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The followig article was written for NPN, the Northwest Physicians Network   September 6, 2017

Patient questions about mesh in hernia repair

Almost daily I have patients ask me about mesh. We are all hearing the growing dialogue over the use of mesh in hernia surgery.  The majority of this hysteria is generated by lawyers, especially through several class action lawsuits that are trying to gain traction.  This has also prompted some surgeons to promote mesh free hernia repair, as if that is a new and improved technique. I think of these surgeons as the anti-vaxers of the hernia community.  Unfortunately the legal and promotional questions have little to do with the realities of mesh in hernia repair.  The majority of mesh complaints come from the early days of mesh, when uncoated mesh was placed in the abdominal cavity.  Surgeons in the early 1960s were just learning about the disasters of mesh in growth into bowel and other structures.  More recently a problem with transvaginal mesh has come to light.  However, that has nothing to do with hernia repair.  From a surgeon’s perspective, mesh has been a godsend.  The magic word is recurrence.  Even when the oldest know mesh (Marlex) was studied, the recurrence rate was dramatically decreased.  One prominent study shows a 8% recurrence rate in incisional hernia repair with mesh compared to a 25% recurrence rate with no mesh.  Similar studies show a dramatic reduction in inguinal hernia rates, from 15 % without mesh to less than 1% with mesh.  So why the fuss with recurrence?  Well recurrence means repeat surgery with repeat surgical risks, repeat anesthesia, repeat complications from the hernia itself, repeat pain, and a huge expense to the patient.  There are certainly problems with mesh, however they are relatively infrequent, and not the recipe for disaster the legal community would have us believe.  Mesh itself has also changed dramatically.  Modern mesh designed for intraabdominal use has a non-adherent coating that prevents the earlier problems of in growth into bowel and other organs.  All mesh is immunologically invisible to the body, and cannot be rejected.  The techniques for mesh placement have also changed.  The latest trend is to place mesh within the abdominal wall rather than in the abdominal cavity.  This avoids any contact with the abdominal organs and can be performed either open, laparoscopically or with the robot.  Some complimentary technique changes include; component separation which creates a tension free repair, the avoidance of bridge repairs where mesh was the only component covering a large hole, and abdominal wall nerve blocks that minimize discomfort and often turn huge repairs into outpatient procedures.  I hope this helps clarify some of your questions.  I am always happy to discuss this problem with you or any of your patients.

James Rifenbery, MD, FACS

General Laparoscopic and Robotic Surgery

 

Dr. James Rifenbery Weighs in on Robotic Surgery Deal

Dr. James Rifenbery, a certified expert in robotic surgery, discusses the rising trend as evidenced by a new licensing deal between top industry players.

Dr. James Rifenbery
Dr. Rifenbery heavily endorses the upward trend and application of robotic surgery.

(Newswire.net — September 18, 2017) Tacoma, WA — Considering the technological advancements in recent years, the medical surgery arena has been on a steep climb. With the advent of robotic surgery, the industry has certainly reached unprecedented heights. The da Vinci Surgical System, which represents the latest in surgical and robotics technologies, is at the forefront of this exceptional innovation. The state-of-the-art system has been applied as a minimally invasive option for otherwise complex surgeries performed on more than 3 million patients worldwide.

Dr. James D. Rifenbery, M.D., F.A.C.S., a General and Laparoscopic Surgeon, is a recommended professional by the da Vinci company. The Washington-based doctor is a certified proctor who trains surgeons all over the country with the robotics surgery equipment that is positively changing the surgery experience for patients.

A highly experienced surgeon who has been in practice for over 37 years, Dr. Rifenbery is a lead surgeon at  Laparoscopic Surgery NW, in Tacoma, Washington. He has performed over 200 robotic surgical procedures as of 2015, including more than 100 single-site, robot-assisted cholecystectomies. By translating the surgeon’s movements into more precise movements, robotics surgery has enabled Dr. Rifenbery is able to operate with enhanced vision, better precision and 100% control. To learn more about him, visit https://www.crunchbase.com/person/dr-james-rifenbery/.

Dr. Rifenbery contends that more and more medical companies are rising up to the challenge by embracing the newest system that is redefining robotics and surgery. JustRight Surgical, a medical device startup based in Colorado, is one of them. The company, which offers the fusing system for pediatric surgery, is teaming up with Intuitive Surgical, makers of da Vinci robots.

Under the new agreement reached with Intuitive, JustRight Surgical aims to “expand the impact of [our] technology beyond pediatric patients” and serve adult populations through the rising robotic surgery trend. Through the inked agreement, both parties are heading toward patent acquisition and exclusive licensing.

Da Vinci has paved the way for better surgical options, other than the traditional large open incision surgery or laparoscopy. Through breakthrough da Vinci robotics technology, patients are able to experience less pain, shorter hospital stay, potentially faster recovery, and increased chances of better clinical outcomes in surgeries involving an extensive variety of organs.

Notably, surgeons utilizing the da Vinci system gain complete control of all aspects of the surgery. Dr. Rifenbery confirms that the da Vinci robot serves to provide proficient assistance to the doctor throughout the procedure. For more, visit https://angel.co/dr-james-rifenbery.

 

The positive predictive value of post-operative tachycardia in laparoscopic gastric bypass

Kelly D. Nolan , MDEugene S. Cho MD, James D. Rifenbery, MD
 
Franciscan Health Systems, Tacoma, WA    https://www.soard.org/article/S1550-7289(06)00408-4/pdf
 
 
 

Determining the Proper Distance for Trans-abdominal Sutures in Ventral Hernia Repairs: The Higgins Formula

Andrew C McCoy, MD, James Rifenbery, MD, Michael Higgins, MD. Franciscan Health System.  https://www.sages.org/meetings/annual-meeting/abstracts-archive/determining-the-proper-distance-for-trans-abdominal-sutures-in-ventral-hernia-repairs-the-higgins-formula/

 

 

 

 

 

Submitted for publication January 2018                                                                                                                             

Laparoscopic TAP Block Using Clonidine

 

 

Dr. Jose A. Lopez, Dr. James Rifenbery, Nam Nguyen

 

 

 

Opioid addiction has become a major topic in the medical field. There use is creating devastating addiction, and as a result, burdening the already stressed health care system. There use in medicine has become second nature, much to the detriment of our profession. In the surgical realm, narcotics are integral to the post-op recovery. Many times surgeons are judged by pain control in the peri-operative period, thus raising the incentive for narcotic prescriptions.  Because of the side effects and increase in abuse of narcotics, surgeons are trying to find adequate, efficient, and cost effective alternatives to oral and IV narcotics in the peri-operative period. Laparoscopic TAP blocks using clonidine have proven to be a great pain control adjunct, and do not add any significant time to the operation. Clonidine is primarily α2 adrenoceptor agonists that are principally hepatically metabolized. It additionally acts upon some α1 and imidazoline receptors. It has a safe side effect profile, is very inexpensive, and can be injected under direct visualization in less than a minute. In our experience, adding clonidine to our TAP blocks has greatly improved pain control in the post-operative period, reduced the need for narcotics, and has raised patient satisfaction.

 

 

 

 

 

Laparoscopic TAP Block Using Clonidine

 

               With so much focus on opioid addiction, surgeons are trying to find adequate, efficient, and cost effective alternatives to oral narcotics in the perioperative period. Pain control in this period has long been the focus of many clinicians, although the proper solution still eludes us despite multiples changes in practice. Multimodal pain control is now being used with some degree of success, although narcotics still play a role in this pain control modality.

               Local anesthetic blocks, including epidural blocks, costal blocks, and field bocks, are also used, but aside from the epidural, these modalities are not too effective for an abdominal operation. The epidural block, when working appropriately, is a great tool for pain control, but the side effects such as drop in blood pressure and lower extremity numbness dictate cessation of these modalities in a significant number of patients. Also, if not properly done, the transition off the epidural can often put patients a day or two behind on their recovery and the pain becomes quite high as the epidural is titrated off. In addition, the inadvertent removal of an epidural can create an unsettling situation for both the patient and clinician alike.

               The transverse abdominis plane (TAP) block has become one of the most used blocks during an abdominal operation, both laparoscopic and open. It is a peripheral nerve block that anesthetizes the nerves supplying the anterior abdominal wall (T6 to L1). Local anesthetic is placed in the tranversus abdominis plane under visual guidance. The anesthesiologist can do these blocks once the patient is intubated under ultrasound guidance, but this adds about 5-15 minutes to the case depending on the skill of the anesthesiologist.  Different anesthetic agents have been used, but our method is a bit different and has come with great results. Our method involves a mixture of 1.6 mcg clonidine, 30cc of ½% marcaine with epinephrine, and 70cc of injectible saline. We perform the block after pneumoperitoneum is achieved and a camera is placed into the peritoneal cavity. Under direct visualization, we use a Veress needle to enter the transverses abdominis plane and inject our anesthetic mixture (Figure 1 and 2). When done correctly, the fibers of the transverse abdominis will be splayed out, and a small opening will be seen where the tip of the Veress needle was placed.  By using this method, we are able to place our block under direct visualization in less than 1 minute. We have found that the addition of clonidine provides much better subjective pain control than those blocks without it. There is literature to support the use of α2 adrenoceptor agonists such as clonidine and dexmedetomidine, but for now we are only using clonidine.

Clonidine and dexmedetomidine are primarily α2 adrenoceptor agonists that are principally hepatically metabolized [1, 2]. Unlike dexmedetomidine, clonidine additionally acts upon some α1 and imidazoline receptors [3, 4]. The analgesic mechanism of these agents on the central nervous system is thought to be through activation of the α2A and α2C subtypes. Stimulation of these receptor subtypes have been shown to inhibit adenylyl cyclase, reducing the levels of cyclic adenosine monophosphate and causing hyperpolarization of noradrenergic neurons in the medial dorsal pons, specifically the locus ceruleus [5]. As cAMP is inhibited, potassium efflux through calcium-activated channels prevents calcium ions from entering the nerve terminal, leading to suppression of neural firing. This suppression inhibits norepinephrine release resulting in hypnosis and sedation [6-8]. Similarly, when used on peripheral nerves, it is thought that the presynaptic activation of α2 adrenoceptors inhibit the transmitter release from primary afferent fibers. Postsynaptic activation of α2 adrenoceptors at the level of the spinal cord increases acetylcholine concentrations in the superficial dorsal horn and inhibits nociceptive neurotransmission by reducing the release of neurotransmitters such as substance P and glutamate [6].

Studies have supported the use of α2 adrenergic receptor agonists for analgesia in many clinical settings [3, 7, 9-16]. Its applications vary widely with use as a monotherapy or as an adjunct in intrathecal injections, regional blocks, parenteral, and oral administrations. Studies have demonstrated superior safety profiles in clinical applications with both clonidine and dexmedetomidine in pediatric and adult populations, with few, and reversible side effects [17-20]. Experimental evidence has demonstrated synergistic interactions between opioid- α2A-AR agonists and local anesthetics- α2A-AR agonists. Since clonidine and dexmedetomidine appear to stimulate the opioid- α2A-AR adrenoceptors, these compounds are excellent candidates as an adjunct to the post-operative use of bupivacaine in peripheral anesthetic blocks [7]. Therefore, the use of bupivacaine and clonidine are excellent candidates for our application of transversus abdominis plane block in minimally invasive and open abdominal surgery.

               In our experience using clonidine with marcaine and injection this under direct visualization, we have found a significant decrease in the amount of post-operative narcotics being used in the recovery area as well as less narcotics being used at home by the patients. We have recently begun doing laparoscopic retrorectus hernia repairs with mesh in conjuction with our modification of the TAP block, and have had several patient leave the hospital the very same day with no narcotics in the recovery room. These patients also return to clinic for their post-operative visit, and report using minimal to no narcotics. Understandably, some of this is due to the minimally invasive method of repair, but we did not witness the same level of pain control when we were doing TAP blocks without clonidine. The low side effect profile along with great preliminary subjective results make the addition of clonidine a great adjunct to the traditional TAP block anesthetic regimen.

               At this time, our evidence is based solely on recent patient verbal feedback. We have not done any formal type of study, but the results so far have been very positive. In the future, we would like to perform a formal prospective study with clonidine and non-clonidine TAP blocks, and see if we can reproduce the results we have seen so far.

 

 

 

 

1.                 Lowenthal, D.T., K.M. Matzek, and T.R. MacGregor, Clinical pharmacokinetics of clonidine. Clinical Pharmacokinetics, 1988. 14(5): p. 287-310.

2.                 Weerink, M.A., et al., Clinical pharmacokinetics and pharmacodynamics of dexmedetomidine. Clinical pharmacokinetics, 2017. 56(8): p. 893-913.

3.                 Zhang, X. and X. Bai, New therapeutic uses for an alpha2 adrenergic receptor agonist–Dexmedetomidine in pain management. Neuroscience letters, 2014. 561: p. 7-12.

4.                 Khan, Z., C. Ferguson, and R. Jones, Alpha‐2 and imidazoline receptor agonistsTheir pharmacology and therapeutic role. Anaesthesia, 1999. 54(2): p. 146-165.

5.                 Unnerstall, J.R., T.A. Kopajtic, and M.J. Kuhar, Distribution of α2 agonist binding sites in the rat and human central nervous system: analysis of some functional, anatomic correlates of the pharmacologic effects of clonidine and related adrenergic agents. Brain Research Reviews, 1984. 7(1): p. 69-101.

6.                 Giovannitti Jr, J.A., S.M. Thoms, and J.J. Crawford, Alpha-2 adrenergic receptor agonists: a review of current clinical applications. Anesthesia progress, 2015. 62(1): p. 31-38.

7.                 Zhang, C., et al., Comparison of Dexmedetomidine and Clonidine as Adjuvants to Local Anesthetics for Intrathecal Anesthesia: A Meta‐Analysis of Randomized Controlled Trials. The Journal of Clinical Pharmacology, 2016. 56(7): p. 827-834.

8.                 Dogrul, A. and I.T. Uzbay, Topical clonidine antinociception. Pain, 2004. 111(3): p. 385-391.

9.                 Babu, M.S., et al., A comparative study in the post-operative spine surgeries: Epidural ropivacaine with dexmedetomidine and ropivacaine with clonidine for post-operative analgesia. Indian journal of anaesthesia, 2013. 57(4): p. 371.

10.              Brummett, C.M. and D.S. Wagner, The use of alpha-2 agonists in peripheral nerve blocks: a review of the history of clonidine and a look at a possible future for dexmedetomidine. Journal of Critical Care, 2006. 25(2): p. 84-92.

11.              Eisenach, J.C., M. De Kock, and W. Klimscha, α2-Adrenergic Agonists for Regional AnesthesiaA Clinical Review of Clonidine (1984-1995). The Journal of the American Society of Anesthesiologists, 1996. 85(3): p. 655-674.

12.              El-Boghdadly, K., et al., Perineural dexmedetomidine is more effective than clonidine when added to local anesthetic for supraclavicular brachial plexus block: a systematic review and meta-analysis. 2017, LWW.

13.              Lundblad, M., et al., Alpha‐2 adrenoceptor agonists as adjuncts to peripheral nerve blocks in children: a meta‐analysis. Pediatric Anesthesia, 2016. 26(3): p. 232-238.

14.              Schnabel, A., et al., Efficacy and safety of intraoperative dexmedetomidine for acute postoperative pain in children: a meta‐analysis of randomized controlled trials. Pediatric Anesthesia, 2013. 23(2): p. 170-179.

15.              Tempest, H., et al., Caudal clonidine-bupivicaine block with bladder hydrodistension: a novel combined treatment for the painful bladder. BMJ case reports, 2011. 2011: p. bcr1120103509.

16.              Zhang, F., et al., Effects of clonidine on bilateral pain behaviors and inflammatory response in rats under the state of neuropathic pain. Neuroscience letters, 2011. 505(3): p. 254-259.

17.              Ellis, J.E., et al., Premedication with oral and transdermal clonidine provides safe and efficacious postoperative sympatholysis. Anesthesia & Analgesia, 1994. 79(6): p. 1133-1140.

18.              Kaabachi, O., et al., Clonidine 1 μg/kg is a safe and effective adjuvant to plain bupivacaine in spinal anesthesia in adolescents. Anesthesia & Analgesia, 2007. 105(2): p. 516-519.

19.              Kim, K.H., Safe sedation and hypnosis using dexmedetomidine for minimally invasive spine surgery in a prone position. The Korean journal of pain, 2014. 27(4): p. 313-320.

20.              Wagner, D.S. and C.M. Brummett. Dexmedetomidine: as safe as safe can be. in Seminars in Anesthesia, Perioperative Medicine and Pain. 2006. Elsevier.