilament polypropylene synthetic mesh covering both stoma sites. Does that that we would recognize. So my hope. Is that what I just said makes absolutely no sense to you and if I do my job over the next 15 to 20 minutes, you will understand what that means and why I made that decision. So in the current market today, there's over 300 meshes available spanning the spectrum of synthetics, bioabsorbables, and biologics. I'm not gonna go into detail on all of those today, uh, but one thing I will mention is you do have to understand that meshes, uh, can make it to the market pretty easy. In fact, when they passed the ruling on for FDA clearance on meshes because it's technically a Class 2 device, it only has to show equivalent to what was there before, which is Marlick's mesh. So any mesh only has to show that it's equivalent to Marleck's mesh, and that's why we have over 300 meshes available. So it makes it pretty challenging for somebody to try and determine what they should actually use. Uh, so first off, what is the ideal mesh? Well, for me, I want it to be durable because I don't wanna come back and fix it again because the most painful hernia is the one that comes back. Uh, I want it to be resistant to infection because only worse than that is actually removing infected mesh. It should be easy to handle for my own personal preference in the operating room, and it should minimize host response or probably more importantly optimize host response. You don't want it integrating into the bowel, but you do want it integrating into the abdominal wall. So if you can achieve that and if you can make it free, you have the ideal mesh. Uh, first to recognize though, it's not all about the mesh. Everything around us is changing. Maybe your patients aren't changing. They're just getting a little bit older and bigger and hitting puberty. Ours are just getting bigger. So, uh, we looked at this and we looked at patients who had at least one comorbidity and, and it turns out, not surprisingly, that the more comorbidities you have, the higher your rate of wound complications after surgery. So you can look at that negatively. And you could say, well, everybody's just, this is my outcome is going to be bad because everybody's just getting more obese and smoking, or you can try and bring them down the ladder. And now a real big concept in abdominal reconstruction is prehabilitation. And so we've gotten to a point where we will not offer surgery for people unless they achieve smoking cessation, achieve weight loss, their blood sugar is under control. These are not cancer operations. These are typically elective surgeries. So we want to try and optimize their outcome at the beginning rather than do the rehabilitation on the end when they have a bad outcome. Uh, so as far as synthetic meshes go, most people recognize this as polypropylenes, polyesters, PTFE composites, which is the polypropylene and polyesters with an anti-adhesive barrier on it that we typically use for laparoscopic vental hernia repairs. So PTFE and abdominal wall reconstruction in this current state is no longer really utilized, and the reason for that is that it's poor integration compared to the other meshes that are available, and if it gets infected, the whole thing typically has to come out. And so at least in abdominal wall reconstruction, we really don't use PTFE any longer. Uh, what's new in synthetic synthetic meshes as far as products go, really not much, but there has been a change, at least in some of our understanding of mesh morphology and how that may play around bacteria. Uh, and that's ultimately changed our indications, uh, for synthetic mesh. So this is a study that we did a few years back where we actually took rats. We, uh, performed a laparotomy, resected part of their rectus muscle, and then, uh, performed a bridge repair with synthetic mesh. And you can see all the meshes that we used on the bottom, which, uh, spans anything from polyesters to polypropylenes, heavyweight, medium weight, lightweights, and monofilaments, polyfilaments. So what we first identified is that the worst were those composite meshes, the one that actually had those anti-adhesive layers on them. Those typically end up acting like auger plates for bacteria, so the MRSA overgrew, you had high rates of uh bacteria when we cultured them out. Uh On the top you'll see that this is the polypropylene meshes which perform the best, but what's interesting is Ultrapro, which is the lightest, that's considered a lightweight mesh, uh, did not perform as well as a heavyweight polypropylene or a medium weight. And the reason is because Ultrapro is a is a polyfilament. There's two filaments to it. One absorbs over time, but they're woven into each other at the beginning. So at 30 days you're still going to have a lot of bacteria that like to adhere into those crevices that cross one another. So what we ultimately determined from that is that soft mesh which or any sort of light or medium weight to lightweight that is a monofilament macroporous polypropylene mesh, actually, and we did the study also with biologic meshes in rats actually performed equivalent to biologic meshes and if you take all the animals that we did, actually 70% of the animals actually cleared the bacteria and didn't have any growth even though we put MRSA on them as far as the soft mesh goes. So we took that from the bench, took it to the clinical practice. Uh, this is 100 patients that had retromuscular, uh, placement of, uh, synthetic mesh in contaminated fields. Uh, overall clean contaminated wound morbidity was 9%, contaminated was 19%, which is pretty respectable for these cases that we're doing. Um, hernia recurrence rate of 10 months was 7%. Uh, big asterisk next, next to that. I mean, gold standard for hernia repair is 2 years follow up, so. Uh, it was lower than you would expect, but it, it's, it is, it is short term as far as long term goes. Uh, 4 partial mesh mesh excisions, no complete mesh excisions though, uh, which again is pretty equivalent to biologic mesh. So we've taken it to the next level to try and define the, you know, the real answer here. Uh, so we're actually undergoing a synthetic versus biologic mesh, uh, randomized control trial, uh, of actually, uh, that mesh I mentioned versus, uh, Stratus, and this is for class 2 and 3 cases with retromuscular mesh placement, which I'm going to talk about a little bit more later. And so hopefully, hopefully you'll invite me back in a couple of years and I can tell you the results of those. We are halfway through that of 250 patients, so. So what about biologic mesh? We've, I've just told you that synthetic mesh can be used in contaminated cases, or at least some contaminated cases. So is there a role or, or why isn't this the ideal mesh for abdominal wall reconstruction? Well, when bio biologic mesh first came out, it was touted as magic mesh. You would put cells inside of this extracellular matrix. And it would turn into a 6 pack and your post-op clinic would look like Miami Beach. And so that sounded great up front, but when you actually take the mesh and you excise it 1 to 5 years afterwards and you start to look at it underneath the microscope, what you see on the left hand side of the screen. Let's see if we can. So underneath the dotted line here, this is the biologic mesh. So you see minimal cellular penetration at the border of the mesh, but nothing in the center of the mesh. So these meshes, yes, some of them will get cellular penetration, uh, but they're not going to remodel into fascia. So that concept of regeneration and remodel has really gone by the wayside. It really, it is what it is. It's a piece of mesh. It's there to provide, uh, reinforcement, uh, of soft tissue. If you're in the office and somebody from the biologic mesh company comes by, what they're going to show you is this in between, which is just peritonealization on top of the mesh, a scar formation that's, uh, with blood vessels in it that you would get with any piece of mesh that's placed intraperitoneally, uh, and so that has blood vessels in it, but that's not actually within the mesh. So on the other end of the spectrum is for biologic meshes is the cross link meshes, and if you're not familiar with cross linking, if you take a piece of, let's say, um, porcine dermis. And you take it right off of the animal that is as minimal of cross linking as you can have. That's considered non-cross link. The most cross link or terminally cross linked material that you can have is leather. So what you do is you take the collagen and they start to cross link with one another and it stabilizes it, but it also makes it a little bit more durable. So the thought was, well, if we can make it a little more durable, that would be better for a hernia repair, but you can see for this you get absolutely no cells inside of the mesh. So, um, there's not as many of those available anymore. Uh, they tend to perform, uh, uh, pretty poor in infection as well. And so, most of the biologic meshes, at least from the dermis, are, are non-crossing. Well, what about durability? So we looked at a 5 year experience with contaminated cases, uh, and abdominal wall reconstruction, 128 patients, large defects, 431 square centimeters. Cases done for a variety of reasons, fistulas, infected meshes, stoma takedowns, um, with almost 2 year follow up, 47% wound complication rate. That's pretty high now. Uh, some of these patients, uh, did have anterior component separations, which required large myofascial advancement flats, and, and so that does increase your wound morbidity, but the recurrence rate was 31% in these patients, which is not very good. And if you actually look at it closer, If you take all the patients you have out to 3 years, the rate is actually 50%, so durability is in question with the biologic mesh is one of the reasons why we're, we're doing this study and we're trying to determine what's really, where do you want to go, durability or infection risk and what's going to win out. And I'm a big value person and so you shouldn't be shocked to know that a biologic mesh is going to cost you in the neighborhood of $250,000 to $30,000 and that same piece of synthetic mesh is gonna cost you less than $200. So we really do have to figure out the answer to that question. One thing that I can say definitively about uh biologic mesh is is that it should not be placed in a bridge fashion if you're doing it for definitive abdominal wall reconstruction. So this is from Chuck Butler down in uh MD Anderson looking at uh um stratus reinforcement of uh abdominal wall, and they looked at those where they actually closed the fascia versus when they could not. And if you look at their outcomes now, you start to separate. When you didn't, when you achieved fascial closure, the recurrence rate actually starts to get a little bit better. It's more about 20%. A rate of recurrence, but by 4 years every patient that had a fascial, uh, a bridge, uh, repair recurred. So I just wanna actually stop and make sure we everyone heard that because we see a lot of people that believe that you can bridge with biologics. And so if you have a fascial defect, you cannot fill the gap with a biologic mesh and expect that it's gonna ingrow to become fascia. Yeah, I was gonna say we, we proved we. Proved that in a series of patients on congenital diaphragmatic hernias where we were bridging gaps using a biologic and found that the ingrowth is from the sides and you and the the tissue failed in the middle which is why we've gone in in that in that setting we've actually gone to uh PTFE and then biologic underlay. Yeah, so, like I said, Uh, stratus mesh place or any biologic mesh place as a bridge, um, for a definitive abdominal reconstruction, you're not going to get that fascial reinforcement that you think it's going to remodel or regenerate into. Not to say that it should never be used in a bridge fashion. I don't want to throw that out there. It has its places and really, you know, disastrous cases, um, and get you out of sort of get you out of dodge. It's not the wrong move. I don't want to bash it completely. But, um, definitely if you think you're achieving definitive reconstruction, it's not there. Uh, it doesn't matter where you actually place the mesh. So, obviously many of you know that you can place it in different positions. Probably the one of the more popular places now is retromuscular, which this is sort of where the technique has changed a little bit, and I'll go into that in a bit. But it does matter where you place it this comparison of intraperitoneal places versus retromuscular placement. Um, this is actually from the RIC trial, which is, uh, uh, industry sponsored for biologic mesh, so just. I'll throw that out there. Uh, and it showed that with similar defects, similar patients, the one year follow up, uh, recurrence rate was 10% for retromuscular mesh placement and 30% for intraperitoneal. So it does tend to be a difference, and it does make sense that for a biologic mesh you want to get as much apposition of tissue to it. So if you can do it on both layers, uh, that is ultimately better. So that gets us into the technique and so posterior component separation, uh, at least in abdominal wall reconstruction has really taken off and maybe being overutilized now, uh, which may have to do more with the billing issue, um, but it, it is a great technique, uh, and, and we do it for most of our patients so. Just as I just described that technique. So, after we complete all of our GI surgery component, we then place a towel over the bowel to exclude it from the abdominal wall, so we can do that without, uh, worrying about injuring the, uh, the, the bowel. So, first we elevate the rectus muscle and the underlying, uh, peritoneum with this picture here, and then we're going to incise just lateral to the linea alba or the defect, exposing the rectus muscle. You can see that we're doing that here. And then we're going to extend that dissection cranially and caudally, uh, and we're going to dissect out to the linea seulinaris, trying to preserve the neurovascular bundles that innervate the rectus muscles. So, this is what the dissection looks like. You can see the arcu aligned very nicely. Uh, this goes all the way up to the rib. Wait, so you got I have a video, so I know we, we went through the pictures last time and so I brought a video this time too. So we'll reinforce it a little bit more. Um, So after we've exposed this, so anybody who knows, uh, Doctor Ntter, he did a great job with his atlas, but he was wrong about the abdominal wall. The upper third doesn't really have a linear semilinearis the way it's initially described. The transverse abdominus does extend underneath the rectus muscle, and so we take advantage of that and we incise that fascia, which is the posterior lamellar of the internal oblique, and that exposes ultimately the transverse abdominus muscle. We then incise that and get to the preperitoneal plane. That dissection gets continued all the way down the posterior rectus sheath. And so now we just have peritoneum. We perform this dissection down to the, if, all, you can go all the way out to the psoas muscle, depending on how much mesh reinforcement you want and how much advancement of the posterior rectus sheath you need. So, after we've completed that, we then, uh, close both sides, uh, and then we place our mesh in an envelope, uh, and then close the fascia over the top. So, with your most traditional pediatric patient, I'm going to show you a video. It's a 74 year old gentleman who actually had, uh, heart surgery and he had a sternal wound infection, treated with a, uh, a mental pedicle flap, um, and he ultimately had a sternal nonunion, developed a, a subxiphoid hernia, sternal hernia. Uh, so this is him in the operating room after we reduced the colon, uh, back into the abdomen. You can see he has the sternal non-union there. With a little gentle intraabdominal pressure, we can push the colon right back up, so it's a happy place. So for this patient, we decided, uh, because of the location of the defect, and, you know, we wanted to reinforce it and get mesh all the way up to the diaphragm and take it all the way down to the central central tendon of the diaphragm. So this gentleman had a posterior component separation. We exposed the diaphragm and you'll see all that here, uh, but the reason was you could get better fixation. Uh, of your mesh by actually putting it in between two layers where it sits in an envelope rather than trying to tack mesh up to the diaphragm and you have to worry about cardiac tampona or whatnot. All right. So, we can put it in our GI part. So, we put it in our towel, measure that defect, ends up being about 10 by 20 centimeters or so. So, we begin, uh, with that dissection of the posterior rectus sheath, separating it just off the, uh, linea alba. Stop. You can see the. Can you pause it? Yep. Or, uh, go onto the video, yeah. OK, so tell me where you're cutting again now. So right now, so we have poker, you have what? So in the poker we have the linea alba elevated, and so now we're on just lateral on the underside of that incising the peritoneum and then the posterior sheath. OK, got it. So this is gonna expose the rectus. So the key here is that you don't continue your dissection until you've exposed rectus muscle, because most people will just think that they're in the plane and it's really just peritoneum, which is a little bit harder, uh, to dissect that off fibers of muscle. You need to see muscle fibers. So we'll continue this all the way up. And you can see that now we're dissecting out towards the linea seminaris. We're getting up to the level of the rib, uh, on the patient's right side here. So, these are actually just some extra uh diaphragm fibers that we're separating off of that posterior sheath, and you can see the diaphragm, uh, will be exposed a little bit more here. So that's what's going up right there, it's diaphragm going up. And so the next we're gonna incise the so this is patient's head is to the right, feet are to the left you can see the rib, the neurovascular bundles, or uh you can see them marked in the middle there so. So that uh yellow line is where we're gonna make our incision across the posterior lamellar of the internal oblique, and that's gonna expose the transverse abdominus muscle. So that's the transition. Can you help me with that again? Can you? So how do you know you're there? So the way, let me just back up a little bit. So the way you know you're there, so you're still going, you haven't gotten that's lint. Let me just stay right here. So, once you've identified the linear semilinears, you should see neurovascular bundles. Let's see if this will work on the video. So, the neurovascular bundles, and so you wanna incise just medial to the neurovascular bundle. So, you do want to preserve those. The other landmark is the rib. So just at the edge of the rib, you can incise here. And then take it down, and that's going to, the, the fascial part that you're opening up there is actually the posterior lamellar of the internal oblique. Yeah. is it playing? Yeah, it is so. Uh, so after you've completed that, you know, then you're, have the transverse abdominus muscles exposed. Uh, and the key to this operation is actually basic surgical tenets of traction, counter traction. If you perform this operation and don't pull really hard with your left hand, then you'll make holes in the peritoneum, and then you have a disaster of an operation because you're not going to get the posterior teeth closed and you won't have that underlying, Um, coverage of the mesh and for synthetic mesh you have to have some sort of coverage. You don't want to have what fibers were those that you were pushing that, that was diaphragm going up and you'll get a better picture of that once we, so then we do that the same thing on the other side. So you're going under the rectus, so we're exposing the rectus. So, after, so, we've done the, uh, started opening up the, um, posterior rectus sheath over here. So, again, this is the posterior lamellar of the internal oblique. We're incising. You can see the rib is right under here, and then you're going to see neurovascular bundles that we're going right adjacent to there. So, using the right angle and tension, again, just incising the muscles, this is going to expose and right underneath that is the peritoneum. So, we don't, for this operation, we didn't go all the way down the patient's abdominal wall cause we really just needed to get coverage up high. So, um, this is the patient's, um, xyphoid process that we're right underneath here. So, we need to ultimately not connect one side to the other side. So, what muscle fibers are you dividing there? So, right now we're really just, that was just division of, uh, some scar from his previous surgeries. So this is diaphragm that's getting pushed up, but now we have diaphragm exposed on the left and the right, and we're just going to connect those two sides, right, so there should not be any muscle fibers you're really dividing at this part right here. There should be no muscle fibers. Uh, there's typically just some preperitoneal fat that you might have, but, but, but period, you're not going to be dividing muscle fibers, right, except for the transverse abdominus muscle. So, as we perform this dissection, the central tendon of the diaphragm is going to get exposed. And this is the beauty of this operation for sub sub xiphoid hernias is now after we close the posterior sheath and we put our piece of mesh in there, we have to, we don't have to have as much fixation as we normally would, and we don't have to, uh, fixate it up right on the central tendon of the diaphragm. We can actually back off a little bit. So, you can see here with this dissection, that's the xyphoid off the one side, the sternal nonunion, and then there's the sternum on the opposite side. There's a central tendon of the diaphragm, and then that's all peritoneum underneath my hand there. So then we close the posterior sheath. So is this retrorectal approach retro rectus, we don't want to get retrorectal. There's no rectal involved. All the way around, all the way around the plate and it might be an effective repair. It might be retro rectus sole, uh, retro rectus approach is that becoming the standard approach across the country now? Yes, this is becoming a standard approach, and the reason for that is because with a traditional anterior component separation where you release the external bleak, you have to make large. Uh, flaps elevating, uh, the, the, uh, fatty tissue off of the muscle and so that is what really increases wound morbidity in those patients. That's a large reason why we had 47% wound morbidity. A lot of those patients had anterior component separation and with these patients' average BMI being in 45, uh, it's still, we'd love to get them all down to 25, but that's just not realistic, so. We can do something by changing our technique and this way we don't have to make those flaps and we've already shown uh in a different study which I'm not gonna talk about today that we actually get equivalent advancement uh of the anterior fascia with both anterior components and posterior component separation. So, but you trained, I mean, how, when do you do a lap ventral hernia repair? Uh, so I do a lap ventral on people who, um, are not really functional, and I'm just trying to prevent them from having incarceration of bowel. So that's not a good, you don't use that as a standard approach ever unless it's an unusual, correct. So my basic tenet is, is mostly that I'm doing this as a functional operation. Uh, I believe pretty heavily in that recreating the linear alba is important from a functional standpoint for people. Uh, they've shown that a lot in the orthopedic literature that when you incise a tendon that it gets scarred down, that muscle gets scarred and fibrosed, and you don't get the function, and you, everybody, it's pretty clear that your core abdominal, uh, muscle is one of the most important parts of your daily function. So, uh, people can be really be impacted when they have these large defects. So I do feel like it's important to recreate the but that's a huge shift, right? And this is important for us, right, so the 16 year olds that I take care of that might have a ventral hernia from a midline laparotomy. That in my training, um, which wasn't too long ago, the fun operation of putting a scope in, taking the adhesions down and putting your suture passers in four quadrants and then taking the tacker and tacking it around that we all love, we, we have moved, that would be the wrong thing for me as a pediatric surgeon to do, yeah, yeah, and I'm also thinking like looking at that. Thinking about that, you know, that high umphalocele that's almost a pentology of Cantrell to be able to, you know, to do this, you know, I mean this, this is sort of an acquired pentology of Cantrell, if you will. We did with Mike and I, we, you might have even been my resident then we, we did that exact case this, so he got this good even though you helped train him. Despite that, despite that, wow, and I promise this is a fun operation too, so you can get over the lap ventrals. This, I enjoy this as well, so it does, I mean, it looks like a fun operation, but I'm just thinking like, like I said, I'm thinking like in these giant phlo seals, especially the high ones that you could come down like I love the fact that you because you can get down to the central tendon and put that mesh in there and then not have to put 300, you know, you're worried about your stitches holding, right? So with this, it's not as important, right? So let me scale it down to a smaller scale. So we, uh, so gastroschisis, uh, probably since your time in pediatric surgery has evolved and many of us are doing a sutureless closure, we basically quickly reduced the, you've done those, right, or no? Did you ever do any with me? I think so. So quickly reduced the contents and basically use the. Um, uh, umbilical cord stock, uh, literally slap it on and let it heal in, and many kids will develop an umbilical hernia postoperatively in the year months, and many of those will close on their own. Can you imagine a benefit to underlaying, laying under a bio biologic and somehow maybe tacking it loosely before slapping not a biologic, right? You showed us that you, you shouldn't be using biologic. You're, you're breaking the biological. that's why I'm asking is it because. Uh, rather than putting in something durable, which we don't long lasting, which we don't need because we know most of the attorneys get better on their own, it's just, but, but it's not a, it's not a risky thing. So why would you do like I just let it get better on its own because then all of them get better on their own. Most of them do. And then you, if, if you don't, then $10,000 would be just out of the drain, yeah, yeah, and you're also introducing aitis, I think, for, yeah, see, they didn't even let let you answer. It was what I was. There was a paper, I don't remember Maura Ziegler used to quote where the people put mesh in like that and it all had to be taken over, yeah, yeah, for a typical gastro closure, normal. So, so I, you, because you answered that first case that you would have tried it laparoscopic and that's what. I thought and now these guys are doing them and these are, let me just the background is these are major MIS focused people. Oh no, no, I get it I get it, but I, but I'll say, but on that first case I'm sitting here in my head I'm thinking, OK, the kid had two stomas, but there was only a peristomal hernia on one, so I would just sort of treat that. Locally what you're saying, I mean that, that you, you did a whole total and maybe I missed it. That was all across the he hasn't gotten to that yet, but all right, so after we close that posterior sheath now we have this envelope for our mesh. It's a 36 by 26 heavyweight piece of mesh that goes all the way down the central to the tendon to the diaphragm. We can wrap our whole patient in that you can, yeah, these are actually blankets for kids also, uh, so. If you get queasy easy, don't look at these stitches. They get pretty close. A little bit of buttressing of the left ventricle, never heard a piece of mesh. Um, so for fixation for these traditionally we, we just use 8 sutures, um, because of the location of this we place a couple more up high, uh, but they're all transfascial, uh, you'll see here after this one, oops. Uh, we use a Carter Thompson suture passer. You can do any suture passing device to just make us a nick incision in the skin, uh, and then pass it, uh, through the abdominal wall. And that's Marlex you said. So, uh, it's bar. It's a heavyweight mesh which is, it's, uh, polypropylene which is essentially Marlex. So this is us passing those transfascials, one at the bottom, and then for this, uh, gentle we'll put 3 on each side, uh, because of the location again because it's high, we actually place, well, you'll see we'll place 1 around the rib, um, actually in the intercostal space, not to actually encircle the rib. Uh, we do that sometimes. We actually encircle the rib. Yeah, we do. Yeah, yeah, we just put it around the rib. So that's the one going around the rib here. So. So once those are all tied down, then essentially we're just fascial closure, uh, and then skin closure for this. So that's the completed piece. Uh, we elected for figure of eight sutures for him, uh, and the reason for that was because up higher, he was a little bit, uh, more, uh, tight as far as his fascial closure still. Um, so in those cases, they do use figure of eights rather than continuous suture. So if you can't get that closed up high, what are your, what are your strategies you, you do? Yeah, so interestingly, if we, let's say we had, uh, a defect left for this gentleman that was maybe 8 by 8 centimeters where we couldn't get the fashion closed, this would still be my operation. Because then he has a bridge repair with a heavyweight piece of mesh, uh, and then it gets skin closure over that. And the only addition was I would put one extra drain which would be right underneath the skin on top of that, uh, piece of mesh. So you, so you'd leave skin on mesh, and he'd leave, yeah, skin on mesh. So do you tack the edge of the fascia down to the mesh up high to try to pull it in or not? You just let it sit there and let it sit, OK. So we, we kind of hurt you because we had technical difficulties and interrupted you at every corner. We're kind of almost out of time. Can you give us some final thoughts about major things that we should be knowing about or just finish it up and tell us? Yeah, I, I guess so the, the final thought would be, uh, that's my email address, my cell phone, and my office number in case you have any patients that you want me to see. If you wanna talk about anyone or, or ever wanna collaborate on anything abdominal or reconstruction related, I'm more than open to it. Let me tell you that you guys have been life saving to me and uh having you down the road has been great for these uh really complex, uh, especially when there's bow a stoma right in the middle of it all um that's a challenge for us and I, I can tell you, uh, I am behind the times. I am. I mean, I was doing lap ventrals. I thought that was the way we're supposed to be doing it. I was not sure what mesh I should be using is it. So the fact that that you can talk to us and tell us and I really would have everyone write that number down and write those emails, Dave has been incredibly responsive, um, and we'll, we'll help you through these tough cases. So any questions from anyone about anything that was said here? That was fantastic, great, yeah, thank you. Thank you very much.