411 - Staged Abdominal Wall Reconstruction

| The Surgical Technologist | MARCH 2018 110 always a challenging situation. In fact, once the condition has progressed to this extent, major invasive surgical pro- cedures are needed, including the possibility of needing to perform a staged abdominal wall reconstruction or SAWR. The SAWR is a complex surgery that can require multiple operations during the same hospitalization, in efforts to remove the infected mesh, while at the same time, repair the complex recurrent hernia. The prognosis of these repairs varies according to comorbidities, overall patient health and an adherence to strict pre- and post-operative nutrition and therapy programs by the patient. To have any discussion about complex redo abdominal wall hernia surgery, the anatomy of the anterior abdominal wall must first be considered. Aside from the obvious mus- cle and fascial anatomy, vascular and neurological anatomy also needs to be considered. Muscular anatomy that plays a key role in abdominal wall surgery includes the rectus abdominus, the internal- and external-oblique muscles and the transversalis muscles. In addition, the tendinous, fascial and other tissue landmarks are important. These landmarks include the linea alba, the anterior layer of the rectus sheath, the aponeurosis of the oblique muscles, Camper’s fascia, Scarpa’s fascia, the arcuate line and the umbilicus. Bone and cartilaginous landmarks include the xiphoid process, the costal margin, the pubis and the anterior superior iliac spine. Vascular considerations include the epigastric vessels, para- umbilical veins and venous plexus and the important peri- umbilical perforator vessels. Neural anatomical concerns include the abdominal and ninth-thoracic nerves, which if severed can cause abdominal wall pain and/or paresis. In essence, “When considering … abdominal hernia repair, the underlying musculature, aponeurotic layers and adipocuta- neous structures are important. The three components are interrelated and should be addressed systematically in order to optimize outcomes.” 6 Preoperative planning for SAWR begins weeks, and sometimes months, in advance of any attempted surgical intervention for such a complicated repair. Typically, nutri- tion and weight loss programs are designed for the patient. The patient must cease smoking, if currently a smoker, and must undergo basic physiologic and psychological review, and treatment if necessary. These programs are in place to provide the patient with all the tools to succeed and to avoid the many well-known complications that can occur after surgery. The patient needs to understand that their complex recurrent hernia (with or without infected prosthetic mesh) is a condition that will not go away without proper care and treatment. This clinical entity may be life threatening if not cared for in the proper manner. Significant efforts are taken on the part of the surgical team to try and ensure that the patient, and their support system, are in complete under- standing of the procedure (and potentially lengthy hospi- talization) that they are about to undertake, so they may be able to regain control of their lives. While the staged abdominal wall reconstruction has been shown to be effective in the treatment for patients with complex recurrent hernias with infected prosthetic mesh, this procedure is a last resort. There is no guarantee that the condition will not re-occur, as the patient has demonstrated tissue with a predisposition to structural failure. There is a high probability for surgical site infections, due to the pres- ence of infected prosthetic mesh and contaminated classi- fication of the surgery. With all this education and prepara- tion to surgery met, the patient, their support system and the surgical team begins a journey that can take months (and even years) to complete. To prepare for the procedure, the room setup needs to include an operative table capable of safely holding the patient, as many of these patients are obese, even after adherence to pre-surgical programs. It is often necessary to install bed extensions or utilize a specially designed table for the morbidly obese. Other positioning aides such as a pil- low for under the knees and ulnar padding need to be read- ily available. Patient warming pads are recommended, with an alternative being upper and lower body patient warming blankets. The patient will need to be positioned in the supine position with the arms extended. Pre-operatively, all hair will need to be clipped from approximately 10 centimeters above When considering … abdominal her- nia repair, the underlyingmusculature, aponeurotic layers and adipocutane- ous structures are important. The three components are interrelatedandshould be addressed systematically in order to optimizeoutcomes.