Abdominal/BARS

The BARs Procedure

BARs (Bony Anchored Reinforcement) is a procedure developed by the surgeons at The Institute for Advanced Reconstruction. The BARs procedure represents a paradigm shift in the repair of difficult and recurrent hernias–even hernias that have failed many other attempts at repair. The BARs procedure is different in two basic ways. First, an immobile mesh is fixed to the pelvic bone, providing a stable foundation for the repair. Second, the BARs procedure is the first procedure that changes the geometry of the abdominal wall.

Normally, weight of the abdominal contents is directed downwards into the pelvis. When there is a large hernia, the weight of the contents is often left lying against the repair, which stretches and loosens over time. The BARs procedure directs the weight back into the pelvis, thereby taking the weight off of the repair. It redirects the intra-abdominal contents anatomically, down into the pelvis, producing a funnel effect. Pressure is taken off of the pannus. The BARs repair relies upon bony anchoring using Marlex mesh that will not stretch but helps bolster the laparoscopic repair. The BARs procedure is often combined with a panniculectomy.

The BARs technique after TRAM flap reconstruction provides excellent reinforcement with improved contour and decreased morbidity for the lower abdominal wall. This procedure is used by only a select number of physicians in the country. The BARs technique, although not used widespread, is a great way to provide support for the lower abdominal wall that is weakened through breast reconstruction. This will prove to be very effective in restoring abdominal strength.

Laparoscopic Hernia Repair Surgery

Laparoscopic surgery can be used for hernia repair. Instead of one long incision, four or five tiny incisions are made in the area around the hernia. A device called a laparoscope, which is a miniature scope attached to a video camera, is inserted into one of the incisions. The surgeon is able to see the hernia and the surrounding tissue and organs on a video screen.

Instruments used to repair the hernia are inserted through the other incisions and the operation proceeds in much the same way as open surgery. Advantages of this technique include shorter recovery time and less postoperative pain. A major disadvantage is that it must be performed under general anesthesia, which carries far more risks than local or epidural anesthesia. Laparoscopic hernia repair has only been used for a relatively brief time, and while research shows it to be safe and effective, long-term results are unavailable.

Hernia Repair Postoperative Complications

Any surgical procedure carries the risk for complications. Only a small percentage of patients who undergo hernia repair surgery have postoperative complications, which include:

  • Black and blue scrotum and shrunken testicles in men following an inguinal hernia repair.
  • Bleeding.
  • Inability to urinate.
  • Infection.
  • Recurrence of the hernia.
  • Respiratory problems, usually resulting from general anesthesia.

The surgeon should be notified immediately if the patient:

  • Cannot urinate after several hours.
  • Develops a fever of 101°F or higher.
  • Experiences severe pain that is unrelieved by medication and/or comfort measures.
  • Has bleeding, discharge or severe swelling at the incision site.

In some cases, a BARs (bony anchor reinforcement) TRAM flap is performed for breast reconstruction. Pioneered by the physicians at The Institute for Advanced Reconstruction, this innovative technique uses reinforced mesh, which is placed on the abdominal wall at the time of reconstruction, reducing the rate of post-operative hernia. In this procedure, skin, fat and muscle are moved from the abdomen to recreate the breast.

Before

Hernia Before

After

Hernia After

Dr. Elkwood Featured on “The Doctors” TV Show

See Dr Elkwood featured on “The Doctors” to talk about the BARs procedure for severe and chronic hernia:

Q & A with Dr. Elkwood

Dr. ElkwoodQ: What is the BARs procedure?

BARs (Bony Anchored Reinforcement) is a procedure developed by the surgeons at The Institute for Advanced Reconstruction. The BARs procedure represents a paradigm shift in the repair of difficult and recurrent hernias; even hernias that have failed many other attempts at repair. The BARs procedure is different in two basic ways. First, an immobile mesh is fixed to the pelvic bone, providing a stable foundation for the repair. Second, the BARs procedure is the first procedure that changes the geometry of the abdominal wall, to which Dr. Elkwood attributes the low recurrence rate.

Q: What is revolutionary about the BARs procedure?

Normally, the weight of the abdominal contents is directed downwards into the pelvis. When there is a large hernia, the weight of the contents is often left lying against the repair, which stretches and loosens over time. The BARs procedure directs the weight back into the pelvis, thereby taking the weight off of the repair. It redirects the intrabdominal contents anatomically, down into the pelvis, producing a funnel effect.

Q: How is BARs related to breast reconstruction following cancer surgery?

One of the most common types of autogeneous tissue (from one’s own body) reconstruction is the pedicled transverse rectus abdominus myocutaneous (TRAM) flap. This method transfers the tissues of the lower abdomen along with the rectus muscle (“ab muscle”) to the site where the new breast is to be constructed. While the benefit of the TRAM flap is a natural looking and feeling breast, it is associated with problems and risks related to the abdominal wall donor site. These include potential abdominal wall weakness, bulging and hernia, which occur in many patients. In an effort to proactively avoid these complications, together with the TRAM flap reconstruction, Dr. Elkwood performs BARs.
The BARs technique after TRAM flap reconstruction provides excellent reinforcement with improved contour and decreased morbidity for the lower abdominal wall. The BARs technique is a great way to provide support for the lower abdominal wall that is weakened through breast reconstruction. This will prove to be very effective in restoring abdominal strength. 

Q: What academic research have you completed on BARs?

We have published two recent studies.

The first study in the June, 2014 European Journal of Plastic Surgery is a retrospective analysis of 63 patients between January 2006 and August 2012 for BARs for the repair of serious or recurring hernias. Patient mean follow-up was 3.1 years (range 6 months to 6 years). None of the 63 patients had recurrent abdominal wall hernias. One patient, from early in the series, had post-operative bulging, which was retreated successfully using the current revised bone anchoring protocol. Five patients developed mesh infections, none of whom required radical debridement or removal of mesh. In a six-year study published in the August, 2014 issue of European Journal of Plastic Surgery, Dr. Elkwood and his colleagues examined the results of the TRAM flap/BARs combination surgery, concluding that the rate of success and patient satisfaction indicate the procedure is highly desirable in selected patients. In fact, in the mean follow-up of 3.1 years, none of the 63 patients studied had abdominal hernias.

 

The studies referenced by Dr. Elkwood above can be found here:
BARs for Serious and Recurring Hernia
TRAM Flap/BARs Combination Surgery



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