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SURGERY


be greater than 10cm in width). Depending on the size and nature of the hernia and the strength of a patient’s abdominal wall, complex surgery may be required. Big, complex incisional or abdominal wall hernia operations can be difficult and traditionally have a high recurrence rate.5 Prior to AWR as a technique, a ‘tailored’ approach was given to incisional hernia repairs. There was heavy reliance on intraperitoneal meshes (open and laparoscopic). Not all surgeons had heard of, or seen performed, any AWR techniques like component separation. Persuading colleagues and peers what best practice could look like can be challenging. All AWR and complex hernia work is now directed through the AWR core MDT at Whiston. Before the existence of the AWR team, patients who had complicated abdominal wall defects were treated in various ways. The surgery could be undertaken by any general surgeon, but this might mean that those surgeons only saw a similar hernia case once a year, which allowed little opportunity to develop experience. Many factors will be considered when looking to repair a complex incisional hernia. The surgeon and plastic surgeon will consider in which layer of the abdominal wall the repair takes place and component separation techniques are discussed.


As the team always uses a mesh in


AWR, the pros and cons for different meshes are considered, based on the requirements for each patient. A synthetic mesh, which is non-absorbable, is extremely strong and permanent. A semi- synthetic mesh will take around a year to 18 months to be fully absorbed, allowing the body to naturally heal and recover, providing both strength and durable integration. A biologic mesh is made from either animal or human tissue. While it is thought resistant to infection, if an infection does occur, the mesh will be completely destroyed. Which mesh to use will also depend on what kind of hernia a patient has, and which layer of the abdomen it needs to be placed in.


The right team and approach for patient optimum outcome Taking a panoramic view in approach to any surgery includes the right people and the right products to deliver positive results for AWR patients. In other centres, AWR usually comes under the remit of general surgeons and the opinion of a plastic surgeon is only asked for in certain cases. At Whiston, the MDT approach means that surgeons and plastic surgeons work in pairs. The plastic surgeons and the general surgeons work together on every single operation in both pre-planning and in the surgery itself. In the last year, approximately 130 cases


Choosing the right surgery, technique and product for an AWR patient Surgical techniques for complex hernia repair have changed in the last 10 years. For many years, an anterior component separation technique and, later (since 2013), a Transversus Abdominis Release (TAR) procedure have been used with excellent results. Alongside this, a biosynthetic mesh (Phasix Mesh) can be used. Like synthetic meshes, this helps rebuild the abdominal wall, but it also reabsorbs after 15-18 months, reducing the risk of wound problems.


The biosynthetic mesh used at Whiston is a long-term absorbable monofilament synthetic scaffold, knitted from P4HB. This has been shown to have antimicrobial benefits including anti-inflammatory properties.6


Having any properties which


help with bacterial resistance is a positive point for AWR open surgery. Monofilament mesh designs have been deemed more biocompatible7,8


and less susceptible to


bacterial adherence and colonisation.9-11 Ultimately, bacteria clear better than with biologics or permanent synthetics in preclinical testing.12


have been operated on by the AWR team. At Whiston, Mr Scott and Mr West operated together on more than 200 patients in the last four years. The recurrence rate is low – it’s around 1.9% for the most complex of hernias. The pair adopt a dual approach to surgery, meaning both the surgeon and the plastic surgeon are there from beginning to end; jointly performing the operation and contributing expertise. Combined experience means more challenging operations are accessible.


However, in cases where bridging is inevitable or where the muscles are extremely thin and extra support is required, polypropylene meshes are used.


Increasing recognition for MDT’s successful approach to AWR More than 350 patients a year are now referred to TIARS, compared with less than 10 a decade ago. GPs make up 50% of referrals, other surgical specialists 35%, and self-referrals are 15%. Referrals from abroad are around 5%.Using a multi- disciplinary approach means all aspects of patient management is examined. A joint wealth of knowledge ensures the best approach. Using the skills of the plastic surgeon brings other advantages; an operation will often involve excision of a great deal of skin, which eliminates the undermining of wound edges, that can cause skin necrosis and wound breakdown. The aims of the successful operation are to restore for the patient, a functioning abdominal wall anatomy which works correctly and has the lowest possible chance of a hernia coming back. The average time for hospital stays at Whiston for AWR surgery is just four days.


Life-changing benefits At Whiston, the mesh


has been used in more than 300 operations. When discussing all options with a patient and encouraging them to take ownership of their care, it offers reassurance to those who do not want to have a permanent mesh.


26 l WWW.CLINICALSERVICESJOURNAL.COM


The life-changing advantages for patients following successful treatment cannot be underestimated. Living life without pain, wearing normal clothes and feeling confident to resume their previous activities, are not uncommon sentiments in regular feedback from patients. One male patient, treated by TIARS, had undergone 14 previous attempts elsewhere at repairing the same problem. This reflects on one hand, how difficult the surgery can be and, on the other hand, the extraordinarily high recurrence rate within hernia patients. Frequently patients have been told that their hernia is ‘unfixable’ or ‘too dangerous’ to fix. These patients are


AUGUST 2021


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