I need help on this difficult surgery!

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Can someone take a look at the following op notes and render their valuable opinion?
POSTOPERATIVE DIAGNOSIS: Right flank bulge/hernia.
PROCEDURE: Repair of right flank bulge with existing mesh and Mitek
interosseous ileal quick anchor securing device
INDICATIONS FOR PROCEDURE: Mr. ______is a 78-year-old man who is quite
vigorous and active and had a right nephrectomy some years ago through a
right flank incision. This gave him a flank bulge and it has been quite
debilitating for him. He has had 3 attempts at repair, the last 2 by
Dr. ____, in which a fairly large sheet of Marlex mesh was placed in.
The last operation was done about 2 years ago and the operative report
suggested this is pretty well fixed superiorly but had to be attached
down to the periosteum of the ileal wing with 2 nylon sutures. That
failed. When the man stands up he has quite a major bulge on his right
side. It is hard to tell whether it is a true hernia or whether just a
typical eventration. We have gone over several times in the office how
difficult these things are to fix and he understands that. He would
just like to be a little bit better so that he does not have the sense
that he has to keep holding his hand on his side every time he stands
FINDINGS: His old mesh was actually fairly intact and once we
identified it I decided to keep it because it would have been quite the
program trying get that out, and as it was not too terribly contracted
and it was in fairly good position, except for the fact that it was not
well secured inferiorly or anteriorly, we decided to keep that in place
and used that. Five Mitek quick anchor devices were placed by Dr.
____ down in the hip and then we used those sutures to secure the
mesh and hold that inferiorly.
PROCEDURE: The patient was brought to the operating room and placed
supine on the operating room table. He was given a general endotracheal
anesthetic. SCDs were on his legs. We put a Foley catheter in. I
wanted to have access to his abdomen but as it turned out, when he would
fully relax his abdomen, it is big enough that it rolls out of the way,
and so we had to essentially established a 45-degree left lateral
decubitus position so that we could get all the way back where the wire
was and get access to his 11th rib.
After he was prepped with Betadine and draped in a sterile fashion, we
made a very lengthy elliptical incision taking out the old incision and
getting down through the scar tissue into the fat. Dissecting through
the fat we came across some of the muscle and the fascia. This was
obviously quite attenuated and the planes were difficult to discern
because of the 4 previous surgeries. I simply dissected down to the
mesh because the previous operative note said that this was
preperitoneal mesh and so therefore it should be underneath the muscles,
and eventually found the mesh and then we just dissected along the mesh,
lifting out muscle as we found it. This was done superiorly and
inferiorly and then we found where the mesh was floating free except for
one area where it was still somewhat anchored down toward the ileal
wing. At one point then we had to decide anteriorly and medially what was
going on, and it looked like the mesh was not particularly supported
over there and so I discontinued to dissect anteriorly until we found
the edge of the mesh and then what we decided to do is put some Prolene
sutures through-and-through the muscle from a para right rectus position
through 5 separate stab incisions in this skin, as though we were fixing
a hernia with the laparoscopic technique. These 0 Prolene sutures were
placed on straight Keith needles, brought through the muscle, through
the mesh and then back out through the muscle and then tied down outside
the muscle. That is to anchor the medial portion of the mesh as well as
we can. This whole piece of mesh that he has in there was probably
about 6 inches by 9 inches, so I thought it was a pretty good healthy
piece of mesh and we decided since most of it was pretty well
incorporated to use it. There was no evidence of infection or slime.
Superiorly, as mentioned, I thought everything was pretty well
incorporated. He did have a bit of meshoma, maybe from a previous piece
of mesh that was sitting on the 11th rib, but I decided to leave that
because I thought if I took it, it would destabilize that posterior
portion of the mesh and so I left that. This is an area of about 3 cm
or so and it was just a thicker portion of the mesh.
Dr. ___ then exposed the ilial wing and we started all the way
from the anterior superior iliac spine and went back as far posteriorly
as we felt we could identify, lifting up the oblique muscles so that
they were superficial and then running underneath them, finding the
iliac wing, exposing a small 1.5 cm area of it and then drilling holes
in for the Mitek quick anchor devices, and he will dictate that
separately, that we did 5 of those. They come with big #1 permanent
woven suture on with needles attached to them. These needles were then
driven through the mesh, trying to be very careful that we did not get
too deep and hit some piece of bowel underneath the mesh, and then the
mesh was anchored down to the ileum trying to make it is straight as we
One of our ways of checking our repair was pushing in on his belly,
which we noticed when we first started the case would make this piece of
mesh balloon out, and when we were finished with our repair it no longer
ballooned out, so I think it is about sturdy from an inferior standpoint
and from a superior standpoint as it can be. Posteriorly we had a
little bit of an opening of about 3 cm between the paraspinous muscles
in the obliques and the mesh and so I took some of the obliques and
sutured them down to the mesh with 0 Vicryl just to obliterate that
space and make sure he does not get some sort of other lumbar hernia.
The whole area was irrigated with antibiotic solution several times
during the case because I was worried about infection because much of
this tissue is not as vascular as it otherwise could be. When we got
ready to close, it looked to me like he had too much redundant skin, but
I took 1 inch of inferior skin and fat in an ellipse from that lower
aspect of the wound in an attempt to make his skin closure a little bit
more anatomic. We did not disturb the muscle or take any of that out.
The muscle layers obviously are confused, particularly anteriorly, and
so we closed in 2 layers, taking interrupted bites of 0 Vicryl on the
transversus abdominis, getting small bites of the mesh as we did that to
try and anchor the muscle down to the mesh, and then a running 0 PDS on
the internal and external obliques to get everything closed up. I did
not use a drain because it looked like we did not have much of a dead
space at that point and there really was not much bleeding, again, which
is a good thing and a bad thing. We did see the inside of the
peritoneal cavity at one point anteriorly. So far as I can tell does not
encounter any intraabdominal contents, and even if did, I think at this
point it is pretty well coated with soft tissue and peritonealized.
Once the muscles were closed we went ahead and closed the fat with 3-0
Vicryl and the skin with staples. Our little incisions that were
anteriorly where we had used the Prolene to anchor the mesh medially
were closed with 5-0 nylon and the patient was taken stable back to the
recovery room. The whole case was very difficult and took over 4 hours.
POSTOPERATIVE DIAGNOSIS: Right flank bulge/hernia.
PROCEDURE PERFORMED: Repair of right flank bulge with existing mesh
and fixation to the iliac crest.
Dr. ___has dictated the bulk of the operative note. I am dictating
the portion involving the work with the bone where the existing mesh was
attached firmly to the rim of the iliac crest.
DESCRIPTION: After exposure of the mesh and internal obliques as they
inserted onto the iliac crest, with Dr. ___, the superior aspect of
the iliac crest was exposed by elevating the soft tissues such that the
internal oblique attachment to the superior aspect of the iliac crest
was identified. As soon as the iliac crest could be palpated
immediately deep to this layer, along the entire course of the desired
attachment for the mesh, several spaces were mapped out for attachment
of the anchors and at each spot a small hole was created in the internal
oblique muscle, as it attached using electrocautery, exposing the
underlying bone, which was only approximately 1-2 mm deep to this layer.
A small area of this bone was exposed, such that the step drill could
be placed under direct visualization on to the bone and drilled in. A
Mitek quick anchor was then placed, such that the wings of the anchor
were parallel to the iliac crest. It was then pulled back to ensure
that the anchor was firmly placed. This was accomplished in a total of
5 locations, extending from the level adjacent to the anterior superior
iliac spine laterally to the posterior aspect of the iliac crest.
The attached #2 nonabsorbable suture was then used to pull the
preexisting mesh, which appeared well incorporated into the soft
tissues, down to the area of the iliac crest. This resulted in firm
approximation of the mesh to the iliac crest and elimination of the
distal aspect of the defect in the abdominal wall. All sutures appeared
to be firmly anchored.
The remaining description of procedure will be by Dr. ___ in his
It should be noted that this procedure was quite difficult overall,
taking about 4 hours of operative time, due to the substantially altered
surgical field, which made exposure and identification of anatomic
structures significantly difficult.