Visit to Rotterdam

Khalid Elmalik
 Abdominal Wall
Reconstruction Workshop

• Adult workshop

• Incisional / para-stomal hernia common

• Risk factors in adult

Types of wounds
 Biodesign
• 1988 - 1998 - 2006 - 2008

• Non dermis

• Non cross-linked

• Collagen, Glycoproteins, proteoglycans,

Glycosaminoglycans & Growth factors

• Numerous applications

• Type II, III wounds

 Biological mesh
• Alloderm (Lifecell): Acellular human dermis

• Allomax (Bard): Acellular non-crosslinked human dermis

• Flex HD (Ethicon): Acellular human hydrated matrix

• Strattice (KCI-Medical): Porcine dermis (tissue matrix)

• Permacol (Coviden): Acellular porcine dermis,

crosslinked
 Hiatal Hernia
• Endoscopy

• Manometry

• 24 pH/ Impedance

• Gastric emptying

• Swallow

10% population takes PPI

 PPI S/E
• Diarrhoea

• Hip fracture

• Pneumonia

• Low Vit B12, Fe, Mg, Zn, Ca

• High Gastrin

• Increase fundic cystic glands

Enteryx
TOGA
Gatekeeper
EndoCinch
NDO Plicator
Esophyx TIF
 Mesh around oesophagus
Good - Bad - Ugly
• No consensus on indication - ideal mesh or method
of placement

• Consider: big defect

• Why mesh? recurrence, tension free, Industry

driven, evidence!

• Why not mesh? no reduction, asymptomatic, await

trials, complications
 Complications of mesh

• Dysphagia

• Erosion

• Trauma from tackers

• Removal can be difficult

under-reported?
 USA survey

• 20% no mesh

• 16% Gortex

• 95% onlay

• 5% bridge configuration
 Technique of repair

• Tension free

• Reinforce onlay

• Keyhole mesh

• U- shaped into diaphragm

Components separation" method for closure of abdominal-wall defects: an anatomic and clinical study

-Separation of the muscle components of the abdominal wall would allow mobilization of each unit as a block
-Dissected 10 fresh cadavers
-external oblique separated from internal oblique in avascular plane
-Rectus with its fascia elevated from the posterior rectus sheath
-The compound flap of the rectus muscle, with its attached internal oblique-transversus abdominis muscle, advanced 10 cm
-Reconstructed 11 defects
-Range of defect (4 x 4 to 18 x 35 cm)

Ramirez OM, Ruas E, Dellon AL

Plast Reconstr Surg. 1990 Sep;86(3):519-26.
 Component Separation
Technique

• CST when to consider:

• Can’t achieve primary facial closure

• Contamination

• With/out mesh
 CST
• Pre-op:

• Physical examination

• CT evaluation

• Evaluate laxity of abdominal wall - ? Botox

• Risk factors
 CST

• Anterior CST (Rameries)*

• Posterior

• MIS anterior
 CST tips
• Open abdomen

• Roll lateral edge over fingers

• 1-2 cm lateral edge (GO SLOW)

• Go high & low

• Reinforce with mesh*

• Put drains

• Do not dissect too much S/C

 Complications of CST

• Deep wound infection

• Seroma/ Haematoma

• Skin necrosis