As COVID-19 first crept up on the world and then stormed it with the increase in cases and clusters across the nation, surgical and other health care associations and entities had difficult decisions to make. Philip Schauer, MD, the executive director of the Minimally Invasive Surgery Symposium (MISS), and staff carefully considered the best plan for the 20th annual MISS that was to be held in Las Vegas, in March—the tipping point of COVID-19.
The prospect of canceling the in-person anniversary event was disappointing, but staff quickly rallied, defying the odds to develop and execute a robust, full-agenda online virtual conference in just two months. Presenters and staff together worked to create a virtual conference that included panel presentations, live debates, continuing medical education and industry-sponsored educational events—all of which are available for online viewing at any time.
Always known for its dynamic and current coverage of the latest techniques and technologies in minimally invasive surgery, this year’s virtual MISS2020 did not disappoint. Coverage of MISS2020 will continue over the next few issues of General Surgery News, as we interview presenters and faculty of some of the most critical presentations from the meeting.
Visit www.globalacademycme.com/ conferences/ miss/ register to register and access part or all of the virtual MISS2020.
My Experience with TAR: The Good, The Bad and The Ugly
Presenter:
Colleen Hutchinson: Seeing as many complex hernia cases as you do in your hernia center, you are a great barometer for what we thought worked in hernia repair, what we think might work and what actually ends up working long term. Please share with us your experience historically with transversus abdominis muscle release (TAR).
Dr. Rosen: Here it is, broken down into the good, the bad and the ugly.
The good: This operation was originally intended to repair large complex ventral hernias in an open fashion while avoiding skin flaps, placing large prosthetic devices in an extraperitoneal position to allow less expensive larger pore material that is potentially more infection resistant. It was particularly suited for lateral defects closer to bony structures, loss of domain and contaminated cases by exploiting the retroperitoneum.
The bad: Many of us were extremely excited with our early results in high-volume centers with fellowship-trained surgeons seeing primarily complex hernias, and we began pushing this procedure as the best operation for all hernias. As a result, it has become a surgical dogma that any intraperitoneal mesh is bad, and we as surgeons should do everything we can to place mesh in an extraperitoneal position, even for small routine defects. Several innovative minimally invasive surgery (MIS) approaches have lowered the threshold even further to attempt these advanced procedures. This has unintentionally resulted in what appears to be overutilization of MIS retromuscular repairs for small defects in an attempt to get the mesh out of the peritoneal cavity at all costs.
The ugly: We are now seeing many devastating complications as a direct result of the overaggressive dissection of the abdominal wall, leading to lateral hernias, breakdowns in the posterior sheath closures and denervations of large segments of the abdominal wall. It is concerning that the cure for intraperitoneal mesh placement [IPOM] might be worse than the disease of IPOM mesh.
Expert Commentary
Guy Voeller, MD: We should pay close attention to what a world authority such as Dr. Rosen is trying to tell us. He is in charge of one of the busiest hernia centers in the world for complex hernia repair, and he sees all of the disasters on which he speaks. While TAR is a wonderful technique when done properly, it has been disseminated far and wide without adequate precautions, training and caveats. Many people have been hurt because of the overuse of this technique.
Phil Schauer, MD: As happens with many new surgical procedures with remarkable early results, we surgeons tend to overuse the procedure and apply it too broadly. It seems like what is needed now for TAR is sufficient outcomes data to determine clear indications and contraindications. Clinial trials or registry data may help.
The Concept of the Critical View Of the Myopectineal Orifice
Presenter:
Colleen Hutchinson: Dr. Daes, the concept of the critical view of safety for laparoscopic cholecystectomy is not new and is accepted by many as resulting in avoidance of bile duct injury. This concept extended to inguinal hernia repair is newer and intriguing. Please tell us about your MISS2020 presentation and what the most critical takeaways are to surgeons who perform MIS.
Dr. Daes: New techniques, technologies, material and equipment have been rapidly integrated into minimally invasive inguinal hernia repair. Standardization remains elusive despite many areas of consensus. Social media has allowed a firsthand look into this phenomenon, with many procedures being undertaken without following proven maneuvers that reduce complications and recurrence.
A group of surgeons who are members of the International Hernia Collaboration (IHC) Facebook group proposed a list of recommendations that must be followed to attain an appropriate exposure of the myopectineal orifice before placing a mesh, regardless of the minimally invasive approach. These recommendations have been taught individually for years, and are based on studies that have shown fewer recurrences and complications. We consolidated these recommendations under the concept of the critical view of the myopectineal orifice (CV of the MPO). The term “critical view of safety,” introduced by Strasberg in 1995, is accepted as standard practice for preventing biliary duct injury during laparoscopic cholecystectomy.
The objective of the CV of the MPO concept is to standardize the procedure, facilitate teaching and evaluation of videos, reduce recurrences, prevent complications, and ultimately improve patient care. Fulfillment of some of these objectives has been observed, especially in social media, but clinical studies are needed to measure the impact of CV implementation in minimally invasive inguinal hernia repair. The steps of the CV of the MPO common to all procedures—totally extraperitoneal [TEP], transabdominal preperitoneal [TAPP], extended TEP, robotic TAPP, Phillips or IPOM—are described in the article by Daes J et al (Ann Surg 2017;266[1]:p1e-p2e).
Expert Commentary
Guy Voeller, MD: Dr. Daes is a wonderful man and surgeon, and I admire his attempt to equate hernia repair to gallbladder removal. He gives a list of “steps” that one does to perform an adequate MIS inguinal hernia repair. I don’t know if they have to be done in the order he lists them since they are “steps.” Just like there is no high level of evidence that the critical view of safety prevents bile duct injuries, there is no proof that the CV for the MPO of Fruchaud will prevent complications, reduce recurrences and do the other things that Dr. Daes details.
Phil Schauer, Md: The critical view concept for laparoscopic cholecystectomy has been shown to reduce catastrophic bile duct injuries. This concept extended to inguinal hernia repair may likewise reduce complications and improve overall outcomes. Now it’s time to study the impact!
Taking Surgery Further: Improving Colorectal Outcomes with Technology and Technique
Presenter:
Colleen Hutchinson: Dr. Lee, how might the newer platforms of indocyanine green (ICG) fluorescence imaging improve colorectal surgery outcomes?
Dr. Lee: Anastomotic leakage after colorectal resection is one of the most devastating complications. Recent studies show consistently high leak rates (3%-15%). Morbidity associated with major leakage is high, and only 40% of the patients who survive go on to have stomas reversed. The economic burden of anastomotic leakage after colorectal surgery is significant. According to a recent study, anastomotic leak increases the index hospitalization cost by an average of $31,000 per patient.
Ischemia at the anastomosis is one of the major contributing factors that leads to anastomotic leakage. Indocyanine green (ICG) fluorescence imaging has shown to be more effective than clinical evaluation of tissue blood perfusion. It appears to have significant impact on reducing anastomotic leakage and may decrease severity of leak when it does occur.
Newer ICG platforms allow real-time quantitative measurements of fluorescence intensity. Its application in patients undergoing mastectomy has shown to be useful in predicting flap viability. The use of the same technology in colorectal surgery patients may allow us to objectively assess tissue perfusion at the anastomosis and prevent anastomotic leakage.
Expert Commentary
Bradley Davis, MD: Anastomotic leak remains a devastating complication for patients, as Dr. Lee points out—mortality and morbidity remain too high despite the advances in management. Assessment of perfusion is a critical component of performing a perfect anastomosis, and historically could be evaluated by demonstrating pulsatile blood flow in the marginal vessels. As more and more of our procedures are being done with no direct ability to palpate the bowel (ie, robotic and laparoscopic intracorporeal anastomosis), and with obesity and visceral fat obscuring a surgeon’s ability to visualize these structures, adjuncts such as ICG fluorescence offer an effective alternative. We will need more data and experience to understand the technology’s impact on rates of anastomotic leak. But with more and more MIS platforms incorporating this technology, it could improve outcomes for our patients and reduce health care costs in the future.
PHil Schauer, MD: Indocyanine green fluorescence imaging for assessing tissue blood perfusion is a promising technology that may help reduce rates of colorectal anastomotic leakage. What we need is a randomized controlled trial to prove or disprove it. With leak rates in the 3% to 15% range, such a study is feasible and should not be excessive in cost. Until then, we can only say it is promising.
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