Peter Landers surgical patient
IF IT WEREN'T FOR a pioneering abdominal wall reconstruction (AWR) surgery, a complex hernia may have prevented Peter Landers from playing with his grandchildren in the sand this past spring break.
"This hernia was debilitating: on a scale of one to 10 it was a 10," Peter says. "I had to wear the girdle 24-7 to hold my stomach in. To do anything was extremely uncomfortable." But thanks to the surgery, which uses mesh to hold together separated abdominal wall muscles, the 65-year-old
Barrie resident was heading south after a long string of health problems kept him laid up for nearly four years.
After a series of surgeries related to cancerous tumours on his bowel and liver, Peter developed an abdominal hernia so big he had to wear pants fives sizes larger. "My stomach was cut up pretty good," Peter recalls. "When I was rehabbing, the incision in my stomach didn't really heal properly so there was a three-inch gap there."
Peter spent five-and-a-half months in a Barrie hospital waiting for the incision to heal. The waiting added to his fear and frustration about being ill. "The oncology team came in because I was supposed to start chemotherapy, but I couldn't get chemo because of the incision not healing," Peter says. "I wasn't in good enough health."
When Peter visited Odette Cancer Centre, Dr. Calvin Law suggested he visit Dr. Fred Brenneman, a Sunnybrook trauma surgeon skilled in complex hernia repair who is pioneering the AWR surgery that uses mesh to hold together the separated abdominal wall muscles. "Hernia surgery is the most common operation that general surgeons do, but these are the most complex hernias that require more resources to look after," Dr. Brenneman says. "They are more complicated and they are often associated with bowel surgery at the same time."
AWR is performed at specialized health centres in the United States, but few are done in Canada. "We are working to help bring this to Canada," Dr. Brenneman says. "There are identified leaders across the U.S. that do this and they are in the same situation as I am, where they will take referrals for the most complex hernias from other surgeons."
Most of these patients are burdened with abdominal pain or discomfort, and a heavy feeling because the hernia is large and hangs from their stomachs. "They struggle to do anything that involves straining or engaging abdominal wall muscles," says Dr. Brenneman – even functions as basic as urinating or bowel movements can be difficult.
There was a need to establish an AWR program at Sunnybrook because of the oncology program and trauma expertise there, Dr. Brenneman says. As of February 2012, he has performed 96 complex AWR surgeries. "There are patients coming out of those programs after their cancer surgery or after their trauma surgery and they develop these complicated abdominal wall hernias. We developed expertise in looking after those patients and that became well-known. And then the referrals started coming essentially from across Ontario and, really, from even further." Dr. Brenneman has travelled to other hospitals throughout Ontario and as far away as Nova Scotia and Newfoundland to help surgeons learn AWR techniques.
For patients with extremely complex hernias and risk of infection, such as Peter, biologic mesh made from real human or animal tissue is used. When Peter heard about Dr. Brenneman's expertise, he was optimistic. But funding limitations threatened his chance of getting the surgery, which is not yet covered by the government. "I was getting very adamant about getting it done to improve my quality of life," Peter says. "After three and a half years, you get depressed."
Peter finally underwent chemotherapy early last year. In September, when funding was secured, Dr. Brenneman performed a seven-hour-long surgery. Six months later, Peter had his bags packed for Florida, brand new beach buckets for his grandchildren and his golf clubs waiting by the door.
"My hand is on the switch now, and it's a matter of taking my time and doing it right and we don't end up with a problem again."
What is Biologic Mesh?
An abdominal wall reconstruction (AWR) procedure generally involves synthetic mesh, which reconnects the separated sides of the abdomin and corrects the hernia. But in some patients, the surgeon can't use synthetic mesh because of a high risk for infection – which can mean more surgery and a long, painful recovery. Biologic mesh is made from human or animal tissue and is resistant to infection.
Without biologic mesh, these high-risk patients (patients with infected mesh, those undergoing bowel surgery, the immunosuppressed and others ) can't have the procedure at all. "We use either a synthetic or a biologic mesh and our decision on which one to use is determined by the risk of surgical site or wound infection," Dr. Brenneman says.
Both synthetic and biologic meshes are improving every year. "There's a lot of research and development put into these meshes," says Dr. Brenneman. "The synthetic meshes we are using today are a lot better than the synthetic meshes we were using 10 years ago, even five years ago," he says. "There's continual innovation. The biologic mesh, although expensive, has meant a huge improvement to the AWR surgery that we are now able to do at Sunnybrook." •