0:05

Behind. The Night The Surgery

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Podcast Relevant and engaging content

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designed to help you dominate

0:12

the day. Will

0:22

come back to behind the night this patch or

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George off and Jason being I'm here and I

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was always thank you for tune in Emma does

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as a quick reminder. That. If you are

0:30

in need of see and credit check us out

0:32

is completely free. Just had to the website where

0:34

the app. For. More information into

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day. Jason. I are joined

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by absolute titans in the field

0:41

of hernia surgery. As I said

0:43

Titans! his. Doctors. Are taught Hannaford

0:45

and my frozen household name is practically by

0:47

now. especially are behind a knife and we're

0:49

pleased to have you been with us. Welcome

0:52

to the show gentlemen. A. Doctor

0:54

I Hannaford is cheap or the

0:56

Division of gastrointestinal and minimally invasive

0:58

Surgery and Director of the Carolinas

1:00

Ernie Institute at Atrium Help Carolina's

1:02

Medical Center. And. Doctor. Rosen is

1:05

professor of Surgery and director of a

1:07

comprehensive. Or new Center at the Cleveland

1:09

Clinic. And. So I think it's

1:11

safe to say that these guys know a thing or

1:13

two. About. Hernia So and

1:15

Jason. I recently read a paper in

1:17

Jama showing a five year recurring right

1:20

after better a hernia repair a greater

1:22

than forty percent in patients with mess

1:24

repairs. And. Greater than seventy percent.

1:26

And. Patients without mesh. We.

1:29

Knew we need to get the real experts on

1:31

the horn to help us make sense of these

1:33

results. and it morally more importantly. A

1:35

to break down. What? It means

1:37

for the hernia surgeon who does

1:39

not the vote one hundred percent.

1:42

of their time to the abdominal wall. But.

1:44

do quite a bit of hernia surgery so

1:46

really the some the questions or come up

1:48

or we collectively. Family. In our

1:51

patients. When it comes to earn your repairs, how do

1:53

we counsel them? Shag. Free have

1:55

my patient. Or. How long? How much weight

1:57

do they need to lose? His. The

1:59

retro rec this may overplayed was

2:01

the perfect place. For. Piece of

2:03

Mass. What about eat have a banning in the sack?

2:06

Or. About and here. Capone Separations on Twenty

2:08

Twenty Four. There's. A lot for the

2:10

hernia search and to consider. So. Let's

2:12

get to run use a D It paper

2:15

as a launching point. Where. I'm

2:17

sure we'll be an absolutely fantastic

2:19

discussion. Chasing. Him I give us some

2:21

of the key points and and we're going to bring

2:23

in our most esteemed and guest to sell a said.

2:27

Yes, Sir says imagine This is a

2:29

paper recently came out Jama looking at

2:31

the year over year bed for hernia

2:33

recurrence rates and the some associated risk

2:35

factors. That. Was a retrospective

2:37

population base study using a D

2:39

Abdominal A Core Help quality collaborative

2:42

registry to a by year over

2:44

year recurrence. Really, it's in patients

2:46

from two thousand and twelve two

2:48

thousand. when it's you, There.

2:50

Are large number of patients, Thirty thousand patients

2:53

with mass and five and a half thousand

2:55

with no mess. As you mentioned that, the

2:57

findings were somewhat surprising. So. Five.

2:59

Year recurrence race real gory, percent with

3:02

mess and seventy percent with no mass.

3:04

What's. Important and will probably a back with

3:06

little bit as the meantime. From index

3:08

ventral hearty repair to latest follow up

3:11

was one hundred and twenty days with

3:13

mess and seventy eight days for those

3:15

without. And among patients with

3:17

spears recurrence, the meantime to recurrence was

3:19

one hundred and ninety five days for

3:21

patients with mash and three hundred and

3:23

thirty days for those without Mesh. With.

3:27

Regard to factors there was associated with

3:29

a higher odd of recurrence. ah a

3:31

lot of it was not surprising higher

3:33

be a my demeanor suppressed. Those.

3:35

With incision on pair still more hard to

3:37

as. Rate. A hernia with. Abuse

3:40

of reasonable measures and those

3:42

with complications such a surgical

3:45

site, infection or he operation.

3:47

Some. Are more surprising like a robotic

3:49

approach. Had a higher odds ratio. Bird.

3:53

Factors with low rods again not

3:55

really surprising greater met with. My

3:58

a facile release. The

4:00

already had an apostle closure. Interestingly,

4:03

The study found that smoke even greater

4:06

a as a class and prior mess

4:08

infections were not associated with a recurrence.

4:11

So. There's lots on tax year so

4:13

let's get into it. I think that Rosen

4:15

will start with you. Get. Also

4:17

bit about the abdominal Ct Health

4:20

Quality Collaborative: What is it to

4:22

participate out? Why was it warms

4:24

and what are It's some of

4:26

his strengths and limitations. Jerk.

4:29

As a result they slapper have me is a

4:31

pleasure to be here. I'm not a.

4:34

Permit. Living in a cave sitting terrible harmony

4:36

is the only way to get me out

4:38

these days is bring our taught Hannaford South.

4:41

I've yeah, haven't been here. And.

4:43

Say they have this conversation for transparency. I

4:45

and medical director and I'm one of the

4:48

cofounders of the abdominal cramps. Or.

4:50

How polyglot and so. The. My

4:52

perspective this has been around the started

4:54

actually touch and said was president. Of

4:56

the H Or and the next present

4:58

H S is incredibly supportive. This Ah

5:01

Xian surgeon. Try. To find my

5:03

way and and we started the sauce. And.

5:05

More of a database where we

5:07

could put our data isn't share

5:09

data. Is. Morphed into several things

5:11

and now you look at Moore's a colleague

5:13

collaborative. Where. We have almost

5:15

five hundred Sergeants across the country.

5:18

ah, half a private practice. Some.

5:20

Solo private practice surgeons out there

5:22

are A and people major academic

5:24

centers. And. We'd basically share

5:26

data for England, old, actual, and and

5:29

most recently bad at idle. Korea's. Will.

5:31

A lot of demographic detail, a lot

5:33

of granular operative details, and we have really

5:36

good during a follow up. But

5:38

I think that as I'm sure talked about this paper. Like.

5:41

Everything in the United States you struggle with

5:43

long term follow. That and so again

5:45

at all of the south has to be wade in.

5:48

What? It can offer. I think the

5:50

best way to think about the Que

5:52

Sea. Is. That it gives

5:54

you the thirty thousand slit view. Of

5:57

what. We hope this happening in the real

5:59

world. We will never be able to prove

6:02

that because obviously there's 16,000 surgeons fixing

6:04

hernias in the

6:06

United States. So we have a small sample of that.

6:09

I think we have a pretty good swatch of community

6:11

academic facilities. So I think we get close

6:13

to the real world, but it's

6:15

a place, particularly for these type of

6:18

analysis to look at broad themes

6:20

and then dig down deeper into those to

6:22

try and get as close to the truth

6:24

as possible. So what would

6:26

you say is the greatest strength of the collaborative,

6:28

the greatest limitation that someone was interested in contributing,

6:30

what does it take to be a part of

6:32

it and to contribute the data? Sure,

6:35

sure. So the greatest strength of the

6:37

quality collaborative, I believe is that it

6:39

allows you to track your own data

6:41

and your own outcomes and see where you

6:44

kind of land with people. It's

6:46

also a collaborative. So I mean,

6:48

the concept of it is that we all

6:50

share data. There's no

6:52

advantage to being great and there's no disadvantage to

6:54

not being great. We identify high

6:57

performers. We learn from them and

6:59

we make everybody better. So it's a shift you.

7:02

I mean, I think one of the hardest things for

7:04

everybody to accept in surgery is

7:06

just like anything. It's a bell curve,

7:08

right? We're all a bell curve. And

7:11

so the goal of us at

7:13

the collaborative is to shift you as far

7:15

up on the bell curve as

7:17

you can be, but recognizing that there will always

7:19

be a bell curve. And I particularly

7:22

say that because there's often a concept of kind

7:24

of the centers of excellence type

7:26

thing, you can situate in your introduction

7:28

about experts, non-experts. And I

7:30

think that's actually a bad concept, particularly

7:32

in the world of earning surgery because

7:34

that kind of draws arbitrary lines based

7:36

on outcomes and people gain the system.

7:39

So this is really an distinction of that. This is

7:41

just about share your data and become the best you

7:43

can. So I think that's the

7:45

biggest stray. The limitations are several.

7:48

Number one, it takes time to put the data in. It

7:51

takes two or three minutes after every case trying to

7:53

get patients to fill out questionnaires.

7:56

It's not easy. It's not even consuming.

7:58

I Will just put it out there. We actually

8:00

have finally accomplish. Yeah.

8:02

Maher Integration and the Party Collaborative

8:05

so you can now. We. Should

8:07

integrate with your Bmr and there's no actual

8:09

work in the database I have is automatically

8:11

so that's one of our hopes. His to

8:14

believe that barrier. As. He delimitation

8:16

again is we work with

8:18

passive follow ups. We have

8:20

several mechanisms: emailing people get

8:22

it's all up and in

8:24

clinic. But. It's heart and

8:26

probably will talk about this. Why are

8:28

your patients are not necessarily gauged. In.

8:31

Follow up to it and why they don't

8:33

participate. it violate to get bored. Really

8:35

easy. Totally. Free. Go.

8:38

A cease to see.already to join. His.

8:40

Ordered a contract process which can be painful

8:43

because we. Collect. Ph I but otherwise

8:45

job if i as is why they are put

8:47

out there like. It's. Way to check Today

8:49

At the end though, he is. dinner. So.

8:54

You mention that the goal of this is to

8:56

shudder what's happening. Or what we

8:58

hope is hop in the real world. I. Think

9:00

the reason this paper caught somebody people's

9:02

attention was that hide it be that

9:04

really high recurrence rate was higher than.

9:07

People. Like to believe. Is happen

9:09

in real world are certainly my record.

9:11

Certainly, my recurrence rate isn't greater forty

9:13

percent or greater than seventy percent. Opens

9:16

up to both you. How does

9:18

this compare to prior studies that

9:20

showed different data, different recurrence rates?

9:22

What's different about it? And

9:24

why do you think the studies, your eye or failure

9:26

rates and that have to do with population you will

9:28

do. I know if we need to get into that

9:30

fall what this you is it is is that the

9:32

reason. That. Have to do with

9:34

repair technique. Would. Nod and

9:36

Hernia centers to perform a hernia as what?

9:39

What you guys is. Of

9:42

the bottom or ideal a wide it showed

9:44

so tired or interest. Ah

9:47

out I got my to Starbucks and and

9:49

again thank you guys were having us and

9:51

now gives I do want to give to

9:53

those from like my guest. Spent a decade

9:55

of as life building this database. and

9:57

everywhere i guarantee works on an everyday

10:00

When surgeons come up to me and say how do

10:03

I track my data, how do I make this happen

10:05

for myself, I want to build a hernia center, the

10:07

easiest thing to do is log on, you can easily

10:09

follow your own data, you don't have to build a

10:11

data set and you can get fancy

10:14

reports from Mike and his group comparing yourself

10:16

to yourself, comparing your growth and also comparing

10:18

yourself to other people. So it's super easy

10:20

to get started with this. As

10:23

far as we want to get into this paper

10:25

itself, I think there are certainly

10:27

limitations in this paper. If you

10:29

look at the patients without mesh, like 1

10:31

in 14 of those patients had fistulas or

10:34

mesh infections, really a tough group and why

10:36

they didn't have mesh and then you look

10:38

at the number of patients who had stomas and if

10:40

you want to make yourself look bad, follow your barastoma

10:42

or hernia repairs. And then the other

10:44

consideration and probably the most important thing and Mike and

10:46

I have talked about this is the follow up in

10:48

this paper and so it's

10:50

hard to get patients to follow up. But

10:53

if you want to talk about this paper, Mike is

10:56

an expert in this and getting patients to follow

10:58

up with the quality collaborative. But if you

11:00

look at the follow up in this paper, and

11:03

you mentioned the average follow up is 128 days for the mesh group. But

11:07

if you look at the average follow up until recurrence, it's

11:09

495 days. So the

11:11

follow up is not longer than the time

11:13

to recurrence. So it's 4 times longer to

11:16

the time to recurrence and so with that,

11:18

it starts to break down and it's almost

11:20

exactly the same as the 4

11:22

times longer follow up in the non-mesh group as

11:25

to the average follow up. But it starts

11:27

to make you believe that if you start breaking this down,

11:29

that perhaps the patients who are coming back, the patients who

11:31

have a problem, squeaky wheel comes back and they got a

11:34

problem, they come back and see their surgeon. If

11:37

you look at the one year follow up in the mesh group, it's

11:39

just over 15%. If you look at the non-mesh group,

11:41

the follow up is 7%. So

11:44

you start to say, well, what is our recurrence rate at one year when

11:46

you only have 15% of the patients that come

11:48

back? When you go to three years, it's

11:50

2% for the mesh group and it's 1%

11:53

for the non-mesh group at three years of follow up. So

11:56

when 99% of your patients don't follow up, what

11:58

Does that number actually need? As.

12:01

Who who those bases are? Coming back were

12:03

suspicious. Don't come back. I think.

12:05

It. I think it speaks to

12:07

the difficulty. In. Gathering.

12:10

Data with long term file with patients will

12:12

come into your office. They're nervous about their

12:14

tear, they seem they were nervous about mashing.

12:16

We did a study where in where we

12:19

interviewed to interfaces for the certain solemn if

12:21

forty five percent of the basin said mesh

12:23

equals complications out of the gate themselves. And

12:27

they're worried about this but the what follows need

12:29

to give us follow up for their new but

12:31

after they. Knew. In in most

12:33

or does a really good at acting harness.

12:35

And. Basis go out and you'd expect to do

12:38

pretty well. And they don't follow up

12:40

with are certain so we don't want their outcomes are. Ah

12:44

I companies are as I'd pretty much of your

12:46

there they are did it a Buddha are at

12:48

odds of that just a little bit I think

12:51

so first of all maybe just a public service

12:53

Announcements Everybody is looking at papers. In

12:55

this paper there is a Caplin marker.

12:58

And. I think said. I mean honestly, the

13:00

gym surges Incredibly high impact journal. And.

13:02

I think that this was a mess To be fair,

13:05

At. The date the data is in

13:07

the paragraph below. That is every Kaplan

13:09

Meier Curve. On the

13:11

exit access should have the time

13:13

which this does and then below

13:16

it. It should have the number

13:18

of patients that actually our Solomon And so

13:20

the data is there. It is It is

13:22

there. But. It's cypriot a graph of an

13:24

I think that to me and me what this paper

13:26

shows. Is it It is T

13:29

V Auto Theft. It. Consists. In

13:31

the sack to this is to see David because. You

13:34

see data and it's always a he can win

13:36

the argument right. It's either to but experts who

13:38

are the real world. Or yeah,

13:40

it's about people who can all that face

13:42

a job that is so mad. Release or

13:44

five hundred people. Who. Are super

13:47

engaged in hernia surgery. Who.

13:49

Cared enough to put data into

13:51

this database. To. Be by the

13:53

top one percent of people who were doing stuff. Just.

13:56

by effort not saying outdoors move by

13:58

efforts to do this And

14:00

I think that's one of the things, my message to

14:02

everybody is we have to

14:05

get comfortable understanding that

14:07

we don't know the answer, right? And

14:09

that's hard to do as

14:12

a population, right? Because if

14:14

the most engaged people in the United States can't

14:17

get more than 10% follow-up, that's

14:21

a problem. And I have a, we'll

14:23

talk about it a while, but I think

14:25

one of the problems is the way we couch this disease

14:27

to patients. But I'll add one

14:29

extra thing just as a little kind of

14:31

controversial comment is, again,

14:34

I don't think this data tells the

14:36

whole truth. Like I want to be clear about that

14:38

because as Todd said, we're missing a ton of follow-up.

14:41

But if you ask everybody in the

14:43

world why they use

14:46

mesh, the reason

14:48

why they use mesh is because of

14:50

the Lewindeig trial, which is one

14:52

of only four hernia studies

14:54

ever published in Lewindeig and Journal of

14:56

Medicine. And shockingly

14:58

enough, their recurrent

15:01

rate in the mesh and no mesh

15:03

group is actually exactly

15:06

the same as this

15:08

study. And to

15:10

add on even to that, that

15:13

they were dealing with hernias that

15:15

were substantially small that they

15:17

were dealing with three or four centimeter hernias. So

15:21

hopefully we'll get to delve into this.

15:23

The story of we found the radical

15:25

cure to hernia and let me prove

15:27

that I'm right for the next two years and

15:29

then prove that I was wrong for the next

15:32

five years, that story has been told

15:34

over and over again, certainly by me and a

15:36

little bit by Todd. And I

15:38

think that, again, I don't think that

15:41

this trial shows that for sure,

15:43

but it always strikes me

15:46

how people forgot that although

15:48

we all pull 2% recurrence rate, we're

15:51

using mesh because it reduced the recurrence

15:53

rate from 60% to 30%, not 2%. And

15:57

that's our level one, probably the best. highest

16:00

impact trial ever written ever in

16:02

hernia surgery. So again, no

16:05

question you got to look at the literature carefully,

16:07

but it always shocks me how easy

16:09

we are willing to walk away from

16:12

some of the best data we have. If

16:14

you look at that study Mike and that

16:16

Lew and Dyke study with Hans Jekyll's the

16:19

senior author changed hernia surgery and launched

16:21

a revolution of in the mesh industry all

16:23

these meshes that have come out launched since then

16:26

it's falls back to that paper and

16:29

you guys know what the fragility index is right?

16:31

You have you have two things that you're testing

16:33

you have a recurrence in one group or recurrence

16:35

in the other group to no recurrence But if

16:37

two people in this study if two people either

16:39

had a failure it didn't have a failure on

16:41

one side of the other this is no longer

16:43

statistically significant and the

16:46

hernias were six centimeters and the largest turning was

16:48

six centimeters Mike talked about and you know how

16:50

they fix their hernias they whip stitch a piece

16:52

of mesh in the middle of it. Wow,

16:55

it's small but you're what year was this study

16:57

about New England Journal of Medicine in 2000. We'll

16:59

put it in. Yeah, you know and that launched

17:02

revolutionized hernia surgery and launched an industry.

17:06

Not a small. And you can

17:08

forget I mean and again, I mean to Todd's

17:10

point like it's different techniques, but I mean

17:12

again like to me

17:16

again, I mean hopefully we'll dig into this a little more but

17:18

right like what

17:20

I think we forgot as we have

17:22

like embraced mesh in outcomes which I

17:24

mean I think it's appropriate

17:27

to fix hernias with mesh like don't mistake

17:29

what I'm about to say but what we've forgotten

17:31

in all of this is the

17:34

disease of hernias right and

17:36

how hard it is

17:38

to treat this disease. This

17:41

is yeah, this is exactly

17:43

where we want to go with it

17:45

because the question then is are we

17:47

as surgeons collectively lying to ourselves failing

17:50

or missing the greater point when it comes

17:52

to the disease process and so exactly how

17:54

do you bowl as true

17:56

experts in this field that people have thought about this

17:58

so much. How do you Think about it

18:00

yourself and you teacher trainees and how you

18:03

talk to your patience about it when it

18:05

comes to. This. Bigger picture odds,

18:07

Of. Cornea. As

18:09

a disease process and how you approach it

18:11

surgically especially as is one one part of

18:13

it. Will

18:17

be a star That so so. I changed

18:19

tremendously over the years in this and that

18:21

and I have to tell you, That.

18:23

I think department does kinda look at older,

18:25

loaded, more mature as and and having a

18:27

look at a perspective. And. Like facing

18:30

fail it's right on the side says like. If.

18:32

You to stick around in the same place.

18:34

Wanted us. All of this humbling

18:36

and such. Oh. So. I sinks

18:39

it when I was younger. a lot of

18:41

what I sought about the what I wrote

18:43

about. Was. Truly to show how

18:45

good I was as an individual. Why?

18:48

They like look what I can do it and it

18:50

is amazing. I think many people that when I had

18:52

an enemy. And he, that's actually five?

18:54

I could surgery. He should. Feel. That

18:56

way. But. As you look at a time

18:58

you realize it and I think. That

19:00

initial our toes. I think we

19:02

need to complete the have a different conversation piece. If

19:05

you go see a orthopedic surgeon. is Todd now

19:07

get older It has to see them at died.

19:10

And. They put a hip of serpentine as two

19:12

hips in today's by that but it if they

19:14

put hips and knees did you and shoulders.

19:17

They. Tell you straight up. This.

19:19

Know as you. Five years, ten years you

19:21

need every day. And there's no

19:23

conversation about less we just as a prosthetic

19:25

is dead. And that's because I'm not a

19:27

very good surgeon. And as because if you want to see

19:29

the really good surgeon, It's. Gonna work

19:32

better. It's a high the mechanical straining

19:34

area. There's a lot of the load. There's a

19:36

lot of things are happening. And. This is

19:38

break down and now animals. It's exactly

19:40

the same. But. I try and

19:42

set a realistic expectation pace. Of say about this

19:45

is just as it's. I will do

19:47

my best. It and I would just shut Like

19:49

what I tell faces of you just want to know about recurrence.

19:51

Is. What's a lot of people focus our crisis? I have the

19:53

that's really what we should be looking at. but. When.

19:56

When people ask me about occurrence based on my did

19:58

i say his pupils it was. This is. My.

20:01

Hurting. too bad. I see what? You know what? It's.

20:03

A much more complicated question that because

20:05

it depends on perspective, If. I

20:07

ask you, what's the chances you might have a bolts.

20:10

After my operation, you complain about probably

20:12

twenty five percent. You're. Gonna notice

20:14

some asymmetry? You have heard it is something

20:16

wrong with your daughter. Was about to make

20:18

all that go away. If. You if

20:20

I get a city see down on everybody. Maybe

20:23

wanted ten chance I'll find some small the doesn't

20:25

bother. But. Maybe about three or

20:27

four percent chance you need another operation for

20:29

it. so. Good depending on

20:31

the prospective. It's. Much much

20:33

more complicated. Than just one

20:36

said at it but more that any the

20:38

I'd really take if we showed up say

20:40

look this a chronic disease. So. I

20:42

call you would ask use a solid a three to

20:44

five years or ten years. It's. Important that

20:46

you let me get hired on. This things can

20:48

happen. Over. Time and if we

20:51

just change that, A doesn't mean

20:53

we're that. It just means it's

20:55

just a sec. The. Bullet Else. It's

20:57

like obesity, right? It's i'll be cured

20:59

obesity with those basic surgery sleeves. Whatever.

21:02

Such. Hearing anything, So long term

21:04

disease. That. Is constantly have to

21:06

do with laws to make it bad or.

21:09

And as surges if we got a waste of the one

21:11

and done. And. Were. Take

21:13

care of you. sought the teaching. you have this disease.

21:15

And. Sought about our surgical procedure that were.

21:18

As they could be much better for patients and

21:20

much more realistic for us. Out

21:23

or think Mike's right and In In. So

21:25

what do I tell? my students and. Residents.

21:28

And bells first think by Mike's tax but

21:30

so best in the world still to welcome

21:32

might invent a second and it elicited is

21:34

a pretty that it is a pretty remarkable

21:36

Dexter's to our video her the Alice are

21:38

behind the knife in a future and is

21:40

just plain seed nasa wagon like and are

21:43

to honor to let's go the but I

21:45

think that it one of those things of

21:47

the surgeons have to understand. I'll start with

21:49

the surgeons and a Star Hotel the same

21:51

things start to the turret. Trainees is at.

21:53

New people in your office for a reason. And.

21:55

I'll say this to the patience as well. if

21:57

new patients who were just talked about incision or and

22:00

patients who develop an incisional hernia have separated

22:02

themselves from the herd. If 18%

22:04

was just saying we develop an incisional hernia,

22:07

they're there for a reason. And most

22:09

often it's not because the surgeon closing mist

22:11

a stitch or something of that sort. And

22:14

when we look at our data, the patients who walk

22:16

in our office, let's just say that the

22:19

patients we looked at about 800 patients had

22:21

component separations. And when we write about this,

22:23

we write about the whole group and it's

22:25

a very complex group. But then we want

22:27

to figure out what we're doing is works.

22:30

Then we eliminate people with a body mass

22:32

index over 35 people, then contaminated wounds, people

22:34

where we couldn't get the fascia closed, people

22:36

who were active smokers, uncontrolled

22:38

diabetics. You start eliminating those people, we're down to

22:41

22% of the population of the patients that we

22:43

wrote about. Out of

22:45

the gate, these people are complex. And then if

22:47

you look at all the incisional hernias, we looked

22:49

at almost a thousand consecutive incisional hernias, not just

22:51

component separation patients. And then you add into

22:53

it defect greater than 200

22:55

square centimeters, and you add in

22:58

immunosuppression and those sorts

23:00

of things. And off midline hernias, now we're

23:02

talking about almost 84% of

23:04

the people that we see. And so

23:06

these are complex patients walking in the

23:08

door, complex operations. And you have to give

23:10

credit or you have to give it a due,

23:13

let's just say. It's

23:15

not just a hernia. This is a

23:17

complex operation in a complex patient. And

23:20

I tell the patients, mostly like Mike said, my

23:22

number one thing that I want to do is one is to keep

23:25

most importantly is keep you safe, short term,

23:27

keep you safe long term, protect your quality

23:29

of life is two on that list. And

23:31

then thirdly is recurrence that we worry about.

23:35

But if we can get, if we can make

23:37

patients better patients, and we may talk about comorbidities

23:39

and that sort of thing, but we can take

23:41

complex patients and make them better patients and influence

23:44

their outcomes. And I don't think there's any question

23:46

about that. So

23:49

I really like that, that approaching this as

23:51

a chronic disease. I love the way you

23:53

guys laid out how we should be talking

23:55

to patients. To follow up on that, then how

23:57

do you, what are the, you talk about the The

24:00

stock rosenberg the used to boards for school.

24:02

They are like what are the things that

24:04

we should be following how on we fall

24:06

and you guys follow your patience your hernia

24:08

patients. What? Are you looking

24:11

for do damage them routinely?

24:13

At some said interval. Or.

24:16

Are you more focused on yell louder and

24:18

fall the of light on how only fallen

24:20

out up frequently hands ads earth? What? Imaging

24:23

it at all do you get? Yeah let

24:25

me scary answer that for media. And

24:27

as a tight, Todd's are the same way. but

24:29

the me also answer that for like. The.

24:32

Realistic, but none and nine point nine percent

24:34

in preserving six by jowl surges in the

24:36

real world. Would. Is a reasonable

24:39

expectation right? So. Me personally.

24:42

I. Try to see everybody back at one year.

24:44

Get a seat east? yeah, but I think

24:46

probably. I mean if I

24:48

get seated reset, I'd be surprised that we try.

24:51

An. Egg I'll try. I would love

24:53

as I target imaging every year. And.

24:55

We made him and are a lot of papers. I

24:58

wanna know it. The truth is I wanna know what

25:00

things are. Some. Actively seeking that

25:02

stuff out. And would try to

25:04

get we email patience every year these patients

25:06

put it all comes with. Quality.

25:08

Of Life Metrics: Pain. And. Weather

25:11

out there, proceed, recurrences are.

25:13

So. Like we actively do that but to

25:15

his son is you get a follow up.

25:18

And so Id dig for

25:20

that brother world surgeons out

25:23

there. Is outside The and the

25:25

collaborative were were emailing your patience. Is.

25:27

Still, the response. Race: Fifteen. it's wiper. Sad.

25:29

It's. Unsafe air to ask them to. See.

25:32

All these people back what was up. So

25:34

what I see is a fair. Responses.

25:36

What I see you as and before which is. Just.

25:39

To accept the I Know. And accept

25:41

that like little due to lie these cases and

25:43

like with we don't know what the solve this.

25:46

I'll. Add one thing though that that

25:48

I would have liked to see this paper

25:50

do. It. Maybe to be done in

25:52

the future again with limitations. But. There's

25:55

another thing that we the do with a

25:57

Q see that we just recently. a

25:59

dent is really champion this is

26:02

we can now link Medicare

26:05

and Medicaid patients to the QC.

26:08

So it's roughly we have

26:11

about 150,000 patients in the QC and about a

26:13

third of them are Medicare and

26:15

Medicaid patients and so what

26:17

that does now the limitation is now you're

26:19

just Medicare and Medicaid patients. So

26:21

that introduces some bias so it's not perfect

26:24

but what that does do is that we

26:26

can get almost a hundred percent follow-up and

26:28

remember we know everything that happened to the

26:30

OR that they don't know with

26:32

the CMS data but now we

26:34

have a true re-operation rate and

26:37

we can actually calculate the mess related

26:39

problems long term based on different ICD-9

26:42

and CPT codes. So

26:44

then you get to like near a hundred percent

26:46

follow-up of 30% of the patients. So

26:49

again not perfect but getting

26:51

yourself there and finally I think

26:53

just acknowledging that like measuring recurrence is

26:56

hard, is it re-operation, is

26:58

it the quality of life and all those different

27:00

things and then I think you just gotta get

27:02

comfortable realizing that and

27:04

then look at the literature carefully

27:07

and realize that a lot of people when they

27:10

report the two percent recurrence rate and all that stuff

27:13

they're missing tons of their patients. This

27:15

happens to show it the other way because they're

27:17

only picking up people who show

27:19

up with problems versus assuming

27:22

that if you don't show up everything is

27:24

fine and so it's funny if

27:26

you would have taken this paper right and you played

27:28

it out the other way just to show you how

27:30

data could be used however you want and

27:33

let's say that you just assumed that

27:36

everybody who didn't follow up was

27:38

okay then you would

27:40

have a one percent of recurrence rate at

27:42

four years, a two percent recurrence rate at

27:44

five years. So it just showed us how

27:46

hard it is to sift through how people

27:48

take the data and present it in a way

27:50

and both are fair and accurate but

27:52

they will just draw the opposite conclusion. And

27:57

so those are wildly different numbers

27:59

you'd The percentage of a

28:01

possible recurrent is an imaging

28:03

inner. Clinically. Sniffier occurrences

28:05

require and reaffirmation better far

28:08

cry from. The numbers are

28:10

toss around any studies here and vast majority so

28:12

does during hernia surgery and be able to see

28:14

a patient when you're let alone. Get.

28:16

Him cities can cover it and or com

28:18

interface and turned across more radiation for the.

28:21

Sake! Of. Take. A look at

28:23

as I was at May be. In.

28:25

He said except the unknown. Is it a simple as that?

28:27

Then there's that big. Space. Where

28:30

as I I don't I don't know the

28:32

honey rated or my current rate is exactly

28:34

were clinically significant recurrence raiders. As a

28:36

Midas gonna on their cell and over

28:38

deliver? Is that all this in terms

28:40

of my pre operative discussions? And except

28:42

there's a and I know and maybe

28:44

it's. Ten. Percent neighbors, twenty percent,

28:47

maybe thirty percent the rates is going to

28:49

out there. And well,

28:51

my take on that. Is.

28:53

Really easy My did surprise. Patients.

28:56

Love honesty. I think it's

28:58

okay. To. Tell to base it a

29:00

lot. When. On out. A muddy

29:02

my best with what I'd know today. How

29:04

much? As far as I can. But. Like April. When

29:06

I call you in a year and want to know

29:09

what's up, it's important to. As important

29:11

as you, let me know where you're at, because the truth

29:13

is. We. Don't know and

29:15

like. It. Is been shot over

29:17

and over again like. It.

29:20

In the United States? we don't know.

29:22

In Europe. All. They really know

29:24

is what the react ration rate for

29:26

recurrences. They don't know what the patients

29:29

client lives are, they don't know pain.

29:31

They. They have good administrative databases,

29:33

so. I.

29:36

Get I'm an eternal optimist, I just

29:38

see this as. All.

29:40

Young people out there listening to this

29:42

podcast. This. Is it? This.

29:44

Is your future. Figure. It

29:47

out. Find a way to get

29:49

to swallow up, make it and make an

29:51

ai midway like. Like. Just it's okay

29:53

to say we don't know in somebody Go save

29:55

your it out. And. Don't just accept

29:57

that we know. What? respect

30:00

and disagree a little bit in this and

30:02

that when Mike you have the privilege of

30:06

stating this and I think we should always be honest with

30:08

our patient absolutely. So when

30:10

you start to talk to patients

30:12

honestly about not knowing and what

30:15

those outcomes are most of your patients

30:17

referred in to you and you're the last

30:19

hope. When I see patients they go you're

30:22

my last chance. The patients that we see on average

30:24

of that three and a half failures and they're like

30:26

you know and so whatever you tell

30:28

them they're like we're gonna be with you no matter what

30:31

and so physicians should be

30:33

honest and no question about it but you

30:35

have the privilege of I mean they're with

30:37

you no question. The how we

30:39

get follow-up is we often especially in patients who

30:41

are from out of town we work with we'll

30:43

work with their family doctors and

30:45

we basically exam is what we go by. It's

30:47

hard to get patient-free images, it's hard to get

30:49

insurance companies to pay for it and

30:51

then it's hard to do it in really organized

30:53

way where the numbers actually mean something. So if

30:55

you get 20% of your people you get CT

30:57

scans and 40% of them

30:59

you get a physical exam and so

31:02

what does all that mean? I mean you can make

31:04

something out of that but for

31:06

the most part go by a physical exam and if someone

31:08

complains of something then we'll CT them or

31:10

we'll ask for them to be seated. I

31:13

want to see the films and there's lots written

31:17

discussing whether a radiologist sees or herniated or

31:19

doesn't see a hernia and Mike's actually written

31:21

some interesting things about hernia surgeons looking

31:23

at CT scans but hernia surgeons looking at

31:26

CT scans are better diagnosing hernias than radiologists

31:28

are because they don't really look at them

31:30

or look for them. They're looking for

31:32

your cancer or your adrenal mass or whatever and

31:35

so we work with the family doctors

31:37

and physical exam and quality of life

31:39

lures us to like get a deeper

31:42

dive in these patients absolutely.

31:45

We want to learn from this and we won't give ourselves

31:47

a pass and when I talk to patients every single patient

31:49

I talk to I said the reason I can talk to

31:51

you like this is because the patients who came before you

31:54

we've tracked 22,000 patients and the patients who

31:56

come before you have made me a better doctor because

31:58

I give myself a work hard at every opportunity.

32:01

And I have gotten better and strive

32:03

for a good report card and this keeps

32:05

me motivated, keeps me honest and also the

32:07

changes that we've made over the last 25

32:10

years that we can track those compared to what

32:12

we used to do and all of

32:14

this it's it's it you

32:16

don't want to you don't want to live in suspended

32:19

animation in your practice. You want to keep

32:22

learning from your own practice and you can

32:24

learn from people like Mike, perhaps from me,

32:26

you can learn from other experts but even

32:28

if like you compared to like computer chess,

32:31

the stock fish that learned from all the

32:33

masters games and beat the international champion then

32:36

played Alpha Zero which was Google's

32:39

computer game that played itself

32:41

over and over again, learned its

32:43

own weaknesses, never learned anything but the rules

32:45

that played itself, Alpha Zero then beat stock

32:48

fish 28 times in a row. And

32:51

so you can learn from us and get better

32:53

but learning from your own mistakes and your own

32:55

data is the best way to grow. And again,

32:57

I'll fall back to like you want to learn

32:59

from your own data? I mean you can plug

33:01

into the the quality collaborative and be able to

33:03

track your own data pretty effectively and efficiently. So

33:07

how do you guys

33:09

think we're doing? I mean I think so I

33:12

think this I'll preface this by saying I think it's

33:14

a super exciting time for I

33:16

mean her knee surgery is sexy. I

33:18

mean when has I don't

33:20

think her knee surgery has ever been as sexy as it is

33:22

right now. With there's all

33:24

these online communities all

33:27

these online communities new techniques videos.

33:29

Everybody's excited about surgeries. You guys

33:32

know that our both the the

33:35

pony of the monsters that are

33:38

at these tertiary refers rural centers.

33:40

What do you guys see in it collectively? What's your

33:42

sense of how we're doing as a community? Do

33:45

most surgeons understand the basic principles? Are

33:48

we following the core principles of hernia surgery on the

33:50

whole or do we have a lot of work to

33:52

do? I

33:54

mean I so it's I mean I'm

33:56

gonna steal a line from Todd like

33:58

we're both Those are sitting at the

34:01

bible and fall. So. Are our lives

34:03

and our perspective on the world is

34:05

busy. Stated that as take it. didn't

34:07

share the say I I. I.

34:09

Would say that it is. Equally.

34:13

Exciting to me how sexy

34:15

hernia surgery has become. But.

34:18

Equally concerning to me.

34:20

That the side effects of that and

34:22

the potential influences. Upon surgeons

34:25

in some the choices that they

34:27

make an understanding. Who's. Driving

34:29

the conversation. Who's driving the bus and

34:31

so I think it's just like as

34:33

it always comes back to me. it

34:35

Just understand yourself. Understand.

34:37

What You're doing. I don't agree with

34:39

to as I got it isn't there from his

34:42

age celebrate although as discussed. Upset with

34:44

your clumsy meet? I'm a be brand of the matter

34:46

what I say. They're. Just like signed

34:48

the I'm So So that's important to acknowledge

34:50

that. But. I also like maybe

34:52

I would a backwards of like when

34:54

somebody comes with. The. Newest technique,

34:56

the newest mass, the newest layer

34:58

to put the mesh, and that

35:00

the whatever. To. Stick with a

35:02

grain of salt because we don't know. right?

35:05

Is so you don't need to be rapidly going.

35:07

I was actually gonna. I do think. That.

35:10

I would city that what

35:12

concerns me the most about

35:14

for new surgery today is

35:16

that we are applying very

35:18

advanced techniques to somewhat routine

35:21

hernias. Both. Ultimate a robotic

35:23

eight and Steiner a bash on a

35:25

robot but that in all different ways.

35:27

Adding understanding the thresholds of when we do

35:29

say is in in like. If

35:32

you listen to us, talk about what we do

35:34

every day. Yeah. Do a big

35:36

abrasives everyday cause that's I will ever get

35:38

to see anymore. Big Earnest. But. If

35:40

I see a small hernia. I'm. Gonna

35:42

lie by apart by law but I still get

35:45

to see those cases very much anymore. I.

35:47

Am butter make big deal out of that and and

35:49

kill myself to get a mass. Outside

35:51

the Pair Academy so so I

35:53

see. That. With

35:55

the lack of good data to

35:58

guide these decisions, just. The

36:00

he had some of these newer things just.

36:02

Taking. A pause. And letting the

36:04

data build up before we'd rapidly adopt them.

36:07

Is. Probably best for patients

36:09

because. I'm. Sure dies say damn

36:12

it. Is the preset a

36:14

my practice. Is. Really do tars

36:16

and redo retro. massive surgery was is

36:18

challenging, complicated it and the results are

36:20

not very good. And they're

36:22

out of operations and the patients. Are

36:25

being hurt I'm in many places are being

36:27

helped. Don't. Want to? Undersell? Don't

36:30

undersell that. But. That. A lot of

36:32

people being hurt by where this field is going.

36:35

I think that in will need to fall

36:38

just adept with one Mike said as the

36:40

technology is not useful and towards boring. And

36:43

so where are the issues that we haven't surgery

36:45

and and and I'll do say a lot of

36:47

space in this as humans. But. Surgeons

36:50

are compelled of surgeons heavy go

36:52

surgeon serve. Don't. Want to be

36:54

last in the pool? And. So the but

36:56

know what we need to do is like if he

36:59

can take robotic surgery. When it came out. And.

37:01

He allowed people jumping the pool and swim or held

37:03

on. Figure out how this works. When. What

37:05

we should do is let some really town people.

37:08

Do get in the or work it out. Tell.

37:10

Us. How to use it? And.

37:12

Then go from there, And. So technology

37:14

and is to be wins boring. It's useful

37:16

and didn't mean same thing. Their message has

37:19

come out and will be. no data whatsoever

37:21

and is. One particular mashup was launched in

37:23

two thousand and Thirteen. No doubt it until

37:25

Two thousand and Eighteen Hundred Sixty Three Eight.

37:27

It is a hundred sixty five million dollars

37:30

spent on his mastery. Nine thousand patients treated

37:32

and we had zero data points. Not a

37:34

clinical data point. That's not the

37:36

mess company problem As a surge about. And.

37:39

Even used backup What? Mike said, an ad

37:41

and and I think that we're doing better.

37:44

And whatever it is, I think we're doing better.

37:47

Ask about your question. Is. If

37:49

you look at the data, we're actually now. when

37:52

there's a puzzle effort started this were

37:54

putting more complications and more recurrences new

37:56

say well how the better i think

37:58

because we're being honest Until

38:00

surgeons become honest in their data reporting, you

38:02

can't get better. One of

38:05

the first times I was ever in the American Heart Aid

38:07

Society, and I won't give specific numbers, but if someone was a

38:09

surgeon who stood up at the front of the room in 400

38:11

cases and no recurrences and

38:13

every one wound complication, everybody was

38:15

just like perfect. And I

38:18

was standing back and I said, we should

38:20

stop everything we're doing going forward because that's

38:22

perfect. We should do that repair forever. But

38:26

being honest and presenting data like this paper that

38:28

Jeff Janis and these guys put together, what they're

38:30

trying to do is be honest with us and

38:32

here's the data we have. It's not very good,

38:34

but this is the best data we got. So

38:37

let's talk about it. But

38:39

I also think that we're producing some

38:41

pretty good hernia surgeons out of my

38:43

ex-fellowship is fantastic and you've got Igor

38:45

and Yuri and Kristy Harold and some

38:48

others around the country really producing

38:50

some true hernia superstars and

38:53

they're diffusing around the country and I think

38:55

we're going to see an improvement, but we can't and

38:57

people like that are free of fellowship, big hernia

38:59

train can't fix all the hernias. We couldn't fix

39:01

all if we wanted to and

39:03

it is our responsibility to train good general surgeon,

39:06

the best operations performed at all. And

39:08

so the good general surgeon can do it in

39:10

any operation in their home hospital,

39:12

it needs to be performed there and it's up to

39:15

us to help train people to

39:17

do that. I'll

39:19

echo what Todd said just to, I think this

39:21

may be like worth discussing too about like what

39:24

should the average general surgeon be doing? Should we

39:26

be having a sense of excellence? That always comes

39:28

to that. I want to like completely

39:31

agree with Todd too. I mean like you

39:33

cannot take away hernia surgery from general surgeons.

39:35

I mean this is their bread and butter,

39:37

meat and potatoes. It is

39:40

completely unrealistic. So

39:42

what I would say, what we

39:44

should stop doing is

39:46

telling the kind of

39:48

real general surgeons out there that

39:51

you need to do some of

39:53

these advanced complex procedures for

39:55

what they can repair with their routine

39:57

methods right now. The

40:00

hard to draw the line was something

40:02

becomes complex but we all know it.

40:04

will. We see it in so complicated

40:06

things? Yeah. Those. Should go to the

40:08

satirists where people do the stuff all the tide.

40:10

Just like we don't have centres of excellence opaque

40:13

rak surgery, As offers ya cancer

40:15

surgery. Because we just accept does a really

40:17

hot operation most you been a lot to do. It

40:19

it is somewhat of a natural thing in

40:22

hernia surgery that when things are truly complicated.

40:24

Most. People don't want to deal with that. The yeah, we have. Your

40:27

spouse insults in a very interested in it. I

40:29

think we have to be careful because. He.

40:32

Not take away. The

40:34

lifeblood and how these people see

40:36

their families. Were. Doing john

40:39

surgery and sixty? Hurry as and

40:41

let them. Do. Their online

40:43

let them do their open I

40:45

palms for small routine hernias. It's.

40:47

Okay, And the results

40:50

suggest that. For. The routine things

40:52

as a fine first approach. So.

40:55

When it comes to

40:58

ventral/incision harness specifically. What?

41:00

Is routine I'd soft toy fair question book

41:02

to to some degree what is your teen

41:05

and then when it comes to let them

41:07

or the core principles to approach he knows

41:09

patients in terms of work on. And.

41:11

Then decision making when it comes to

41:13

types of repair, And again,

41:15

that's a at broad but there are

41:18

some core principles I know that I've

41:20

heard both of you talk about that

41:22

would love to hear. I'll.

41:25

Just say that the source. Had

41:28

truly the core principles who are taught to

41:30

basis all the time. When I tell them

41:32

it is there to think that are super

41:34

it wouldn't One is about when gulf coast

41:36

since if I can eliminate the instruction and

41:39

you. And. I have an infection and

41:41

you'd my legs were currently on one times. And.

41:45

An. Idiot you fancy close. By don't

41:47

Get Your Bachelors A recurrence eight seven times

41:49

higher. Long term. And

41:51

I got any to put abroad is about behind

41:53

You're gonna warn. Him. And we we've seen

41:55

in we do a lot of preparing your honey

41:58

or appears more recent we found a pre. Your

42:00

meal and into even more return honeys we can.

42:02

You're preparing order better and over nine percent of

42:04

those stations. And is because

42:06

we can put a broad piece of messenger

42:08

admin. And site for the purest

42:11

of necessary and it goes wide as

42:13

you want a in his patients and

42:15

it by can get those core things

42:17

done when I talk to patients than

42:19

a chance of not every Hertz. Hertz

42:21

is really high. So. We've

42:24

worked out what. Nash, New. Works

42:26

really well for us as far as probably mess

42:28

goes in those sorts of things. I.

42:30

We stumbled a little bit in the past using

42:32

lightweight National Events Eleven and we saw that of

42:34

course I saw know that we've eliminated that with

42:36

our follow up. But. Those are

42:39

the three the core principles and then you

42:41

can go back to or how you decrease

42:43

your when complications of do you get the

42:45

fashion close What mashed you choose what plainly

42:48

put it out in In around those three

42:50

principles you can wrap around the other court

42:52

issues. They. Make for good on European. Yeah.

42:57

I think I would say I'm adding that the

42:59

most important core principle of any sort of first

43:01

be a good doctor and so like a as

43:04

as Taza at. Are they make

43:06

sure you're basing his his optimizers? they can

43:08

d and that are sick or chips or

43:10

so and. We. Don't want to delay

43:12

or withhold surgery. But. You the to

43:14

Deca doc because you're there and I take.

43:17

I like to tell basis that Greece to

43:19

use it every operation night. As patient

43:21

that as a surgeon. And there's a prosthetic. At

43:24

it. If you write those three

43:26

it ordered. I. Think probably the

43:28

surgeon is number one. That. Has so.

43:31

Whatever. Layer you put the

43:33

measure with your old and lab or of lot.

43:35

whatever you do. You are doing

43:37

good surgery. The results are

43:39

probably to be despised. For. The

43:41

right patient in one. And the

43:43

right size detect the Odyssey. There's all the letters

43:45

of the size of the whole. It

43:48

well you did really the says it at

43:50

all that I will say again since before

43:52

I just reiterate I do think to there's

43:55

been a trend. To. Blurring

43:57

the lines between for open

43:59

complex, This is. Reasonable. Question

44:01

whatever best you choose. It's.

44:03

Probably better the red mosque in the position.

44:06

But. Apply those principles, To.

44:08

Small routine hernias. I think that's a

44:10

bit of an overstep. To. Go it

44:13

using minimization. A approaches. I

44:15

think that if there was one thing out says.

44:18

Gets. A small room to harness the layer

44:20

of the bastards you put it in. Is.

44:22

Probably overstated seen this.

44:25

Dagger. Or yes, No. Question

44:27

about. But. But it bigger.

44:29

Who's worried about the section and I'll

44:31

stop when you already it was them

44:33

on de Gar discussed Ross you numbers

44:35

are concede lesson five to seven centimeters

44:38

of with. I. Would say is it

44:40

is inside Center is probably a. Small.

44:42

To me recently that all the am I

44:44

was awesome Debatable. Seven. Assists:

44:47

T. Is where it better

44:49

be prepared to do some extra things

44:51

and aging overseas t. This. Better

44:53

be something you do quite a bit. So. Let's

44:55

talk about that seven to fifteen really quick because

44:57

I got an interesting. Place. To

45:00

be when it comes to. I'll

45:02

stick with an open venture on says on

45:04

repair. Seven. Centimeters

45:06

greatest with. May. Be

45:08

a small back containing second hernia.

45:11

Will. The farther up. At. The midline.

45:15

Was a again New York when I can hear

45:17

what you're trainees. You. Look into C

45:19

D stand space is gonna be a my thirty

45:21

five. no major other major from a bit it

45:23

is. This. Is our of recurrence

45:25

is no mass and know process, no prior

45:27

mash. Had

45:31

you after that and docket minute cancer You

45:33

mentioned Rex Erectus. You mentioned Amazon? And

45:35

actor and of her demented specific mess types

45:38

of money comes a permanent massive Learn things

45:40

over time. Wax.

45:42

Poetic, a bit on that patient and

45:44

in again as a Ramsey A rebate

45:47

Different and very highly specific, but. God.

45:51

You I target for as I type it I got. a

45:54

certain the to work with am i thirty five

45:56

and them and that there are other things i

45:58

would go into this and And one would

46:00

be is like how much is outside the abdomen? You

46:05

can have a seven centimeter defect and you can

46:07

have tremendous loss of domain through that. Or

46:10

is there just a small bulge? And

46:12

also too is, you mentioned no comorbidities.

46:14

What does the abdomen look like? What's the

46:16

skin look like? Those things play a role.

46:19

If you're gonna do a minimally invasive surgical

46:21

repair but the hurting comes right up to

46:24

the skin, you have really thin

46:26

skin over the top of it. That goes

46:28

into my decision making of open or laparoscopic

46:30

or even possibly robotic. But when I'm

46:32

looking at this patient and talking to

46:34

him, one BMI of 35, for every point of BMI

46:36

greater than 26, not 25 for us,

46:38

but 26 and looking at our data. And now

46:40

we repeated our data with 1800 patients. And

46:43

again, if it was a BMI, anything over a

46:45

BMI of 26, you slightly increase your chance of

46:47

wound complications. So I have some more than a BMI of

46:50

35 or a BMI of 31 or

46:52

a BMI of 30 and I'll say, can

46:54

you lose a little weight? I'm gonna hedge

46:56

my margins in everybody. I mean,

46:58

you guys are pretty fit looking right here. And I'll just

47:00

say, dude, can you probably lose a little weight for me

47:02

before I've read on it? Cause we're gonna

47:04

drop the BMI point, it decreases your chance

47:06

of overall complications by 6%. And

47:09

so that person, can you lose weight for me? I

47:11

will find and I'll say, any weight you can lose

47:13

will help me. The other consideration

47:17

is as far as mesh choice, in

47:19

that patient, I'm gonna use a permanent synthetic. And

47:22

most often with our data, it

47:24

would be a polypropylene, in the mid-weight polypropylene

47:26

mesh in that space. We're gonna

47:28

most often, we will, Mike, we

47:31

did lots of lapis, Kevin Dventrale, hernia pears

47:33

when you were in Charlotte. But in this

47:35

space, in this patient, typically we do an

47:37

open pre-pare at Neal, the rectus muscles, I'll

47:39

look at why the rectus muscles are. That's

47:41

my fall back. If the rectus muscles are

47:44

four centimeters wide, like Dr. Rosen's, I'm like,

47:46

I'm not doing, I'm gonna have to be just

47:48

thick. Thick, okay. I'm not

47:50

doing an air pair. I

47:53

mean, we're gonna do a pre-pare at Nealward pair. And

47:55

like, if you're gonna do something, one of

47:57

these robotic repairs, like rectus,

48:00

wouldn't fit either. So looking at

48:02

the width of the rectus muscle makes a difference and

48:04

helps in my planning. Previous operation, then can we get

48:06

in a pre-peritoneal plane and then

48:09

I ask the patient what they want. Does the

48:11

patient actually need an operation? One thing

48:13

we know, if you have a 7-centimeter defect, let's

48:15

just say the 7-centimeter rectus vector and you mention

48:17

a hernia a little higher up like

48:19

it's in a laparotomy incision but they got one

48:21

hernia and then another hernia above it, what

48:23

you would expect over time is that your oblique

48:25

muscles are going to pull that wound

48:27

open. And so they're going to

48:30

slowly tear this wound open. That's how hernias

48:32

get bigger and bigger over time. They're going

48:34

to compress your abdomen and we've seen

48:36

in patients in this description, is the patient watchful

48:39

waiting appropriate in this patient? My

48:41

response to that is no. I mean

48:44

we're going to do watchful improvement in

48:47

getting this patient ready for surgery and

48:49

then I will tell the patient you're going to need

48:51

to have an operation because your hernia

48:53

will get larger. No question. And

48:55

we found we followed almost 1200 patients

48:57

with multiple CT scans. 18

49:00

months, the average increase in size

49:03

of the hernia was over 80 square centimeters

49:06

and over 18 months, 80 square centimeters increase in size of the

49:08

defect and also 550 cubic

49:16

centimeters of loss of extra

49:19

abdominal hernia volume. So

49:22

now what you've done is created another

49:24

animal. These are in lab patients who

49:26

have previous laparotomies. And so if you've got

49:28

a small primary hernia, that's not going to grow very

49:30

quickly. And a couple of people at

49:32

the gas service say that the rest

49:34

of the fascia is intact and it hasn't been

49:36

lacerated, hasn't been injured. It's not crystalline in its

49:39

healing. But these hernias will get larger

49:41

over time and that data was done by

49:43

Katie Slasher when she was in our lab and

49:45

published in surgery and our research on dioskopoeia

49:47

rather and I'll tell you it really changed my

49:49

approach to patients. So when we tell patients to

49:51

get ready for surgery, smoking, diabetes, weight loss

49:53

and those sorts of things, we

49:56

now call the patients you

49:59

typically a four six weeks, how are you doing, how's

50:01

your weight loss, what how can we help you. Here

50:03

you go, here describe, we previously described the ketogenic diet

50:05

as working for you, if it's not working for you,

50:08

we'll advance to a dietician, if that doesn't work for

50:10

you, we'll advance you to a bariatrician, kind of talk

50:12

directly to you, to your endocrinologist, your family

50:15

doctor to help you get to the point

50:17

where you're an improved surgical patient expecting

50:19

better outcomes because we've pre-habited

50:22

you, but we're gonna keep chasing those

50:24

patients now. We'd also go get yourself right and

50:26

come back when you're right. The

50:28

people who come back live tremendous hernia, that's

50:31

your experience Mike. Yeah

50:33

I mean I think I'm pretty similar, so listen,

50:35

semi-senator defect back in the day, no question that

50:37

would be a lot ventral, but I think

50:39

again like the same stories we're having now that

50:42

venture was overused, it depends on the swan way

50:44

too far. So for me if it

50:47

was just that little defect up high in

50:49

the BMI of 35, that'd be a lot

50:51

of ventral for me, like a two to

50:53

three centimeter defect in an obese patient that's

50:55

symptomatic, that's to me that's

50:57

a perfect lab ventral, eye palm

50:59

candidate, seven centimeter defect, that's gonna be too big for

51:01

me. So I actually

51:04

I want to like expand on one thing

51:06

that Todd did mention which is the minute

51:08

you start messing around in the retral and

51:10

muscular space, whether open or robotic, when

51:13

you're not as experienced with it, what

51:15

you realize is when people have a

51:17

hard time understanding is, and

51:20

we've done some work on this, that

51:22

when you release the posterior rectus sheet

51:25

to do the retrorectus

51:27

dissection, that's helping the midline

51:29

come together, but it's

51:31

not helping the posterior sheet come

51:33

together. And so as soon

51:35

as you mess around in the retral

51:37

muscular space, the Achilles heel

51:39

of all retro muscular surgery, tars,

51:42

all that stuff, this posterior sheet

51:44

breakdowns, and then you get these

51:46

internal hernigas with bowel and mesh. So

51:49

what the surgeons often find, open or robotic, is all

51:51

of a sudden the posterior sheet won't come together, and

51:54

now you're stuck in a tar where perhaps you don't

51:56

know how to do it, you're not as experienced, and

51:59

you're compromising. So I actually think

52:01

this is a Subway example of. This.

52:03

Prepared the a hernia repair. the has

52:05

on challenges but. It. Of leads.

52:08

Having. A mess with the facile

52:10

releases. So. That you didn't

52:12

get post your seat closer into your

52:14

extra muscular. Or extra pair to

52:17

the old sublet a repair so get. A

52:19

effort meet me personally. I

52:22

get a less direct. Muscles were very

52:25

wide, like nine ten centimeters. Gb

52:27

uncommon in a hernia operation. Then.

52:30

The that patients probably be and the tar.

52:32

And I won't compromise. is a sushi

52:34

closer and that gets to like Is

52:36

that over treaty? Seven. Centimeter

52:38

hernia and. As. A fair

52:41

critique. An idol. Promote. That

52:43

for everybody. A Certainly if you

52:45

have led the toolbox, either prepare the or. Or.

52:48

Tar is acceptable to, but you're probably gonna

52:50

be doing a tar. Because.

52:52

It a plus your seat. Not.

52:54

Because of the. Trying. To get a

52:56

couple of separation get the fashion get. This

52:59

one day I'll say as a kid get the

53:01

poster City other you were raised described actually suit

53:03

in the a mental to the edges of the

53:05

post right to sheath and use the amount of

53:07

did he has Richard intention. Stages. Like

53:09

a decision. Vehement and to keep the bow

53:11

added that space. Choose what mess you want.

53:14

And. The immense him with inventum stick to of

53:16

I'll probably mesh of course will with a bow

53:18

will come in there and you prevent these I

53:21

interstitial honey a smooth out a failure, the post

53:23

right to shoot and other than you can do

53:25

that he cut the honey a sack off. And

53:28

stitch that in there. You'll.

53:30

Need a like buy an expensive absorb will mash

53:32

and put it in. They are by for mash

53:34

or something that's worth. It. Just use what

53:36

the body gave your for the most part and instill

53:38

in that space. Or as easy

53:40

enough, I'm the I just like Botox. And

53:43

we used. As. I mentioned. That

53:46

required Like a three core principles in we can

53:48

do about wound issues and skin and we may

53:50

as a skin there's other for principles but. The.

53:53

Getting the admin closed Know cup

53:55

know that when calvin cases or

53:57

eliminating fashion. Did. In the edwin closed

53:59

and you. using mesh and so getting the

54:01

abdomen closed and so the way we get

54:03

the abdomen closed number one is weight loss

54:06

and we're we press all people to the

54:08

weight loss we teach them by the ketogenic diet I

54:10

never thought in my whole life I'd be talking to

54:12

people about what they eat how they eat and

54:15

the ketogenic diet and what it means to like we

54:17

were a hundred gathers for 75,000 years

54:19

and all that kind of business but

54:22

we try to influence people for weight loss and

54:24

weight loss I mean you will

54:26

decompress someone's abdomen make them healthier make

54:29

some a better patient you decrease risk of infection and

54:31

you get their abdomen closed the

54:33

other consideration that we will do is

54:35

Botox and so we use a lot

54:37

of Botox now it doesn't work for

54:40

the European Hernia Society M1 hernia it's

54:42

a sub xiphoid hernia because it won't

54:44

release the muscle off the costal margin

54:47

lower in the midline it actually

54:49

works pretty well it's not an end all be

54:51

all and there are often patients that we will

54:53

actually do Botox but also have

54:56

to elect a unilateral component separation for the

54:58

really big defects but do I think it

55:00

helps us I think by looking at our own data and

55:02

so it is just published something on this we indeed

55:05

we can now with this AI project he's

55:07

done we can predict who Botox will help

55:09

us with it's not approved by the

55:12

FDA getting it to insurance is difficult but

55:14

our data is really pretty convincing that

55:16

in lower abdominal hernias it can be

55:19

super helpful you

55:21

ejected it in your clinic you have an IR do

55:24

it you doing it six weeks out I'm

55:26

four weeks two months you

55:28

know so we yeah so we got Rob Rabel

55:30

and Bob Lopez two of our radiologists who do

55:33

it for us and we got as a comprehensive

55:35

hernia center these guys have been with us and

55:37

working with us for 15 years and

55:39

they make a lot more money by reading MRIs and

55:41

CT scans and that sort of stuff but they love

55:43

to do this with us and they they

55:45

are part of our group a big part of our

55:48

group actually they help us with a lot of things

55:50

that either to sweep up behind us or get patients

55:52

ready for surgery but and there are surgeons who are

55:54

that that will get anesthesia the pain specialist to do

55:56

the injection because they have ultrasound and are good at

55:58

that sort of thing or they do it

56:00

themselves? All

56:04

right, last question and we'll get this wrapped up.

56:08

What about the the patient in

56:10

clinic that you're particularly worried about

56:12

a strangulation? Let's

56:14

say particularly obese BMI of

56:17

40 or 50, bad

56:19

knees, won't lose weight, can't lose weight. Maybe

56:22

they already even had a bypass and it's

56:24

failed and they're going to be a

56:27

heavier regardless and they

56:29

have a nice,

56:31

perfectly sized midline

56:34

ventral nirnia that they came

56:36

to the ED for a few

56:38

weeks ago because small bowel had slipped right

56:40

into there and had become incarcerated and it

56:43

was fortunately reduced. How

56:46

do you think about those patients and what your obligation

56:49

as a surgeon is to them when

56:52

you know that failure is

56:54

near imminent with any type

56:56

of surgery? But you

56:58

do want to avoid a catastrophe

57:01

as well. I'll take on

57:03

that. My take on that, I do

57:05

so I completely agree with everything

57:08

that Todd said. I mean, listen, weight

57:11

loss and hernia patients beyond

57:14

hernias when you have a patient lose

57:16

weight, it is the

57:18

most rewarding thing you can do for another human

57:20

being. I mean, anybody who's ever taken care of

57:22

patients knows that. So like, let

57:25

me just start by saying that. But

57:28

I also think that the

57:30

pendulum has swung a

57:33

bit too far that I

57:35

will occasionally see people who come in with neck fash

57:38

who have seen a surgeon multiple times with a BMI of

57:40

38 and a very symptomatic

57:43

hernia that eventually comes in with a dead

57:45

piece of bowel. I think that's equally wrong

57:48

to let that happen. So my

57:51

recommendation to everybody out there in the real

57:53

world who's taking care of real people and

57:56

maybe doesn't have tremendous hernia expertise

57:58

is to There will

58:00

be operation right. So. Sometimes

58:02

you just gotta get these people

58:05

through this hernia of the end.

58:07

So. That they can go on and maybe

58:09

exercise a little bit for a year. Maybe.

58:12

Get A Life Together was having terrible

58:14

symptoms. Where. Did it is So I would

58:16

say there's one option. Is. It's a

58:18

small, tiny. He added

58:20

that all about their their a high be a my.

58:22

That. Of a small with three or four centimeter honey

58:25

in it. As the person to slip

58:27

into a lot by Bob. And. Then

58:29

like let them get, then set. Of than nutrition

58:31

is send him to die Do everything to I

58:33

mentioned. But. Six him if it's

58:35

a big veronica. That. I think

58:37

it's a little bit more complicated, didn't

58:40

I think sometimes. Going in there

58:42

and just close it primarily. In

58:44

getting and through this of that what's

58:46

could have sale like the study showed.

58:49

But. You know, a a year later. If.

58:51

You have a real hard to her conversation so

58:53

that. I'm. In a bristle? Do it?

58:55

Yeah. Operation on you today. So.

58:57

That a years of now. You'll. Be ready

58:59

for your outlaw rigid structure. They were do

59:02

x y z. But. We can't way.

59:04

That's okay, too hard on the road.

59:06

made like a bloody Korea. Was.

59:09

An of job is a masseur. I probably would do that.

59:11

Or. Even just pick see them doing the best you can

59:13

buy as he did. We.

59:15

Have gotten a little too out of control

59:18

with with was a say no to all

59:20

symptomatic or years now. And. I think

59:22

that's too bad so I think you can look at it.

59:24

As a stage approach. As a

59:27

teacher New bomb. As a recurrences

59:29

inhabitable by avoiding the dead bow a

59:31

bird seen in a bill that I.

59:34

It. Is something that will need a real look at.

59:37

It. He could fall been that

59:39

is one reason is one episode of

59:41

incarceration. Enough or maybe

59:43

no other sorts of incarceration, but again

59:45

own image and perfectly sized. Pizza.

59:48

For centimeter round defect where the small

59:50

bowels perfectly innocent there and get twisted

59:52

out and get stuck. on

59:54

of i know that about us if i use his look

59:56

at the city scare when it came in our as an

59:58

aside they had a good amid bows construction, where

1:00:01

they got an NG tube, one's enough for

1:00:03

me. Like I, it's

1:00:05

much more complicated in the really large hernia. So

1:00:07

like that's, we could talk about that for hours.

1:00:10

But just if you kick those out and you just

1:00:12

take the two to three to four centimeter

1:00:14

hernia that a piece of bile got stuck up there, which is

1:00:17

in reality the more common situation,

1:00:20

that those people, I think

1:00:22

you should give some consideration after

1:00:24

a heartfelt discussion of

1:00:26

why today they're not going to

1:00:29

get the grand slam, but

1:00:31

we need to make a commitment for the year. It

1:00:33

would benefit patients if we took that approach. But what do

1:00:35

you think? Because I know you've certainly evolved

1:00:38

into thoughts on weight loss. So like what, how

1:00:40

do you handle that? Because it is challenging. I

1:00:43

think what you said is right. And that

1:00:45

if you have a patient who's coming with a bowel obstruction,

1:00:47

has had a couple of bowel obstructions, their

1:00:50

BMS44, they got a supposedly

1:00:52

two to seven supposedly, it's not really good data,

1:00:55

but two to seven centimeter defects are the ones

1:00:57

that most more commonly get you in trouble. Those

1:00:59

are the ones that come out of the acute angles. I mean,

1:01:01

trying to predict who's going to be, get you in trouble and

1:01:03

not get you in trouble. Yeah. I mean,

1:01:06

you're more likely wrong than not. And

1:01:08

most of those patients don't get you in trouble. But

1:01:10

once they have, I think doing a laparoscopic repair in

1:01:12

a high risk patient, you got a guy

1:01:14

who smokes, who's, he said two bowel obstructions. I'm going

1:01:16

to tell you the accurate. I'm going to do a

1:01:18

laparoscopic repair. I'm going to do my best to do

1:01:20

a middle invasive repair and try to do my best

1:01:22

to get complications out of it. And

1:01:24

I'm going to tell him that his chance of recurrence at the BMI44 is at

1:01:26

least four times higher than an average

1:01:28

weight patient. But I'm going

1:01:30

to do my best to take care of you

1:01:32

so you don't have a bowel obstruction. But I'll

1:01:35

try and get him to step up and say,

1:01:37

yeah, I'll try and get my weight off, decrease

1:01:39

my recurrence rate, make myself a better patient and

1:01:41

those sorts of things. But I'm not

1:01:43

going to let Mike off the hook here. I tried,

1:01:45

what I'm going to do is I want to be a doctor. And

1:01:49

so my favorite, like someone asked me at a

1:01:51

meeting not too long ago, like tell me your

1:01:53

best case this year. And it's

1:01:55

super easy. A young woman

1:01:57

with a BMI41 with two young children and she's

1:01:59

plugged. She's had three failed her hands. Her

1:02:01

husband's morbidly obese and he smokes. And

1:02:04

she lost pretty

1:02:06

quickly with exercise and ketogenic diet stuff. She

1:02:08

locks over 60 pounds. She

1:02:10

now the BMI is less than 30. She stops

1:02:12

smoking. Her husband lost 60 pounds to stop smoking. And

1:02:14

then we fixed her honey. We did a panic like

1:02:16

to meet. And that's why you think it's a beautiful

1:02:19

case. It's actually it's a beautiful case because she lengthened

1:02:21

her life expectancy. If you look at the New York

1:02:23

time, the New York life insurance data and the framing

1:02:25

of the time study, she lengthened her life expectancy by

1:02:27

over 14 years. And

1:02:30

her husband by 17 years. And

1:02:34

so she influenced him and who knows what's going

1:02:36

to happen to their children. And there's a lifestyle

1:02:38

change. And then now she's caught fire. And now

1:02:40

she's actually continued to lose weight since I operated

1:02:42

on her. And so I

1:02:46

like I can reconstruct addons, but also what I want to

1:02:48

do is reconstruct lives. And if

1:02:50

I can use my podium as a surgeon and

1:02:53

they come in to see your family doctor, forgive me,

1:02:55

family doctors out there. And they say, oh, you got

1:02:57

all this weight. You got to eat right. We got

1:02:59

to get your cholesterol under control. You got to stop

1:03:01

smoking. It's like your mom and nagging on you a

1:03:03

bit. But when Mike

1:03:06

Rosen says you come in to see me, you

1:03:08

got your white coat on, you use that. I

1:03:12

mean, he's got a pulpit. He doesn't have like a podium.

1:03:15

It's a pulpit he can talk from. And

1:03:17

as surgeons, we should use that pulpit

1:03:19

to try and influence our patients to

1:03:22

do better and make their

1:03:24

lives better. And I don't have

1:03:26

a chance to save lives very much anymore. And

1:03:28

you only save someone's life for so long to the natural death.

1:03:30

Of course, if you run out in the street and save them.

1:03:33

But say, you know, extending someone's life for 14

1:03:35

years, I'll take it. I

1:03:38

will echo all of that. And I will say,

1:03:41

as Todd is well aware of, you

1:03:43

can stand up on a pulpit and do amazing

1:03:45

things or you can do bad things, too. So

1:03:48

you've got to be careful from the pulpit. But

1:03:51

this is such a challenging conversation

1:03:54

because I believe

1:03:56

in optimization. I have my whole

1:03:58

life and I believe. That

1:04:00

you change people's lives if you help them

1:04:02

get through this up and I believe that

1:04:04

the surgery is a teachable moment That we

1:04:06

should not that we should not

1:04:09

miss and miss our responsibility but

1:04:11

I also believe that we have to

1:04:13

look at it carefully thoughtfully and I

1:04:16

guess my message would be Absolutely

1:04:20

try to optimize patients, but

1:04:23

hard cut-offs might be where

1:04:25

we got on a wrong path My

1:04:27

patient who goes from 50 to 39 That's

1:04:30

a tremendous amount of effort making

1:04:32

it a hard cutoff for them to be 35. It's

1:04:34

probably not in their best interest I wouldn't do that.

1:04:36

Yeah, no, yeah I know you would but like I

1:04:38

think that's the message for people is like Have

1:04:41

be a good doctor because it's the both it's way better

1:04:43

than putting in mesh getting people to be helped But

1:04:47

just realize like work with them Be

1:04:50

with them and sometimes you gotta do what

1:04:52

you got to do But but it shouldn't be the first

1:04:54

move and I think it can swing too far

1:04:56

the other way where we just operate on everybody Which isn't right.

1:04:58

I Can't

1:05:01

help myself. So this patient then

1:05:03

are you obligated lab or scabric or robotic

1:05:05

approach? Five centimeter

1:05:08

hernia obese. Are you

1:05:10

obligated to close fashion? If

1:05:12

you're more certainly more fast out of it robotically are

1:05:14

you in a closed fashion do your whether

1:05:16

to true under live home? Or a pre-peritoneal

1:05:18

mesh placement. What are your thoughts on

1:05:20

that? You're not obligated close

1:05:22

fashion in this patient And

1:05:24

I will say is if you look at

1:05:27

if you go and look at the national

1:05:29

data from Denmark the national data from Sweden

1:05:31

And you start looking at I palm laparoscopic

1:05:33

ventral hernia appears. He do pretty well And

1:05:36

so you might go in from like I do an open

1:05:38

tour and then 999

1:05:41

out of a thousand patients. I'm just teasing

1:05:43

Mike, of course, but but using an appropriate

1:05:45

I palm ventral hernia repair Me

1:05:48

those patients actually do pretty well most of them

1:05:50

actually do pretty well. I Will

1:05:53

add to that so that I just said that because I

1:05:55

completely agree it's like we're all two old guys like nobody's

1:05:58

listen to anymore, so So listen,

1:06:00

the reality is, this

1:06:03

is one thing I would add to it, but you

1:06:05

have to select that patient well. And

1:06:07

to be honest, 5 centimeters would be

1:06:09

at my like upper limit of the

1:06:11

lab bipedal. It's safe for some reason.

1:06:14

It's like 2 or 3 centimeters with

1:06:16

the nuckelobal up there or something. That's

1:06:18

the perfect lab bipedal and I

1:06:20

do not close any of them. I put a

1:06:23

15 centimeter piece of mess, I cover

1:06:25

it and they do just fine.

1:06:27

Most of them are obese, they don't notice the

1:06:29

bulge or anything like that and they're

1:06:31

totally fine. I think if

1:06:33

you push IPOM to

1:06:36

larger deep, 7, 8, 9,

1:06:38

10 centimeter defects, then maybe you're going

1:06:40

to have to start seeing that bulging but they

1:06:42

should be at IPOM kit. That's the wrong

1:06:44

person. So it actually, if you

1:06:46

look at the best data out there is a

1:06:48

study by Mike Blaine that did a randomized control

1:06:51

trial to answer this question and

1:06:53

he found a statistically significant difference but

1:06:55

my only critique of that trial is

1:06:58

it was based on a quality of life

1:07:00

tool that was to make it simple. It

1:07:03

was on a scale of 1 to 10 and

1:07:05

the difference between the two groups was a 4 or a 5.

1:07:09

So like it's probably not clinically

1:07:11

relevant. And

1:07:13

I also bring this up because you mentioned

1:07:15

it. If you believe you

1:07:18

need to close the fascia of everybody, then one of

1:07:20

the things you've done is you said you must use

1:07:22

the robot to do all IPOMs because

1:07:24

there's no question, closing the fascia

1:07:26

with the robot is much more elegant. You

1:07:28

can do it laparoscopically, obviously you can soloing.

1:07:30

I guess that's my question then if you're

1:07:33

going to be doing more robotic surgery and

1:07:35

you have an opportunity to close fascia and or

1:07:37

as Dr. Hanover has mentioned, the beauty of a

1:07:39

pre-pairing needle space, is that a better – we

1:07:42

don't know. There's no right answer, we don't know answer this question

1:07:44

but is that a better repair than an open

1:07:46

fascia with an IPOM and a large overlap?

1:07:49

You could get a large overlap in a pre-pairing needle space

1:07:51

as well or even a sewing mesh

1:07:54

in a true IPOM space. So I will say,

1:07:56

and I'll fall back to if I can close

1:07:58

the fascia if I'm doing – a laparoscopic

1:08:00

ventral heart ear repair or robotic, I will

1:08:02

close the bash if I can. But in

1:08:05

a morbidly obese person with a

1:08:08

tense abdomen occasionally, you can't. And so

1:08:10

then I would just do an eye pump. I

1:08:12

didn't want to mention that. And

1:08:15

one thing we do know, if you do an

1:08:17

open repair with a protected mesh, and I believe

1:08:19

Michael will agree with this, then

1:08:21

the mesh infection rate is higher. And

1:08:24

so doing an open eye pump has a... And certainly

1:08:27

we've seen that. We published data recently

1:08:29

on that as well, using a protected

1:08:32

mesh in the prepretinal space as well,

1:08:34

is what we published versus a non-protective

1:08:36

mesh as a higher mesh infection rate.

1:08:38

So there is that. It

1:08:41

is statistically greater. It's not like all of

1:08:43

them get infected, but a small percentage of

1:08:45

patients will have an infected mesh.

1:08:48

All right. I'm trying to say I've done that. That

1:08:50

was too much. Yeah. This has been fed down with

1:08:52

you guys. We could talk for... I mean, Patrick and

1:08:55

I could sit here and pamper you guys with questions

1:08:57

about hernias for hours. I know it's

1:08:59

late there. I want to thank you guys for being

1:09:01

so generous with your time. I think this was extremely

1:09:03

helpful. Like we all

1:09:06

said, it's amazing. I've

1:09:08

heard people ask me about the study

1:09:11

from students to

1:09:13

patients to colleagues. It's

1:09:15

all over the Facebook groups. A lot

1:09:17

of people have questions about the study.

1:09:19

So we really appreciate your guys' expertise,

1:09:21

your experience coming on behind the night

1:09:24

and helping us unpack some of

1:09:26

these questions and waxing

1:09:28

poetic about hernias. We need to do this

1:09:30

again. There's a lot more to cover. So

1:09:32

thank you. Thank you. Thank you. Well,

1:09:36

thank you guys. Great time. Really enjoyed

1:09:38

it. Everybody, the virtual world, just

1:09:40

take a deep breath. Take

1:09:43

a deep, deep breath and dominate the day. Be

1:09:49

sure to check out our website at www.behindtheknife.org for

1:09:51

more great content. You can also follow us on

1:09:54

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1:09:56

Behind the Knife podcast. If you like what you

1:09:58

hear, please take a deep breath. a minute

1:10:00

to leave us a review. Content produced by

1:10:02

Behind the Knife is intended for health professionals

1:10:04

and is for educational purposes only. We do

1:10:07

not diagnose, treat, or offer patient specific advice.

1:10:09

Thank you for listening. Until

1:10:11

next time, dominate the day. Mo,

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