I think the key is to have a clear discussion of, uh, we don't want to cure one problem to create another disease. And so I typically start with those types of patients to say clearly that The best operation we have to prevent reflux is a Nissent fundoplication, and while it's a very good operation to let the acid not go back up, the pump of your esophagus doesn't work good enough to make it past that barrier.
I think you also have to remember that, and I said this before, but, you know, the benefits of laparoscopy are small for the vast majority of patients. Still worthwhile. But you have to check your minimally invasive ego at the door and make sure that you also can do opening oral hernias or in a patient who's a candidate, send it to somebody who can do opening oral hernias.
And so if you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon. It's that you didn't dissect out the space to put the mesh. And it's not because you have too big of a mesh. It's because you need to take out the mesh and dissect bigger.
I think the disadvantage of it is that you have to operate near the intestines, whereas open, you're in a separate plane. So there is a risk of intestinal injury. There's a risk of injury to the major blood vessels because you're in that area. But again, if you are safe and know those planes, that risk should be incredibly low.
If you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon. It's that you didn't dissect out the space to put the mesh. And it's not because you have too big of a mesh. It's because you need to take out the mesh and dissect bigger.
If you go back and read Stopa's original descriptions, his description, if you were doing a unilateral inguinal hernia was to never use less than a 15 by 15 centimeter piece of mesh or a 6 by 6 inch piece of mesh, which is much bigger than the vast majority of laparoscopic pre-formed meshes or or meshes that are being placed.
quoteI think like anybody who sent you with an inguinal hernia, first you want to do an exam and you want to confirm whether they have an inguinal hernia. I have to say that can be one of the hardest things to do because there are small hernias that on physical exam are extremely difficult to feel.↗
▶Ep 3 · 3:22
epidemiologicalIn Fitzgibbons' VA study of minimally symptomatic to asymptomatic hernias in patients in their 70s-80s, the risk of presenting with an emergency problem requiring operation due to incarceration or strangulation was less than 1% (actually one-third of 1%).↗
▶Ep 3 · 4:00
quoteSo it's safe to watch people. But the problem with this study is this study was over two years. Almost a third of the patients went on to develop symptoms and need an operation.↗
▶Ep 3 · 4:00
epidemiologicalIn Fitzgibbons' original two-year VA study, almost one-third of patients in the observation group went on to develop symptoms and need an operation.↗
▶Ep 3 · 4:20
epidemiologicalIn long-term follow-up of Fitzgibbons' VA study patients (approximately five years), almost three-quarters of patients developed symptoms requiring repair.↗
▶Ep 3 · 8:20
quoteI think that the right answer to that question would be defined based on the patient that you have in front of you. And I think equally, if not more important, based on your skill set and where you're at with the learning curve of all of these operations.↗
▶Ep 3 · 8:30
quoteAnd it's been shown in the literature that the best approach is what you do best.↗
▶Ep 3 · 8:40
clinicalThe learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200 to 250 cases required.↗
▶Ep 3 · 9:20
clinicalIn laparoscopic inguinal hernia repair, mesh is placed away from the nerves, and the risk of chronic pain when done correctly is lower than in open inguinal hernias.↗
▶Ep 3 · 12:10
clinicalLaparoscopic repair offers approximately one week to 10 days earlier recovery compared to open repair, not a month or three to four months.↗
▶Ep 3 · 12:30
quoteI think the disadvantage of it is that you have to operate near the intestines, whereas open, you're in a separate plane. So there is a risk of intestinal injury. There's a risk of injury to the major blood vessels because you're in that area. But again, if you are safe and know those planes, that risk should be incredibly low.↗
▶Ep 3 · 15:50
quoteYou have to check your minimally invasive ego at the door and make sure that you also can do opening oral hernias or in a patient who's a candidate, send it to somebody who can do opening oral hernias. Because if you're pushing it laparoscopically in a sick, comorbid patient, more often than not, it's because you don't feel comfortable doing it the opening of the way and you use your go-to move.↗
▶Ep 3 · 18:20
quoteI think the most important part of any laparoscopic repair, and it's a basic principle that Rene Stoppa promoted during open preperitoneal repairs, which is parietalization of the cord, which essentially just means stripping the peritoneum off the cord inferiorly and posteriorly.↗
▶Ep 3 · 18:20
clinicalThe most important part of any laparoscopic repair is parietalization of the cord (stripping the peritoneum off the cord inferiorly and posteriorly), a principle promoted by Rene Stoppa during open preperitoneal repairs.↗
▶Ep 3 · 18:40
clinicalThe risk of recurrence in laparoscopic repair is the peritoneum coming under the mesh and then going back out to the defect inferiorly.↗
▶Ep 3 · 18:54
quoteAnd the inferior dissection is the Achilles heel of any laparoscopic repair because it's awkward to view it. It's a little bit scary that you're going to start to make holes in it, and you're taking it very close off the vessels.↗
▶Ep 3 · 20:00
clinicalAccording to Stoppa's original descriptions, for a unilateral inguinal hernia repair, one should never use less than a 15 by 15 centimeter piece of mesh (or 6 by 6 inch), which is much bigger than the vast majority of laparoscopic preformed meshes being placed.↗
▶Ep 3 · 21:20
clinicalHeavyweight mesh is approximately 90 grams per meter squared (Marlex or Prolene mesh), midweight mesh is 40-50 grams per meter squared, and lightweight mesh (Ultrapro) is less than 30 grams per meter squared.↗
▶Ep 3 · 22:00
clinicalThe advantage of lighter weight mesh is less foreign body and potentially less contraction due to better ingrowth; the disadvantage is half the material, which in direct hernias where muscles never come back together puts the mesh at risk for fracturing.↗
▶Ep 3 · 23:00
quoteIf you're doing an inguinal hernia, I don't think you should ever use smaller than a large of those preformed meshes because you need to cover the whole myelope.↗
▶Ep 3 · 23:20
quoteIf you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon. It's that you didn't dissect out the space to put the mesh. And it's not because you have too big of a mesh. It's because you need to take out the mesh and dissect bigger.↗
▶Ep 3 · 24:09
clinicalThere is no evidence that absorbable fixation causes reduction in pain, better fixation, or improved long-term outcomes compared to permanent fixation.↗
▶Ep 3 · 24:20
clinicalIf absorbable fixation is put through a nerve, it is the neuroma that causes the problem, not the tack itself.↗
▶Ep 3 · 24:56
clinicalThere is mounting evidence that medium-weight polypropylene mesh can be placed in a contaminated field, with several series demonstrating this in ventral hernias.↗
▶Ep 3 · 27:00
clinicalFor incarcerated femoral hernias, the lacunar ligament can be released medially to gain an extra centimeter of space for reduction without destroying the inguinal floor or inguinal ligament.↗
▶Ep 3 · 28:12
opinionFor recurrent hernias, the surgeon should go where nobody has been before; if somebody has been in both places, go where you are best.↗
▶Ep 3 · 28:30
opinionFor bilateral hernias in a skilled laparoscopic surgeon, laparoscopy is the best approach.↗
▶Ep 3 · 28:40
opinionSurgeons learning laparoscopic inguinal hernia repair should avoid bilateral and recurrent hernias during their learning curve, although these patients might benefit most, they have the highest risk.↗
Inguinal Hernia With M. Rosen
▶Ep 4 · 4:40
opinionFor an 89-year-old with asymptomatic hernia, observation is appropriate because odds are in a couple years they might not develop symptoms, but in younger patients the odds are against them living the rest of their life without symptoms.↗
▶Ep 4 · 6:32
clinicalInguinal hernias can be repaired under local anesthesia in high-risk patients with severe comorbidities (cardiac disease, ascites, coagulopathy).↗
▶Ep 4 · 8:20
quoteI think that the right answer to that question would be defined based on the patient that you have in front of you. And I think equally, if not more important, based on your skill set and where you're at with the learning curve of all of these operations.↗
▶Ep 4 · 9:20
quoteWith the primary reason that there is one difference in skilled surgeons' hands that seems to be consistent, is that laparoscopy, you're putting the mesh away from the nerves, and the risk of chronic pain in laparoscopic inguinal hernia repair, when done right, is lower than the risk in open inguinal hernias.↗
▶Ep 4 · 9:20
clinicalThe primary advantage of laparoscopic repair is placing mesh away from nerves, resulting in lower risk of chronic pain compared to open repair when done correctly.↗
▶Ep 4 · 9:50
epidemiologicalChronic pain incidence in open inguinal hernia repair varies depending on measurement method: very high if detailed surveys are used, lower if only counting patients who present with complaints.↗
▶Ep 4 · 12:10
clinicalLaparoscopic repair offers approximately one week to 10 days earlier recovery compared to open repair.↗
▶Ep 4 · 12:25
clinicalThe disadvantage of laparoscopic repair is operating near intestines with risk of intestinal injury and major blood vessel injury, though this risk should be incredibly low with proper technique.↗
▶Ep 4 · 13:20
opinionIn elderly patients or those on anticoagulation requiring quick restart, open repair is preferred to avoid dissecting the retroperitoneal space.↗
▶Ep 4 · 14:26
opinionIn a 78-year-old with symptomatic hernia on one side and asymptomatic hernia discovered laparoscopically on the other side, repairing the asymptomatic side doubles anesthetic time and increases hematoma risk without clear benefit.↗
▶Ep 4 · 15:50
quoteI think you also have to remember that, and I said this before, but, you know, the benefits of laparoscopy are small for the vast majority of patients. Still worthwhile. But you have to check your minimally invasive ego at the door and make sure that you also can do opening oral hernias or in a patient who's a candidate, send it to somebody who can do opening oral hernias.↗
▶Ep 4 · 16:26
opinionPrevious lower abdominal surgery increases risk of enterotomy and OR time for laparoscopic repair; if patient has not had previous open inguinal hernia, open approach is preferred.↗
▶Ep 4 · 16:55
opinionPrevious prostate surgery creates unpredictable difficulty for laparoscopic repair, ranging from straightforward to brutal; currently managed with open repair.↗
▶Ep 4 · 17:58
clinicalThe most important part of laparoscopic repair is parietalization of the cord (stripping peritoneum off cord inferiorly and posteriorly), a principle promoted by Rene Stoppa in open preperitoneal repairs.↗
▶Ep 4 · 18:10
quoteI think the most important part of any laparoscopic repair, and it's a basic principle that Rene Stoppa promoted during open preperitoneal repairs, which is parietalization of the cord, which essentially just means stripping the peritoneum off the cord inferiorly and posteriorly.↗
▶Ep 4 · 18:40
quoteAnd the inferior dissection is the Achilles heel of any laparoscopic repair because it's awkward to view it. It's a little bit scary that you're going to start to make holes in it, and you're taking it very close off the vessels.↗
▶Ep 4 · 18:40
clinicalThe inferior dissection is the Achilles heel of laparoscopic repair because it is awkward to view, risky for creating peritoneal holes, and close to vessels.↗
▶Ep 4 · 20:30
opinionFor large direct hernias, heavier weight mesh material should be used.↗
▶Ep 4 · 21:02
clinicalHeavyweight mesh is approximately 90 grams per meter squared (Marlex or Prolene), midweight is 40-50 grams per meter squared, and lightweight (Ultrapro) is less than 30 grams per meter squared.↗
▶Ep 4 · 21:50
clinicalLightweight mesh has less foreign body and may contract less due to better ingrowth, but has half the material and is at risk for fracturing, particularly in direct hernias where it bridges and muscles never come together.↗
▶Ep 4 · 22:30
clinicalHeavier weight mesh rarely breaks but can cause chronic pain if wrinkles or buckles are present in the groin.↗
▶Ep 4 · 23:00
opinionSurgeons commonly downsize preformed meshes; for inguinal hernia repair, never use smaller than a large preformed mesh to cover the entire myopectineal orifice.↗
▶Ep 4 · 23:24
quoteAnd so if you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon. It's that you didn't dissect out the space to put the mesh. And it's not because you have too big of a mesh. It's because you need to take out the mesh and dissect bigger.↗
▶Ep 4 · 23:24
clinicalIf struggling with mesh placement during laparoscopic repair, the problem is inadequate dissection of the space, not oversized mesh; the solution is to remove mesh and dissect more widely.↗
▶Ep 4 · 24:09
clinicalThere is no evidence that absorbable fixation causes reduction in pain, provides better fixation, or improves long-term outcomes compared to permanent fixation.↗
▶Ep 4 · 24:20
clinicalIf absorbable tack is placed through a nerve, it is the neuroma that causes the problem, not the tack itself.↗
▶Ep 4 · 25:10
opinionBassini or McVay tissue repairs remain appropriate operations for contaminated fields.↗
▶Ep 4 · 25:55
clinicalFor incarcerated femoral hernia with bowel compromise, an infrainguinal vertical incision allows direct access to the hernia sac, bowel resection if needed, and reduction without dividing the inguinal ligament.↗
▶Ep 4 · 26:35
clinicalTo facilitate reduction of incarcerated femoral hernia contents, the lacunar ligament (medial to femoral space) can be released with scissors or bovie to gain an extra centimeter, avoiding destruction of the inguinal ligament.↗
▶Ep 4 · 27:20
clinicalReverse McVay repair for femoral hernia involves taking the inferior border of the inguinal ligament and sewing it down to Cooper's ligament from below, starting immediately lateral to the femoral vein to avoid impingement.↗
▶Ep 4 · 27:46
clinicalMesh plugs in femoral hernia repair can cause DVT due to irritation of the femoral vein, particularly in thin women who typically present with femoral hernias.↗
▶Ep 4 · 28:12
opinionFor recurrent hernias, operate where no prior surgery has been performed; if both spaces have been operated, choose the approach where you have the most skill.↗
▶Ep 4 · 28:30
opinionFor bilateral hernias in a skilled laparoscopic surgeon, laparoscopy is the best approach, but surgeons learning laparoscopy should avoid bilateral and recurrent hernias as these are twice as hard despite potentially offering the most benefit.↗
▶Ep 4 · 29:09
opinionLarge inguinoscrotal hernias are managed with open operation; if truly incarcerated and cannot be reduced in office, open approach is used.↗
▶Ep 4 · 29:30
clinicalFor difficult-to-reduce but not truly incarcerated hernias, patient can be put to sleep for reduction under anesthesia, then TAPP repair performed; the internal ring can be cut laparoscopically at the two o'clock position (avoiding epigastric vessels) to facilitate reduction.↗
▶Ep 4 · 30:00
clinicalIf bowel holes are made during incarcerated hernia repair, the morbidity of the operation increases unacceptably high.↗
Inguinal Hernia With M. Rosen
▶Ep 5 · 2:10
quoteI think like anybody who sent you with an inguinal hernia, first you want to do an exam and you want to confirm whether they have an inguinal hernia. I have to say that can be one of the hardest things to do because there are small hernias that on physical exam are extremely difficult to feel.↗
▶Ep 5 · 4:30
opinionFor an 89-year-old with asymptomatic hernia, observation is appropriate because in a couple years they might not have symptoms, but in younger patients the odds are against them living without it becoming symptomatic.↗
▶Ep 5 · 6:32
clinicalInguinal hernia repairs can be done under local anesthesia in patients with severe comorbidities, and it is worse for them to present with an emergency problem in the middle of the night.↗
▶Ep 5 · 8:20
quoteI think that the right answer to that question would be defined based on the patient that you have in front of you. And I think equally, if not more important, based on your skill set and where you're at with the learning curve of all of these operations.↗
▶Ep 5 · 9:20
clinicalThe primary advantage of laparoscopy in skilled hands is that mesh is placed away from nerves, and the risk of chronic pain is lower than in open inguinal hernias.↗
▶Ep 5 · 9:40
quoteI think that how do you measure chronic pain in open inguinal hernias depends. If you do a very detailed survey, you'll have a very high incidence of chronic pain. If you just wait until patients come back and present with chronic pain, it will be lower. But those patients are absolutely miserable.↗
▶Ep 5 · 10:44
quoteI think the TEP pair, it's a little bit more expensive because you need to use the balloon. It's a little bit smaller of a space, but perhaps the angles are a little bit easier to operate with. I think a TAP, you get a little bit of a better view. You get a little bit more of a working space.↗
▶Ep 5 · 11:20
quoteThe way that I look at it is it's the same room. One comes through the front door. One comes through the ceiling. Ultimately, you work in the same space, and it should be the same operation regardless.↗
▶Ep 5 · 11:53
opinionFor young, healthy, active patients with unilateral hernia who are not anesthetic risks, laparoscopic repair is preferred in experienced hands, offering about a week to 10 days earlier recovery than open repair.↗
▶Ep 5 · 12:30
clinicalDisadvantages of laparoscopic repair include operating near intestines with risk of intestinal injury and risk of injury to major blood vessels, though these risks should be incredibly low if planes are known.↗
▶Ep 5 · 13:00
opinionIn elderly patients or anyone on anticoagulation who needs to restart quickly, open operation is preferred to avoid dissecting the retroperitoneal space.↗
▶Ep 5 · 14:09
opinionIn a 78-year-old patient with symptomatic hernia on one side and asymptomatic hernia discovered laparoscopically on the other side, the asymptomatic side should not be repaired due to doubled anesthetic time and increased hematoma risk.↗
▶Ep 5 · 14:58
opinionIn younger active patients, an asymptomatic contralateral hernia discovered laparoscopically should be repaired because the chance of it becoming symptomatic is much higher.↗
▶Ep 5 · 15:50
quoteI think that you also have to remember that, and I said this before, but, you know, the benefits of laparoscopy are small for the vast majority of patients. Still worthwhile. But you have to check your minimally invasive ego at the door.↗
▶Ep 5 · 16:26
opinionPrevious lower abdominal surgery increases risk of enterotomy and OR time for laparoscopic repair; if patient hasn't had open inguinal hernia, open approach is preferred.↗
▶Ep 5 · 16:55
opinionPrevious prostate surgery cases are unpredictable laparoscopically and can be brutal; in current practice these get open inguinal hernia repair.↗
▶Ep 5 · 17:58
clinicalThe most important part of any laparoscopic repair is parietalization of the cord (stripping peritoneum off the cord inferiorly and posteriorly), a principle promoted by Rene Stoppa during open preperitoneal repairs.↗
▶Ep 5 · 18:10
quoteI think the most important part of any laparoscopic repair, and it's a basic principle that Rene Stoppa promoted during open preperitoneal repairs, which is parietalization of the cord, which essentially just means stripping the peritoneum off the cord inferiorly and posteriorly.↗
▶Ep 5 · 18:40
quoteAnd the inferior dissection is the Achilles heel of any laparoscopic repair because it's awkward to view it. It's a little bit scary that you're going to start to make holes in it, and you're taking it very close off the vessels.↗
▶Ep 5 · 18:40
clinicalThe inferior dissection is the Achilles heel of any laparoscopic repair because it's awkward to view, scary to make holes, and taken very close off the vessels.↗
▶Ep 5 · 20:40
opinionFor large direct hernias, mesh choice should change to a heavier weight material.↗
▶Ep 5 · 21:02
clinicalHeavyweight mesh is around 90 grams per meter squared (Marlex or Prolene), midweight is 40-50 grams per meter squared, and lightweight (Ultrapro) is less than 30 grams per meter squared.↗
▶Ep 5 · 21:50
clinicalAdvantage of lighter weight mesh is less foreign body and less contraction; disadvantage is half the material with risk of fracturing, particularly in direct hernias where it's a bridge.↗
▶Ep 5 · 22:30
clinicalHeavier weight mesh rarely breaks but sometimes people feel it in their groin if there are wrinkles or buckles, which can cause issues.↗
▶Ep 5 · 23:00
opinionFor inguinal hernia repair, should never use smaller than a large preformed mesh because you need to cover the whole myopectineal orifice.↗
▶Ep 5 · 23:00
quoteSo if you're doing an inguinal hernia, I don't think you should ever use smaller than a large of those preformed meshes because you need to cover the whole myelope.↗
▶Ep 5 · 23:24
clinicalIf struggling with mesh placement during laparoscopic repair, it's not that you're not a good enough laparoscopic surgeon, it's that you didn't dissect out the space enough - you need to take out the mesh and dissect bigger.↗
▶Ep 5 · 23:24
quoteAnd so if you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon. It's that you didn't dissect out the space to put the mesh.↗
▶Ep 5 · 23:53
opinionMesh should be fixed in place; options include Protack tacks, glue, or no fixation, though for big direct hernias everybody uses fixation.↗
▶Ep 5 · 24:09
clinicalThere is no evidence that absorbable fixation causes reduction in pain, better fixation, or improved long-term outcomes; permanent fixation is used because if absorbable fixation goes through a nerve, it's the neuroma that causes the problem, not the tack.↗
▶Ep 5 · 24:09
quoteNo evidence that absorbable fixation causes reduction in pain, better fixation, or improve long-term outcomes. So I use permanent fixation. And absorbable fixation, if you put it through the nerve, it's the neuroma that causes the problem, not the attack.↗
▶Ep 5 · 25:55
clinicalFor incarcerated femoral hernia with bowel compromise, make a vertical incision for vascular-type exposure, dissect onto hernia sac, bring out compromised intestine infrainguinally, resect and anastomose, then reduce.↗
▶Ep 5 · 26:32
clinicalTo reduce incarcerated femoral hernia without dividing inguinal ligament, release the lacunar ligament medially (which gives off from the inguinal ligament) to gain an extra centimeter of space.↗
▶Ep 5 · 27:10
clinicalA 'reverse McVay' repair can be performed from below for femoral hernias, taking the inferior border of the inguinal ligament and sewing it down to Cooper's ligament starting immediately lateral to the femoral vein.↗
▶Ep 5 · 27:46
clinicalMesh plugs are not preferred for femoral hernias because femoral hernias tend to occur in thin women and there have been DVTs due to irritation on the femoral vein.↗
▶Ep 5 · 28:12
opinionFor recurrent hernias, operate where nobody has been before; if both spaces have been operated, go where you're best.↗
▶Ep 5 · 28:30
opinionFor bilateral hernias in a skilled laparoscopic surgeon, laparoscopy is the best approach, but if learning, avoid bilateral and recurrent hernias laparoscopically because it makes it twice as hard despite these patients getting the most benefit.↗
▶Ep 5 · 29:09
opinionFor really big inguinal scrotal hernias that can't be reduced in office, open operation is preferred; when younger, these were done laparoscopically but now all done open.↗
▶Ep 5 · 29:40
clinicalFor incarcerated hernias, TAP approach is preferred over TEP because you want the contents out of the hernia; can laparoscopically cut the internal ring at the two o'clock position relative to epigastric vessels to help reduce.↗
Michael's statements about Gastroesophageal Reflux Disease127 statements
clinicalPPIs reduce gastric acid secretion more effectively than H2 blockers and are more convenient as once-daily medication↗
▶Ep 8 · 2:59
quoteI think you have to take them more often. They don't last as long and it's just more convenient to take a once a day drug.↗
▶Ep 8 · 3:34
clinicalMounting data shows that lifetime use of proton pump inhibitors has consequences↗
▶Ep 8 · 3:34
quoteSo I certainly think there's mounting data that a lifetime of proton pump inhibitors, it has consequences associated with it.↗
▶Ep 8 · 4:06
guidelinePatients with reflux symptoms requiring chronic PPI use need endoscopy at minimum to assess esophagitis and rule out Barrett's esophagus↗
▶Ep 8 · 4:26
quoteAt a minimum, to assess the esophagitis and in particular to rule out Barrett's.↗
▶Ep 8 · 5:00
opinionIn 2016, patients without esophagitis, hiatal hernia, or Barrett's on endoscopy require additional workup before indefinite PPI therapy, especially young patients at risk for osteoporosis↗
▶Ep 8 · 5:48
clinicalBravo pH study is preferred over nasal catheter for patient comfort, measuring 48 hours of pH data via endoscopically placed capsule 6cm above GE junction↗
▶Ep 8 · 6:17
opinionBravo pH testing off PPIs is preferred to establish symptom correlation, which is important for setting patient expectations about surgical outcomes↗
▶Ep 8 · 6:17
quoteI like the Bravo test to tell me symptom correlation. Uh, because as we talk about surgery, it's important to I think set patient's expectations about what you're going to make better because it's related to reflux and what might not be related to reflux and it's not going to change.↗
▶Ep 8 · 6:51
guidelineManometry is required before any surgical discussion for reflux, though not necessary for initial medical management↗
▶Ep 8 · 7:50
clinicalFor mild reflux (pH <4 for 6-8% of time, DeMeester score 20) without esophagitis or Barrett's, lifestyle modifications and PPI trial are appropriate before considering surgery↗
▶Ep 8 · 8:59
clinicalLong-term PPI use in women is associated with osteoporosis risk; calcium supplementation and periodic bone density testing may be protective↗
▶Ep 8 · 10:14
clinicalPPIs should be taken within 30 minutes before a meal, not at night before bed or in the morning without breakfast, to maximize effectiveness↗
▶Ep 8 · 11:19
clinicalThe primary reason for manometry before fundoplication is to rule out achalasia, as wrapping a patient with achalasia destroys esophageal function↗
▶Ep 8 · 11:29
quoteBecause if you wrap somebody with ankylasia, you have really destroyed their esophageal function.↗
▶Ep 8 · 11:47
clinicalPatients with achalasia can present with heartburn due to stasis and fermentation of food in the esophagus↗
▶Ep 8 · 12:26
clinicalManometry findings guide fundoplication type: total LES relaxation with low resting pressure supports full Nissen, while poor distal esophageal amplitudes may indicate need for partial wrap to avoid postoperative dysphagia↗
▶Ep 8 · 13:58
clinicalFull Nissen fundoplication (360-degree wrap) is appropriate for patients with normal peristalsis (amplitude 30mmHg or higher), total LES relaxation, and DeMeester score around 28↗
▶Ep 8 · 15:17
opinionNissen fundoplication technique is highly variable among surgeons with poor standardization, making it difficult to reproduce outcomes; proper wrap geometry is critical↗
▶Ep 8 · 15:17
opinionTaking down short gastric vessels during Nissen makes it easier to avoid twisting the wrap and ensures proper orientation of posterior to anterior stomach↗
▶Ep 8 · 15:17
quoteI think the way that a Nissan is created is highly variable, and one of the downsides of this operation that makes it hard to reproduce the data is everybody does it just a little bit differently, and there's not really great standardization, and it's easy to twist. It's easy to bring anterior wall to anterior wall.↗
▶Ep 8 · 15:17
opinionLaparoscopic fundoplication has the disadvantage of producing less scar tissue than open surgery; full mediastinal dissection helps create scarring to reduce recurrence rates↗
▶Ep 8 · 15:17
clinicalMediastinal dissection during fundoplication provides additional esophageal length, which is critical for a tension-free repair↗
▶Ep 8 · 15:17
quoteI think one of the disadvantages of laparoscopy, Is we don't get a lot of scar tissue, and I think one of the ways to reduce recurrences is to actually do a full mediastinal dissection and create ability for that area to scar down.↗
▶Ep 8 · 16:14
clinicalNissen wrap should be approximately 2cm long with 3 sutures; making the wrap too long (wrapping all available intraabdominal esophagus) is a common mistake that increases dysphagia↗
▶Ep 8 · 16:14
quoteI think one of the mistakes that people make is they make the wrap too long, uh, and it adds to dysphagia. So I typically do 3 stitches, um, in that I like it to be about 2 centimeters, nothing longer.↗
▶Ep 8 · 16:54
clinicalFirst suture in Nissen should be stomach-to-stomach so the knot can be used to position the wrap before securing it; subsequent sutures are stomach-esophagus-stomach↗
▶Ep 8 · 17:06
quoteI don't like to do it, which I know you do it, uh, beforehand, uh, because I, I think that's a little bit cheating that the stomach should be sitting there without tension.↗
▶Ep 8 · 17:06
opinionPosterior gastropexy (fixing posterior stomach to crura) should be done after wrap creation to ensure stomach sits without tension, not beforehand↗
▶Ep 8 · 17:39
quoteI think you need it less and less. Um, so, I don't use a bougie anymore, uh, and, and I close it, uh, enough where the esophagus comfortably has that little V sunlight below it. And I would probably say, as I've gotten older and older, I make it tighter and tighter.↗
▶Ep 8 · 17:39
clinicalCrural closure should create a 'triangle of air' or 'V sunlight' below the esophagus; experienced surgeons can achieve this without routine bougie use↗
▶Ep 8 · 18:16
opinionWith increasing experience, surgeons tend to make crural closure progressively tighter↗
▶Ep 8 · 19:02
quoteI think the key is to have a clear discussion of, uh, we don't want to cure one problem to create another disease. And so I typically start with those types of patients to say clearly that The best operation we have to prevent reflux is a Nissent fundoplication, and while it's a very good operation to let the acid not go back up, the pump of your esophagus doesn't work good enough to make it past that barrier.↗
▶Ep 8 · 19:02
clinicalPatients with weak esophageal peristalsis (amplitude below 20mmHg) and connective tissue disease require clear discussion that full Nissen may cure reflux but create dysphagia due to inadequate esophageal pump function↗
▶Ep 8 · 19:42
clinicalToupet fundoplication (270-degree posterior wrap) is indicated for patients with weak motility to prevent pseudoachalasia↗
▶Ep 8 · 19:44
clinicalToupet wrap is made slightly longer than Nissen (2.5-3cm vs 2cm) with 3 sutures on each side, all esophagus-to-stomach, plus single posterior gastropexy↗
▶Ep 8 · 20:33
opinionFixing Toupet wrap to lateral crura is not recommended as it angulates anatomy awkwardly and pulls the stomach↗
▶Ep 8 · 21:28
quoteI would say the hardest transition of becoming and attending 12 years ago and doing 4 gut surgery. was managing patient satisfaction after this operation and realizing when you don't go off service and you don't leave after you do 20 Nissans that people come back with complaints.↗
▶Ep 8 · 21:28
clinicalFundoplication changes how patients swallow, how the stomach works, and how acid moves through the body; setting these expectations preoperatively is critical for patient satisfaction↗
▶Ep 8 · 21:28
clinicalFundoplication is tightest immediately after surgery and loosens over time; early dysphagia is expected and desired↗
▶Ep 8 · 21:28
clinicalEndoscopic intervention for persistent dysphagia should not be considered until 3 months postoperatively with no progression and inability to tolerate anything beyond liquids↗
▶Ep 8 · 21:28
quoteThe person I worry about the most is the person who shows up two weeks after an innocent and says they've been eating everything they want and they don't have any dysphagia because you know you made it too loose and you're in trouble.↗
▶Ep 8 · 21:28
quoteIt is critical, and this is clear to patients in my pre-op discussion. That this operation changes things. It's going to change the way you swallow. It's going to change the way your stomach works, and it's going to change the way acid moves throughout your body.↗
▶Ep 8 · 21:28
clinicalDysphagia in the first 6 weeks post-fundoplication should not prompt intervention, even if patient maintains liquid-only diet↗
▶Ep 8 · 21:28
clinicalPatients with no dysphagia at 2 weeks post-Nissen likely have a wrap that is too loose and will have long-term problems↗
▶Ep 8 · 23:17
clinicalWorkup for dysphagia at 6-8 months post-fundoplication includes upper GI to rule out hernia recurrence and identify anatomic causes, followed by endoscopy with dilation if wrap is too tight↗
▶Ep 8 · 24:06
clinicalPseudoachalasia presents as dilated esophagus with bird's beak appearance, retained fluid pool, tight GE junction, loss of peristalsis, and non-relaxing LES on manometry after fundoplication↗
▶Ep 8 · 24:06
quoteI am very concerned about pseudoacallaia in that situation.↗
▶Ep 8 · 24:43
quoteYou know, likely due to the wrap potentially just being too tight and this long of dysphagia, the esophagus is burned out and it's no longer able to pump the food through.↗
▶Ep 8 · 24:43
clinicalPseudoachalasia likely results from overly tight wrap causing esophageal burnout where the esophagus loses ability to pump food through↗
▶Ep 8 · 25:14
clinicalTreatment options for pseudoachalasia include taking down Nissen with Heller myotomy plus Dor, or converting to Toupet with long Heller on both sides↗
▶Ep 8 · 25:14
clinicalPseudoachalasia requires nutritional optimization before reoperation; PEG tube feeding may be necessary if nutrition is compromised↗
▶Ep 8 · 26:57
opinionFor reoperative foregut surgery, the best approach is to plan to start over and take down the entire wrap, though this may not always be necessary or possible↗
▶Ep 8 · 27:36
clinicalGastric bypass is an excellent operation for morbidly obese patients with failed fundoplication↗
▶Ep 8 · 27:48
quoteI think it's really important because the Nissan doesn't work well in morbidly obese patients.↗
▶Ep 8 · 27:48
clinicalFor primary reflux surgery in patients with BMI over 35, gastric bypass should be considered instead of Nissen because fundoplication does not work well in morbidly obese patients↗
▶Ep 8 · 28:17
quoteI am putting the brakes on rushing to do this and and really wanna understand what's going on.↗
▶Ep 8 · 28:17
clinicalNausea and vomiting as large component of reflux symptoms are red flags to delay surgery and investigate further, as symptoms of delayed gastric emptying overlap with reflux↗
▶Ep 8 · 28:17
clinicalReoperative fundoplication patients require repeat Bravo pH study for symptom correlation, repeat manometry, and gastric emptying study, especially if nausea and vomiting are prominent symptoms↗
▶Ep 8 · 29:44
quoteI've seen a re-operative surgery. Is where the liver and the wrap are obliterating the right cruise. You drift off of the wrap and you wind up in the cave.↗
▶Ep 8 · 29:44
quoteThis has to be identifying name structures, digging them out in a very systematic fashion, and not being erratic or you get lost quick.↗
▶Ep 8 · 29:44
quoteThe reason why a lot of these things come back is there's just not scar tissue in the chest. So, if you're really struggling down there, my second move is to get up in the chest wherever I can find a hole and then work my way back.↗
▶Ep 8 · 29:44
quoteIf somebody had a Nissan and they have an incision in the belly button, you know it's an easy day because they never went up in the chest and they never dissected up in the chest.↗
▶Ep 8 · 29:44
clinicalReoperative foregut surgery requires identifying named structures and systematic dissection rather than trying to make spaces, or the surgeon gets lost quickly↗
▶Ep 8 · 29:44
clinicalMany fundoplications recur because there is insufficient scar tissue in the chest; if struggling with dissection from below, alternative approach is to enter chest wherever possible and work back down↗
▶Ep 8 · 29:44
opinionTaking liver off wrap in reoperative surgery can be done sharply accepting some bleeding, which is compressed by paddle retractor, rather than risking wrap injury with harmonic scalpel↗
▶Ep 8 · 29:44
clinicalFirst goal in reoperative fundoplication is to identify the right crus at its base to know where the IVC is and avoid major vascular injury↗
▶Ep 8 · 29:44
clinicalIn reoperative fundoplication, prior port placement indicates extent of original dissection: umbilical incision suggests no chest dissection, while 5 ports with lowest 5cm from umbilicus indicates thorough original operation↗
▶Ep 8 · 31:57
opinionFor vagal injury with poor gastric emptying, early Botox of pylorus is preferred over pyloroplasty unless both vagal nerves were clearly transected↗
▶Ep 8 · 31:57
clinicalIf anterior vagus nerve is injured during reoperative fundoplication but posterior vagus is intact, no acute intervention is needed; postoperative upper GI on day 1-2 assesses gastric emptying↗
Gastroesophageal Reflux Disease
▶Ep 13 · 1:38
quoteI think when you see a patient like that, particularly as a surgeon, if you're seeing them the first time and they really haven't had any workup, I, I think that surgery should be looked at and disease of gastroesophageal reflux is very far down on the treatment line.↗
▶Ep 13 · 1:38
clinicalSurgery for gastroesophageal reflux disease should be far down the treatment line after appropriate medical management and workup↗
▶Ep 13 · 2:27
clinicalInitial trial of 20 mg daily Prilosec (omeprazole) for 6 weeks is appropriate first-line therapy for GERD symptoms↗
▶Ep 13 · 3:34
clinicalThere is mounting data that a lifetime of proton pump inhibitors has consequences associated with it↗
▶Ep 13 · 3:34
quoteI certainly think there's mounting data that a lifetime of proton pump inhibitors, it has consequences associated with it.↗
▶Ep 13 · 4:06
clinicalEndoscopy is needed at minimum to assess esophagitis and in particular to rule out Barrett's esophagus in patients with persistent reflux symptoms↗
▶Ep 13 · 4:26
quoteAt a minimum, to assess the esophagitis and in particular to rule out Barrett's.↗
▶Ep 13 · 5:02
opinionIn 2016, for a patient without esophagitis, hiatal hernia, or Barrett's, more workup is warranted before keeping them on PPIs indefinitely, especially in young active persons due to concerns about osteoporosis and other issues↗
▶Ep 13 · 5:33
clinicalA pH study is needed to confirm the diagnosis of gastroesophageal reflux disease when endoscopy does not show evidence of esophagitis↗
▶Ep 13 · 6:19
clinicalThe Bravo test should be done off PPIs to provide symptom correlation, which is important for setting patient expectations about what surgery will improve↗
▶Ep 13 · 6:26
quoteI like the Bravo test to tell me symptom correlation.↗
▶Ep 13 · 6:51
clinicalManometry is essential before any surgical discussion and should be part of the preoperative workup for patients potentially going down the operative road↗
▶Ep 13 · 11:19
clinicalThe basic reason for manometry is number one to rule out achalasia, because wrapping someone with achalasia destroys their esophageal function↗
▶Ep 13 · 11:31
quoteBecause if you wrap somebody with ankylasia, you have really destroyed their esophageal function.↗
▶Ep 13 · 12:25
clinicalManometry findings consistent with reflux include total relaxation of the lower esophageal sphincter with swallowing and low resting pressure of the LES↗
▶Ep 13 · 12:38
clinicalDistal esophageal amplitudes on manometry can be used to tailor the fundoplication, with discussion about the difference between a floppy Nissen and a Toupet based on esophageal motility↗
▶Ep 13 · 13:27
clinicalA patient with normal peristalsis (amplitude of 30 mmHg or higher), total LES relaxation, DeMeester score of 28, and a 2 cm hiatal hernia should receive a full Nissen fundoplication↗
▶Ep 13 · 14:20
clinicalOne disadvantage of laparoscopic fundoplication is that it does not create much scar tissue; full mediastinal dissection helps reduce recurrences by creating ability for the area to scar down and provides more esophageal length↗
▶Ep 13 · 14:20
quoteI actually think when you do this laparoscopically, one of the disadvantages of laparoscopy, Is we don't get a lot of scar tissue, and I think one of the ways to reduce recurrences is to actually do a full mediastinal dissection and create ability for that area to scar down and you also get more length on the esophagus.↗
▶Ep 13 · 14:38
clinicalTaking down the short gastric vessels makes it easier to avoid twisting the wrap and to see exactly what is being brought around during fundoplication↗
▶Ep 13 · 14:55
opinionThe way a Nissen is created is highly variable and one of the downsides of this operation is lack of standardization, making it hard to reproduce data↗
▶Ep 13 · 14:55
quoteI think the way that a Nissan is created is, is highly variable, and one of the downsides of this operation that makes it hard to reproduce the data is everybody does it just a little bit differently, and there's not really great standardization↗
▶Ep 13 · 16:19
quoteone of the common mistakes I would make was that I thought I have all this intraabdominal esophageal length and I would feel the need to wrap all of that and I think one of the mistakes that people make is they make the wrap too long, uh, and it adds to dysphagia.↗
▶Ep 13 · 16:19
clinicalA common mistake is making the Nissen wrap too long, which adds to dysphagia; the wrap should be about 2 centimeters with typically 3 sutures↗
▶Ep 13 · 16:43
clinicalThe first stitch in a Nissen should be stomach to stomach so the knot can be used to move the wrap and ensure proper positioning before placing additional sutures↗
▶Ep 13 · 17:42
clinicalA bougie is not routinely needed during crural closure in experienced hands; the esophagus should have a little V-shaped triangle of air below it↗
▶Ep 13 · 19:05
clinicalIn patients with weak peristalsis (amplitude below 20 mmHg) and weak LES, the best operation to prevent reflux is still a Nissen, but the esophageal pump does not work well enough to overcome that barrier, necessitating a Toupet to avoid creating dysphagia↗
▶Ep 13 · 19:05
quoteI think in those type of patients, uh, I think the key is to have a clear discussion of, uh, we don't want to cure one problem to create another disease.↗
▶Ep 13 · 19:14
quoteThe best operation we have to prevent reflux is a Nissen fundoplication. And while it's a very good operation to let the acid not go back up, the pump of your esophagus doesn't work good enough to make it past that barrier.↗
▶Ep 13 · 19:44
clinicalA Toupet fundoplication is a posterior 270-degree wrap that is about 2.5 to almost 3 centimeters long with 3 sutures on either side through esophagus to stomach↗
▶Ep 13 · 21:33
opinionThe hardest transition of becoming an attending doing foregut surgery is managing patient satisfaction after fundoplication and realizing patients come back with complaints and issues↗
▶Ep 13 · 21:33
quoteI would say the hardest transition of becoming and attending 12 years ago and doing for gut surgery. Was managing patient satisfaction after this operation and realizing when you don't go off service and you don't leave after you do 20 Nissans that people come back with complaints.↗
▶Ep 13 · 22:03
quotethis operation changes things. It's going to change the way you swallow. It's going to change the way your stomach works, and it's going to change the way acid moves from out your body.↗
▶Ep 13 · 22:03
clinicalFundoplication changes the way patients swallow, the way their stomach works, and the way acid moves from their body; patients must be counseled preoperatively about these changes↗
▶Ep 13 · 22:17
clinicalThe fundoplication is tightest right after surgery and gets looser over time; early dysphagia is expected and the patient who has no dysphagia at 2 weeks likely has a wrap that is too loose↗
▶Ep 13 · 22:17
quotethis operation is its tightest right after surgery and it's going to get looser over time.↗
▶Ep 13 · 22:30
quotethe person I worry about the most is the person who shows up two weeks after innocent and says they've been eating everything they want and they don't have any dysphagia because you know you made it too loose and you're in trouble, uh, long term.↗
▶Ep 13 · 22:48
clinicalDysphagia should not be a concern for the first 6 weeks postoperatively, even if the patient maintains a liquid diet, and endoscopic intervention should not be considered until 3 months with no progression and inability to tolerate anything besides liquids↗
▶Ep 13 · 23:17
clinicalFor persistent dysphagia at 6-8 months, workup should include upper GI to rule out hernia recurrence and look for anatomic causes, followed by endoscopy with dilation if the wrap appears too tight↗
▶Ep 13 · 24:06
clinicalPseudoachalasia after fundoplication presents with dilated esophagus, retained fluid, tight GE junction on endoscopy, and manometry showing lack of peristalsis and non-relaxing LES; this likely occurs when the wrap is too tight and prolonged dysphagia causes the esophagus to burn out↗
▶Ep 13 · 24:57
clinicalFor pseudoachalasia, nutrition should be optimized before reoperation, with consideration of PEG tube feeding if needed↗
▶Ep 13 · 26:40
clinicalFor complex reoperative foregut surgery, the best approach is to plan to start over and take down the entire wrap, though sometimes dividing it and leaving half a wrap (Toupet) may be acceptable if the wrap cannot be fully taken down↗
▶Ep 13 · 26:40
quoteI think for complex reoperative foregut surgery. You have to start over because dysphagia, was it twisted a little bit? All those things get hard to sort out.↗
▶Ep 13 · 27:36
clinicalFor morbidly obese patients with BMI over 35 and reflux, gastric bypass should be considered instead of fundoplication as the primary operation because Nissen does not work well in morbidly obese patients↗
▶Ep 13 · 28:17
clinicalFor symptomatic herniated wrap, reevaluation should include 48-hour Bravo study for symptom correlation, repeat manometry, and gastric emptying study especially if nausea and vomiting are prominent symptoms↗
▶Ep 13 · 29:02
clinicalNausea and vomiting as a large component of foregut patients' complaints are red flags to put the brakes on rushing to surgery and to understand what is going on, particularly regarding gastric emptying↗
▶Ep 13 · 29:08
quotenausea and vomiting is a large component. Of my 4 gut patients' complaints, I am putting the brakes on rushing to do this and and really wanna understand what's going on.↗
▶Ep 13 · 30:18
quotethe first kind of goal of my operation is to get me to the right crew. I think that's the most important part of the operation simply because then I know where the cava is and where you can get in big trouble.↗
▶Ep 13 · 30:18
clinicalIn reoperative fundoplication, the first goal is to reach the right crus to identify where the cava is and avoid injury; the liver and wrap often obliterate the right crus and drifting off the wrap can lead to caval injury↗
▶Ep 13 · 30:44
clinicalWhen taking the liver off the wrap in reoperative surgery, sharp dissection with hook or scissors accepting bleeding is preferred over harmonic to avoid injuring the wrap that will be used later↗
▶Ep 13 · 31:11
clinicalMost surgeons do not take the dissection low enough to the base of the crus; getting the crus at the base provides a choice of going right or straight up with known anatomy to avoid the cava↗
▶Ep 13 · 31:33
clinicalMany fundoplications recur because there is not enough scar tissue in the chest; if struggling with dissection below, getting up in the chest and working back down is a useful strategy↗
▶Ep 13 · 31:33
quotethe reason why a lot of these things come back is there's just not scar tissue in the chest.↗
▶Ep 13 · 32:01
clinicalIn reoperative surgery, the key is identifying named structures and digging them out in a systematic fashion rather than trying to make a space without proper dissection, or the surgeon will get lost quickly↗
▶Ep 13 · 32:01
quotethe key, and where I've seen young people get in trouble, and what I've been in trouble myself in this is where you try to make a space and not do a dissection. So this has to be identifying name structures, digging them out in a very systematic fashion and not being erratic or you get lost quick.↗
▶Ep 13 · 32:36
clinicalIf the anterior vagus nerve is injured during reoperative fundoplication but the posterior vagus is intact, no acute intervention is needed in the operating room; postoperative upper GI on day 1 or 2 should assess gastric emptying, and early Botox of the pylorus is preferred over pyloroplasty if delayed emptying is a concern↗
Michael's statements about Hepatobiliary & Colorectal Surgery28 statements
quoteI think like anybody who sent you with an inguinal hernia, first you want to do an exam and you want to confirm whether they have an inguinal hernia. I have to say that can be one of the hardest things to do because there are small hernias that on physical exam are extremely difficult to feel.↗
▶Ep 9 · 3:22
epidemiologicalIn Fitzgibbons' VA study of minimally symptomatic to asymptomatic hernias in patients in their 70s-80s, the risk of presenting with an emergency problem requiring operation due to incarceration or strangulation was less than 1% (actually one-third of 1%).↗
▶Ep 9 · 4:00
quoteSo it's safe to watch people. But the problem with this study is this study was over two years. Almost a third of the patients went on to develop symptoms and need an operation.↗
▶Ep 9 · 4:00
epidemiologicalIn Fitzgibbons' original two-year VA study, almost one-third of patients in the observation group went on to develop symptoms and need an operation.↗
▶Ep 9 · 4:20
epidemiologicalIn long-term follow-up of Fitzgibbons' VA study patients (approximately five years), almost three-quarters of patients developed symptoms requiring repair.↗
▶Ep 9 · 8:20
quoteI think that the right answer to that question would be defined based on the patient that you have in front of you. And I think equally, if not more important, based on your skill set and where you're at with the learning curve of all of these operations.↗
▶Ep 9 · 8:30
quoteAnd it's been shown in the literature that the best approach is what you do best.↗
▶Ep 9 · 8:40
clinicalThe learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200 to 250 cases required.↗
▶Ep 9 · 9:20
clinicalIn laparoscopic inguinal hernia repair, mesh is placed away from the nerves, and the risk of chronic pain when done correctly is lower than in open inguinal hernias.↗
▶Ep 9 · 12:10
clinicalLaparoscopic repair offers approximately one week to 10 days earlier recovery compared to open repair, not a month or three to four months.↗
▶Ep 9 · 12:30
quoteI think the disadvantage of it is that you have to operate near the intestines, whereas open, you're in a separate plane. So there is a risk of intestinal injury. There's a risk of injury to the major blood vessels because you're in that area. But again, if you are safe and know those planes, that risk should be incredibly low.↗
▶Ep 9 · 15:50
quoteYou have to check your minimally invasive ego at the door and make sure that you also can do opening oral hernias or in a patient who's a candidate, send it to somebody who can do opening oral hernias. Because if you're pushing it laparoscopically in a sick, comorbid patient, more often than not, it's because you don't feel comfortable doing it the opening of the way and you use your go-to move.↗
▶Ep 9 · 18:20
quoteI think the most important part of any laparoscopic repair, and it's a basic principle that Rene Stoppa promoted during open preperitoneal repairs, which is parietalization of the cord, which essentially just means stripping the peritoneum off the cord inferiorly and posteriorly.↗
▶Ep 9 · 18:20
clinicalThe most important part of any laparoscopic repair is parietalization of the cord (stripping the peritoneum off the cord inferiorly and posteriorly), a principle promoted by Rene Stoppa during open preperitoneal repairs.↗
▶Ep 9 · 18:40
clinicalThe risk of recurrence in laparoscopic repair is the peritoneum coming under the mesh and then going back out to the defect inferiorly.↗
▶Ep 9 · 18:54
quoteAnd the inferior dissection is the Achilles heel of any laparoscopic repair because it's awkward to view it. It's a little bit scary that you're going to start to make holes in it, and you're taking it very close off the vessels.↗
▶Ep 9 · 20:00
clinicalAccording to Stoppa's original descriptions, for a unilateral inguinal hernia repair, one should never use less than a 15 by 15 centimeter piece of mesh (or 6 by 6 inch), which is much bigger than the vast majority of laparoscopic preformed meshes being placed.↗
▶Ep 9 · 21:20
clinicalHeavyweight mesh is approximately 90 grams per meter squared (Marlex or Prolene mesh), midweight mesh is 40-50 grams per meter squared, and lightweight mesh (Ultrapro) is less than 30 grams per meter squared.↗
▶Ep 9 · 22:00
clinicalThe advantage of lighter weight mesh is less foreign body and potentially less contraction due to better ingrowth; the disadvantage is half the material, which in direct hernias where muscles never come back together puts the mesh at risk for fracturing.↗
▶Ep 9 · 23:00
quoteIf you're doing an inguinal hernia, I don't think you should ever use smaller than a large of those preformed meshes because you need to cover the whole myelope.↗
▶Ep 9 · 23:20
quoteIf you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon. It's that you didn't dissect out the space to put the mesh. And it's not because you have too big of a mesh. It's because you need to take out the mesh and dissect bigger.↗
▶Ep 9 · 24:09
clinicalThere is no evidence that absorbable fixation causes reduction in pain, better fixation, or improved long-term outcomes compared to permanent fixation.↗
▶Ep 9 · 24:20
clinicalIf absorbable fixation is put through a nerve, it is the neuroma that causes the problem, not the tack itself.↗
▶Ep 9 · 24:56
clinicalThere is mounting evidence that medium-weight polypropylene mesh can be placed in a contaminated field, with several series demonstrating this in ventral hernias.↗
▶Ep 9 · 27:00
clinicalFor incarcerated femoral hernias, the lacunar ligament can be released medially to gain an extra centimeter of space for reduction without destroying the inguinal floor or inguinal ligament.↗
▶Ep 9 · 28:12
opinionFor recurrent hernias, the surgeon should go where nobody has been before; if somebody has been in both places, go where you are best.↗
▶Ep 9 · 28:30
opinionFor bilateral hernias in a skilled laparoscopic surgeon, laparoscopy is the best approach.↗
▶Ep 9 · 28:40
opinionSurgeons learning laparoscopic inguinal hernia repair should avoid bilateral and recurrent hernias during their learning curve, although these patients might benefit most, they have the highest risk.↗
Michael's statements about Inguinal Hernia253 statements
quoteI have to say that can be one of the hardest things to do because there are small hernias that on physical exam are extremely difficult to feel.↗
▶Ep 6 · 2:17
quoteI have to say that can be one of the hardest things to do because there are small hernias that on physical exam are extremely difficult to feel.↗
▶Ep 6 · 2:38
quoteJust remember that anytime somebody stands up and coughs or does a Valsalva, there's always the cord structures that are gonna be giving you an impulse, so you really wanna make sure that you actually see a bulge, and it's a true hernia.↗
▶Ep 6 · 2:38
quoteJust remember that anytime somebody stands up and coughs or does a Valsalva, there's always the cord structures that are gonna be giving you an impulse, so you really wanna make sure that you actually see a bulge, and it's a true hernia.↗
▶Ep 6 · 3:30
epidemiologicalIn the Fitzgibbons VA study of minimally symptomatic to asymptomatic inguinal hernias in patients in their 70s-80s, the risk of presenting with an emergency problem (incarceration or strangulation) requiring operation was 0.3% over 2 years.↗
▶Ep 6 · 3:30
epidemiologicalIn the Fitzgibbons VA study of minimally symptomatic to asymptomatic inguinal hernias in patients in their 70s-80s, the risk of presenting with an emergency problem (incarceration or strangulation) requiring operation was 0.3% over 2 years.↗
▶Ep 6 · 4:11
epidemiologicalIn the Fitzgibbons study, almost one-third of patients in the observation group developed symptoms requiring operation by 2 years.↗
▶Ep 6 · 4:11
epidemiologicalIn the Fitzgibbons study, almost one-third of patients in the observation group developed symptoms requiring operation by 2 years.↗
▶Ep 6 · 4:21
epidemiologicalIn long-term follow-up of the Fitzgibbons study, almost three-fifths of patients in the observation group developed symptoms requiring operation by 5 years.↗
▶Ep 6 · 4:21
epidemiologicalIn long-term follow-up of the Fitzgibbons study, almost three-fifths of patients in the observation group developed symptoms requiring operation by 5 years.↗
▶Ep 6 · 4:33
opinionFor an 89-year-old patient with an asymptomatic hernia, watchful waiting is acceptable because the odds are they may not develop symptoms over their remaining lifespan.↗
▶Ep 6 · 4:33
opinionFor an 89-year-old patient with an asymptomatic hernia, watchful waiting is acceptable because the odds are they may not develop symptoms over their remaining lifespan.↗
▶Ep 6 · 4:36
quoteThe odds are in a couple of years, they might not have any symptoms and you'll be OK, but in a younger patient, the odds are against them that they're going to live the rest of their life without this becoming symptomatic.↗
▶Ep 6 · 4:36
opinionFor younger patients with asymptomatic hernias, the odds are against them living the rest of their life without the hernia becoming symptomatic, so repair should be recommended when the time is right.↗
▶Ep 6 · 4:36
opinionFor younger patients with asymptomatic hernias, the odds are against them living the rest of their life without the hernia becoming symptomatic, so repair should be recommended when the time is right.↗
▶Ep 6 · 4:36
quoteThe odds are in a couple of years, they might not have any symptoms and you'll be OK, but in a younger patient, the odds are against them that they're going to live the rest of their life without this becoming symptomatic.↗
▶Ep 6 · 6:06
quoteIt's much worse for them to present with an emergency problem in the middle of the night, which could be life threatening.↗
▶Ep 6 · 6:06
opinionFor symptomatic hernias in high-risk patients, it is much worse for them to present with an emergency problem in the middle of the night, which could be life-threatening, so they should still be offered repair.↗
▶Ep 6 · 6:06
clinicalInguinal hernia repairs can be performed under local anesthesia in high-risk patients.↗
▶Ep 6 · 6:06
quoteIt's much worse for them to present with an emergency problem in the middle of the night, which could be life threatening.↗
▶Ep 6 · 6:06
opinionFor symptomatic hernias in high-risk patients, it is much worse for them to present with an emergency problem in the middle of the night, which could be life-threatening, so they should still be offered repair.↗
▶Ep 6 · 6:06
clinicalInguinal hernia repairs can be performed under local anesthesia in high-risk patients.↗
▶Ep 6 · 7:56
clinicalFor unilateral primary inguinal hernias, tissue repair, open mesh repair, or laparoscopic mesh repair are all acceptable approaches with ample literature support.↗
▶Ep 6 · 7:56
clinicalFor unilateral primary inguinal hernias, tissue repair, open mesh repair, or laparoscopic mesh repair are all acceptable approaches with ample literature support.↗
▶Ep 6 · 8:29
opinionThe best approach for inguinal hernia repair is what the surgeon does best, and this is supported by literature.↗
▶Ep 6 · 8:29
opinionThe best approach for inguinal hernia repair is what the surgeon does best, and this is supported by literature.↗
▶Ep 6 · 9:04
opinionFor young, healthy patients with unilateral hernias who are not anesthetic risks, laparoscopic repair is preferred by Dr. Rosen if the surgeon is past the learning curve.↗
▶Ep 6 · 9:04
epidemiologicalThe learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200-250 cases required.↗
▶Ep 6 · 9:04
epidemiologicalThe learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200-250 cases required.↗
▶Ep 6 · 9:04
opinionFor young, healthy patients with unilateral hernias who are not anesthetic risks, laparoscopic repair is preferred by Dr. Rosen if the surgeon is past the learning curve.↗
▶Ep 6 · 9:18
clinicalIn laparoscopic inguinal hernia repair, the mesh is placed away from the nerves, and the risk of chronic pain is lower than in open inguinal hernia repair when done correctly.↗
▶Ep 6 · 9:18
clinicalIn laparoscopic inguinal hernia repair, the mesh is placed away from the nerves, and the risk of chronic pain is lower than in open inguinal hernia repair when done correctly.↗
▶Ep 6 · 9:51
clinicalChronic pain after open inguinal hernia repair can occur due to technical problems or simply due to mesh laying on the nerves, and affected patients are absolutely miserable.↗
▶Ep 6 · 9:51
clinicalChronic pain after open inguinal hernia repair can occur due to technical problems or simply due to mesh laying on the nerves, and affected patients are absolutely miserable.↗
▶Ep 6 · 10:45
epidemiologicalTAPP (transabdominal preperitoneal) and TEP (total extraperitoneal) approaches have not been studied well enough to provide level-one evidence distinguishing their outcomes.↗
▶Ep 6 · 10:45
epidemiologicalTAPP (transabdominal preperitoneal) and TEP (total extraperitoneal) approaches have not been studied well enough to provide level-one evidence distinguishing their outcomes.↗
▶Ep 6 · 10:58
clinicalTEP repair requires use of a balloon dissector, which is more expensive, and provides a smaller working space but perhaps easier angles to operate with.↗
▶Ep 6 · 10:58
clinicalTEP repair requires use of a balloon dissector, which is more expensive, and provides a smaller working space but perhaps easier angles to operate with.↗
▶Ep 6 · 11:09
clinicalTAPP repair provides a better view and larger working space, and makes it easier for surgeons early in their learning curve to look intraperitoneally and confirm hernia reduction.↗
▶Ep 6 · 11:09
clinicalTAPP repair provides a better view and larger working space, and makes it easier for surgeons early in their learning curve to look intraperitoneally and confirm hernia reduction.↗
▶Ep 6 · 11:26
clinicalTAPP and TEP ultimately work in the same anatomical space—one enters through the front door, one through the ceiling—and should result in the same operation.↗
▶Ep 6 · 11:26
clinicalTAPP and TEP ultimately work in the same anatomical space—one enters through the front door, one through the ceiling—and should result in the same operation.↗
▶Ep 6 · 12:11
quoteI think that that surgical skill is critical, and you don't want to be getting an inguinal hernia in the patient's first in the surgeon's first couple laparoscopic inguinal hernia operates because there is a real learning curve.↗
▶Ep 6 · 12:11
quoteI think that that surgical skill is critical, and you don't want to be getting an inguinal hernia in the patient's first in the surgeon's first couple laparoscopic inguinal hernia operates because there is a real learning curve.↗
▶Ep 6 · 12:23
clinicalLaparoscopic inguinal hernia repair offers approximately 1 week to 10 days earlier recovery compared to open repair.↗
▶Ep 6 · 12:23
quoteThe laparoscopic repair offers you about 1 week to 10 days earlier recovery. It's not a month, it's not 3 or 4 months, but it is about 1 week to 10 days in my practice.↗
▶Ep 6 · 12:23
quoteThe laparoscopic repair offers you about 1 week to 10 days earlier recovery. It's not a month, it's not 3 or 4 months, but it is about 1 week to 10 days in my practice.↗
▶Ep 6 · 12:23
clinicalLaparoscopic inguinal hernia repair offers approximately 1 week to 10 days earlier recovery compared to open repair.↗
▶Ep 6 · 12:45
clinicalLaparoscopic inguinal hernia repair carries a risk of intestinal injury and injury to major blood vessels because the operation is performed near these structures, but this risk should be incredibly low if the surgeon knows the planes and operates safely.↗
▶Ep 6 · 12:45
clinicalLaparoscopic inguinal hernia repair carries a risk of intestinal injury and injury to major blood vessels because the operation is performed near these structures, but this risk should be incredibly low if the surgeon knows the planes and operates safely.↗
▶Ep 6 · 13:06
quoteThe consequence of chronic pain, which is starting to become one of the most common things that I see in my clinic with open mesh repairs, it is not worth that risk in a young, healthy, active patient.↗
▶Ep 6 · 13:06
quoteThe consequence of chronic pain, which is starting to become one of the most common things that I see in my clinic with open mesh repairs, it is not worth that risk in a young, healthy, active patient.↗
▶Ep 6 · 13:28
opinionIn elderly patients with any anesthetic risk or anyone on anticoagulation who needs to restart quickly, Dr. Rosen prefers open repair because he does not want to dissect the retroperitoneal space in these patients.↗
▶Ep 6 · 13:28
opinionIn elderly patients with any anesthetic risk or anyone on anticoagulation who needs to restart quickly, Dr. Rosen prefers open repair because he does not want to dissect the retroperitoneal space in these patients.↗
▶Ep 6 · 14:10
opinionIn a 78-year-old patient with a symptomatic hernia on one side and an asymptomatic hernia discovered laparoscopically on the other side, Dr. Rosen does not fix the asymptomatic side, citing concerns about doubling anesthetic time and increasing hematoma risk.↗
▶Ep 6 · 14:10
opinionIn a 78-year-old patient with a symptomatic hernia on one side and an asymptomatic hernia discovered laparoscopically on the other side, Dr. Rosen does not fix the asymptomatic side, citing concerns about doubling anesthetic time and increasing hematoma risk.↗
▶Ep 6 · 15:17
clinicalPneumoperitoneum is rarely a problem in patients with reduced cardiac capacity as long as insufflation is done slowly, pressures are kept low, and the patient is positioned in Trendelenburg to help cardiac return.↗
▶Ep 6 · 15:17
clinicalPneumoperitoneum is rarely a problem in patients with reduced cardiac capacity as long as insufflation is done slowly, pressures are kept low, and the patient is positioned in Trendelenburg to help cardiac return.↗
▶Ep 6 · 15:39
opinionThe benefits of laparoscopy for inguinal hernia repair are small for the vast majority of patients, though still worthwhile.↗
▶Ep 6 · 15:39
opinionThe benefits of laparoscopy for inguinal hernia repair are small for the vast majority of patients, though still worthwhile.↗
▶Ep 6 · 15:55
opinionSurgeons must check their minimally invasive ego at the door and ensure they can also perform open inguinal hernias or refer to someone who can, rather than pushing laparoscopy in sick comorbid patients simply because it is their go-to approach.↗
▶Ep 6 · 15:55
quoteYou have to check your minimally invasive ego at the door and make sure that you also can do opening oral hernias or in a patient who's a candidate, send it to somebody who can do opening oral hernias.↗
▶Ep 6 · 15:55
opinionSurgeons must check their minimally invasive ego at the door and ensure they can also perform open inguinal hernias or refer to someone who can, rather than pushing laparoscopy in sick comorbid patients simply because it is their go-to approach.↗
▶Ep 6 · 15:55
quoteYou have to check your minimally invasive ego at the door and make sure that you also can do opening oral hernias or in a patient who's a candidate, send it to somebody who can do opening oral hernias.↗
▶Ep 6 · 16:24
opinionPrevious lower abdominal surgery is a contraindication to laparoscopic inguinal hernia repair in Dr. Rosen's practice because it increases the risk of enterotomy and OR time.↗
▶Ep 6 · 16:24
opinionPrevious lower abdominal surgery is a contraindication to laparoscopic inguinal hernia repair in Dr. Rosen's practice because it increases the risk of enterotomy and OR time.↗
▶Ep 6 · 16:42
opinionPrevious prostate surgery makes laparoscopic inguinal hernia repair unpredictable—sometimes straightforward, sometimes brutal—and Dr. Rosen now performs these as open repairs.↗
▶Ep 6 · 16:42
opinionPrevious prostate surgery makes laparoscopic inguinal hernia repair unpredictable—sometimes straightforward, sometimes brutal—and Dr. Rosen now performs these as open repairs.↗
▶Ep 6 · 17:52
clinicalBasic tenets of laparoscopic inguinal hernia repair include achieving a wide dissection plane, with parietalization of the cord (stripping peritoneum off the cord inferiorly and posteriorly) being the most critical element.↗
▶Ep 6 · 17:52
clinicalBasic tenets of laparoscopic inguinal hernia repair include achieving a wide dissection plane, with parietalization of the cord (stripping peritoneum off the cord inferiorly and posteriorly) being the most critical element.↗
▶Ep 6 · 18:15
clinicalParietalization of the cord is a basic principle promoted by René Stoppa during open preperitoneal repairs.↗
▶Ep 6 · 18:15
clinicalParietalization of the cord is a basic principle promoted by René Stoppa during open preperitoneal repairs.↗
▶Ep 6 · 18:27
clinicalThe length of parietalization is critical because it prevents the peritoneum from coming under the mesh and going back out to the defect, which is the mechanism of recurrence.↗
▶Ep 6 · 18:27
clinicalThe length of parietalization is critical because it prevents the peritoneum from coming under the mesh and going back out to the defect, which is the mechanism of recurrence.↗
▶Ep 6 · 18:53
clinicalThe inferior dissection is the Achilles heel of any laparoscopic inguinal hernia repair because it is awkward to view, surgeons fear making holes in the peritoneum, and it requires dissection very close to the vessels.↗
▶Ep 6 · 18:53
clinicalThe inferior dissection is the Achilles heel of any laparoscopic inguinal hernia repair because it is awkward to view, surgeons fear making holes in the peritoneum, and it requires dissection very close to the vessels.↗
▶Ep 6 · 18:56
quoteThe inferior dissection is the Achilles heel any laparoscopic repair because it's awkward to view it. It's a little bit scary you're gonna start to make holes in it and you're taking it very close off the vessels.↗
▶Ep 6 · 18:56
quoteThe inferior dissection is the Achilles heel any laparoscopic repair because it's awkward to view it. It's a little bit scary you're gonna start to make holes in it and you're taking it very close off the vessels.↗
▶Ep 6 · 19:03
clinicalWhen surgeons do not take the peritoneum far enough back inferiorly, they tend to use a smaller piece of mesh, which is problematic.↗
▶Ep 6 · 19:03
clinicalWhen surgeons do not take the peritoneum far enough back inferiorly, they tend to use a smaller piece of mesh, which is problematic.↗
▶Ep 6 · 19:30
clinicalAll mesh contracts to some degree and can move.↗
▶Ep 6 · 19:30
clinicalAll mesh contracts to some degree and can move.↗
▶Ep 6 · 19:40
quoteIf you go back and read Stopa's original descriptions, his description, if you were doing a unilateral inguinal hernia was to never use less than a 15 by 15 centimeter piece of mesh or a 6 by 6 inch piece of mesh, which is much bigger than the vast majority of laparoscopic pre-formed meshes or or meshes that are being placed.↗
▶Ep 6 · 19:40
clinicalAccording to Stoppa's original descriptions, for a unilateral inguinal hernia, surgeons should never use less than a 15 by 15 centimeter (6 by 6 inch) piece of mesh, which is much bigger than the vast majority of laparoscopic pre-formed meshes being placed.↗
▶Ep 6 · 19:40
clinicalAccording to Stoppa's original descriptions, for a unilateral inguinal hernia, surgeons should never use less than a 15 by 15 centimeter (6 by 6 inch) piece of mesh, which is much bigger than the vast majority of laparoscopic pre-formed meshes being placed.↗
▶Ep 6 · 19:40
quoteIf you go back and read Stopa's original descriptions, his description, if you were doing a unilateral inguinal hernia was to never use less than a 15 by 15 centimeter piece of mesh or a 6 by 6 inch piece of mesh, which is much bigger than the vast majority of laparoscopic pre-formed meshes or or meshes that are being placed.↗
▶Ep 6 · 20:26
opinionFor large direct inguinal hernias, mesh choice should change and surgeons should use a heavier weight material.↗
▶Ep 6 · 20:26
opinionFor large direct inguinal hernias, mesh choice should change and surgeons should use a heavier weight material.↗
▶Ep 6 · 21:37
clinicalMesh weight categories (heavyweight, midweight, lightweight) were defined by marketing companies, not based on science.↗
▶Ep 6 · 21:37
clinicalHeavyweight mesh is approximately 90 grams per meter squared (e.g., Marlex or Prolene).↗
▶Ep 6 · 21:37
clinicalMesh weight categories (heavyweight, midweight, lightweight) were defined by marketing companies, not based on science.↗
▶Ep 6 · 21:37
clinicalHeavyweight mesh is approximately 90 grams per meter squared (e.g., Marlex or Prolene).↗
▶Ep 6 · 21:57
clinicalLightweight mesh (Ultrapro) is less than 30 grams per meter squared, starting heavier but degrading over time to about 28 grams per meter squared.↗
▶Ep 6 · 21:57
clinicalLightweight mesh (Ultrapro) is less than 30 grams per meter squared, starting heavier but degrading over time to about 28 grams per meter squared.↗
▶Ep 6 · 21:57
clinicalMidweight mesh is between 40 to 50 grams per meter squared.↗
▶Ep 6 · 21:57
clinicalMidweight mesh is between 40 to 50 grams per meter squared.↗
▶Ep 6 · 22:16
clinicalAdvantages of lighter weight mesh include less foreign body, less palpability, and potentially less contraction because it ingrows more.↗
▶Ep 6 · 22:16
clinicalAdvantages of lighter weight mesh include less foreign body, less palpability, and potentially less contraction because it ingrows more.↗
▶Ep 6 · 22:23
clinicalDisadvantages of lightweight mesh include having half the material, and in direct hernias where the mesh bridges and muscles never come together, the mesh is at risk for fracturing, with reports now showing central mesh failures.↗
▶Ep 6 · 22:23
clinicalDisadvantages of lightweight mesh include having half the material, and in direct hernias where the mesh bridges and muscles never come together, the mesh is at risk for fracturing, with reports now showing central mesh failures.↗
▶Ep 6 · 22:42
clinicalHeavier weight mesh rarely breaks, but patients sometimes feel it in their groin if there are wrinkles or buckles, which can cause issues.↗
▶Ep 6 · 22:42
clinicalHeavier weight mesh rarely breaks, but patients sometimes feel it in their groin if there are wrinkles or buckles, which can cause issues.↗
▶Ep 6 · 22:51
clinicalPre-formed meshes for inguinal hernia anatomy are technically easier to place but surgeons commonly downsize to a much smaller piece of mesh, which is problematic.↗
▶Ep 6 · 22:51
clinicalPre-formed meshes for inguinal hernia anatomy are technically easier to place but surgeons commonly downsize to a much smaller piece of mesh, which is problematic.↗
▶Ep 6 · 23:08
opinionFor laparoscopic inguinal hernia repair, surgeons should never use smaller than a large pre-formed mesh because the entire myopectineal orifice needs to be covered.↗
▶Ep 6 · 23:08
opinionFor laparoscopic inguinal hernia repair, surgeons should never use smaller than a large pre-formed mesh because the entire myopectineal orifice needs to be covered.↗
▶Ep 6 · 23:24
quoteIf you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon, it's that you didn't dissect out the space to put the mesh.↗
▶Ep 6 · 23:24
clinicalIf the mesh is too big during laparoscopic inguinal hernia repair, the problem is not the mesh size but inadequate dissection of the space.↗
▶Ep 6 · 23:24
clinicalIf the mesh is too big during laparoscopic inguinal hernia repair, the problem is not the mesh size but inadequate dissection of the space.↗
▶Ep 6 · 23:24
quoteIf you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon, it's that you didn't dissect out the space to put the mesh.↗
▶Ep 6 · 23:53
opinionDr. Rosen believes mesh should be fixed in laparoscopic inguinal hernia repair and uses ProTack, though some surgeons use glue or no fixation.↗
▶Ep 6 · 23:53
opinionDr. Rosen believes mesh should be fixed in laparoscopic inguinal hernia repair and uses ProTack, though some surgeons use glue or no fixation.↗
▶Ep 6 · 23:59
clinicalEven surgeons who advocate no fixation will selectively use fixation for large direct hernias.↗
▶Ep 6 · 23:59
clinicalEven surgeons who advocate no fixation will selectively use fixation for large direct hernias.↗
▶Ep 6 · 24:10
epidemiologicalThere is no evidence that absorbable fixation causes reduction in pain, provides better fixation, or improves long-term outcomes compared to non-absorbable fixation.↗
▶Ep 6 · 24:10
epidemiologicalThere is no evidence that absorbable fixation causes reduction in pain, provides better fixation, or improves long-term outcomes compared to non-absorbable fixation.↗
▶Ep 6 · 24:22
clinicalIf a tack is placed through a nerve, it is the neuroma that causes the problem, not the tack itself.↗
▶Ep 6 · 24:22
quoteIf you put it through the nerve, it's the neuroma that causes the problem, not the attack.↗
▶Ep 6 · 24:22
quoteIf you put it through the nerve, it's the neuroma that causes the problem, not the attack.↗
▶Ep 6 · 24:22
clinicalIf a tack is placed through a nerve, it is the neuroma that causes the problem, not the tack itself.↗
▶Ep 6 · 24:30
opinionDr. Rosen performs Lichtenstein repair as his preferred open inguinal hernia technique.↗
▶Ep 6 · 24:30
opinionDr. Rosen performs Lichtenstein repair as his preferred open inguinal hernia technique.↗
▶Ep 6 · 24:56
epidemiologicalThere is mounting evidence that medium weight polypropylene mesh can be placed in a contaminated field, with several series in ventral hernias supporting this.↗
▶Ep 6 · 24:56
epidemiologicalThere is mounting evidence that medium weight polypropylene mesh can be placed in a contaminated field, with several series in ventral hernias supporting this.↗
▶Ep 6 · 25:01
opinionDepending on the level of contamination and indication, it is also appropriate to perform a Bassini or McVay repair without mesh in contaminated fields.↗
▶Ep 6 · 25:01
opinionDepending on the level of contamination and indication, it is also appropriate to perform a Bassini or McVay repair without mesh in contaminated fields.↗
▶Ep 6 · 25:55
opinionFor incarcerated femoral hernias with bowel compromise, Dr. Rosen makes a vertical incision (vascular exposure), dissects onto the hernia sac, and can resect compromised bowel infrainguinally without dividing the inguinal ligament.↗
▶Ep 6 · 25:55
opinionFor incarcerated femoral hernias with bowel compromise, Dr. Rosen makes a vertical incision (vascular exposure), dissects onto the hernia sac, and can resect compromised bowel infrainguinally without dividing the inguinal ligament.↗
▶Ep 6 · 26:36
clinicalTo gain space for reducing femoral hernia contents without dividing the inguinal ligament, surgeons can release the lacunar ligament medially (which gives off from the inguinal ligament and goes to the pectineal line) to gain an extra 1 centimeter.↗
▶Ep 6 · 26:36
clinicalTo gain space for reducing femoral hernia contents without dividing the inguinal ligament, surgeons can release the lacunar ligament medially (which gives off from the inguinal ligament and goes to the pectineal line) to gain an extra 1 centimeter.↗
▶Ep 6 · 27:19
opinionDr. Rosen performs a 'reverse McVay' repair for femoral hernias from the infrainguinal approach, sewing the inferior border of the inguinal ligament down to Cooper's ligament starting medially to avoid impinging on the femoral vein.↗
▶Ep 6 · 27:19
opinionDr. Rosen performs a 'reverse McVay' repair for femoral hernias from the infrainguinal approach, sewing the inferior border of the inguinal ligament down to Cooper's ligament starting medially to avoid impinging on the femoral vein.↗
▶Ep 6 · 27:44
opinionDr. Rosen does not use mesh plugs in femoral hernia repair because femoral hernias tend to occur in thin women and he has had a DVT occur due to irritation of the femoral vein from the plug.↗
▶Ep 6 · 27:44
opinionDr. Rosen does not use mesh plugs in femoral hernia repair because femoral hernias tend to occur in thin women and he has had a DVT occur due to irritation of the femoral vein from the plug.↗
▶Ep 6 · 28:12
opinionFor recurrent inguinal hernias, surgeons should approach from where nobody has been before, or if both spaces have been operated, go where they are most skilled.↗
▶Ep 6 · 28:12
opinionFor recurrent inguinal hernias, surgeons should approach from where nobody has been before, or if both spaces have been operated, go where they are most skilled.↗
▶Ep 6 · 28:31
opinionFor known bilateral inguinal hernias in a skilled laparoscopic surgeon's hands, laparoscopy is the preferred approach.↗
▶Ep 6 · 28:31
opinionFor known bilateral inguinal hernias in a skilled laparoscopic surgeon's hands, laparoscopy is the preferred approach.↗
▶Ep 6 · 28:36
opinionSurgeons learning laparoscopic inguinal hernia repair should avoid bilateral and recurrent hernias during their learning curve, even though these patients might benefit most from laparoscopy, because these cases are twice as hard.↗
▶Ep 6 · 28:36
opinionSurgeons learning laparoscopic inguinal hernia repair should avoid bilateral and recurrent hernias during their learning curve, even though these patients might benefit most from laparoscopy, because these cases are twice as hard.↗
▶Ep 6 · 29:10
opinionFor large inguinoscrotal hernias, Dr. Rosen now performs all repairs open, whereas when he was younger he did them laparoscopically.↗
▶Ep 6 · 29:10
opinionFor large inguinoscrotal hernias, Dr. Rosen now performs all repairs open, whereas when he was younger he did them laparoscopically.↗
▶Ep 6 · 29:23
opinionFor incarcerated hernias that are difficult to reduce, Dr. Rosen puts patients to sleep and reduces the hernia under general anesthesia, then can proceed with TAPP repair.↗
▶Ep 6 · 29:23
opinionFor incarcerated hernias that are difficult to reduce, Dr. Rosen puts patients to sleep and reduces the hernia under general anesthesia, then can proceed with TAPP repair.↗
▶Ep 6 · 29:30
opinionFor truly incarcerated hernias, TEP repair is not a good idea because surgeons want the hernia contents out of the sac; TAPP is preferred.↗
▶Ep 6 · 29:30
opinionFor truly incarcerated hernias, TEP repair is not a good idea because surgeons want the hernia contents out of the sac; TAPP is preferred.↗
▶Ep 6 · 29:43
clinicalSurgeons can laparoscopically cut the internal ring at the 2 o'clock position while watching the epigastric vessels to help reduce an incarcerated hernia.↗
▶Ep 6 · 29:43
clinicalSurgeons can laparoscopically cut the internal ring at the 2 o'clock position while watching the epigastric vessels to help reduce an incarcerated hernia.↗
▶Ep 6 · 29:53
opinionIf an incarcerated hernia cannot be reduced laparoscopically, it should be done open, because making holes in the bowel increases the morbidity of the operation unacceptably high.↗
▶Ep 6 · 29:53
opinionIf an incarcerated hernia cannot be reduced laparoscopically, it should be done open, because making holes in the bowel increases the morbidity of the operation unacceptably high.↗
Inguinal Hernia With M. Rosen
▶Ep 25 · 2:10
quoteI think like anybody who sent you with an inguinal hernia, first you want to do an exam and you want to confirm whether they have an inguinal hernia. I have to say that can be one of the hardest things to do because there are small hernias that on physical exam are extremely difficult to feel.↗
▶Ep 25 · 3:22
epidemiologicalIn Fitzgibbons' VA study of minimally symptomatic to asymptomatic hernias in patients in their 70s-80s, the risk of presenting with an emergency problem requiring operation due to incarceration or strangulation was less than 1% (actually one-third of 1%).↗
▶Ep 25 · 4:00
epidemiologicalIn Fitzgibbons' original two-year VA study, almost one-third of patients in the observation group went on to develop symptoms and need an operation.↗
▶Ep 25 · 4:00
quoteSo it's safe to watch people. But the problem with this study is this study was over two years. Almost a third of the patients went on to develop symptoms and need an operation.↗
▶Ep 25 · 4:20
epidemiologicalIn long-term follow-up of Fitzgibbons' VA study patients (approximately five years), almost three-quarters of patients developed symptoms requiring repair.↗
▶Ep 25 · 8:20
quoteI think that the right answer to that question would be defined based on the patient that you have in front of you. And I think equally, if not more important, based on your skill set and where you're at with the learning curve of all of these operations.↗
▶Ep 25 · 8:30
quoteAnd it's been shown in the literature that the best approach is what you do best.↗
▶Ep 25 · 8:40
clinicalThe learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200 to 250 cases required.↗
▶Ep 25 · 9:20
clinicalIn laparoscopic inguinal hernia repair, mesh is placed away from the nerves, and the risk of chronic pain when done correctly is lower than in open inguinal hernias.↗
▶Ep 25 · 12:10
clinicalLaparoscopic repair offers approximately one week to 10 days earlier recovery compared to open repair, not a month or three to four months.↗
▶Ep 25 · 12:30
quoteI think the disadvantage of it is that you have to operate near the intestines, whereas open, you're in a separate plane. So there is a risk of intestinal injury. There's a risk of injury to the major blood vessels because you're in that area. But again, if you are safe and know those planes, that risk should be incredibly low.↗
▶Ep 25 · 15:50
quoteYou have to check your minimally invasive ego at the door and make sure that you also can do opening oral hernias or in a patient who's a candidate, send it to somebody who can do opening oral hernias. Because if you're pushing it laparoscopically in a sick, comorbid patient, more often than not, it's because you don't feel comfortable doing it the opening of the way and you use your go-to move.↗
▶Ep 25 · 18:20
clinicalThe most important part of any laparoscopic repair is parietalization of the cord (stripping the peritoneum off the cord inferiorly and posteriorly), a principle promoted by Rene Stoppa during open preperitoneal repairs.↗
▶Ep 25 · 18:20
quoteI think the most important part of any laparoscopic repair, and it's a basic principle that Rene Stoppa promoted during open preperitoneal repairs, which is parietalization of the cord, which essentially just means stripping the peritoneum off the cord inferiorly and posteriorly.↗
▶Ep 25 · 18:40
clinicalThe risk of recurrence in laparoscopic repair is the peritoneum coming under the mesh and then going back out to the defect inferiorly.↗
▶Ep 25 · 18:54
quoteAnd the inferior dissection is the Achilles heel of any laparoscopic repair because it's awkward to view it. It's a little bit scary that you're going to start to make holes in it, and you're taking it very close off the vessels.↗
▶Ep 25 · 20:00
clinicalAccording to Stoppa's original descriptions, for a unilateral inguinal hernia repair, one should never use less than a 15 by 15 centimeter piece of mesh (or 6 by 6 inch), which is much bigger than the vast majority of laparoscopic preformed meshes being placed.↗
▶Ep 25 · 21:20
clinicalHeavyweight mesh is approximately 90 grams per meter squared (Marlex or Prolene mesh), midweight mesh is 40-50 grams per meter squared, and lightweight mesh (Ultrapro) is less than 30 grams per meter squared.↗
▶Ep 25 · 22:00
clinicalThe advantage of lighter weight mesh is less foreign body and potentially less contraction due to better ingrowth; the disadvantage is half the material, which in direct hernias where muscles never come back together puts the mesh at risk for fracturing.↗
▶Ep 25 · 23:00
quoteIf you're doing an inguinal hernia, I don't think you should ever use smaller than a large of those preformed meshes because you need to cover the whole myelope.↗
▶Ep 25 · 23:20
quoteIf you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon. It's that you didn't dissect out the space to put the mesh. And it's not because you have too big of a mesh. It's because you need to take out the mesh and dissect bigger.↗
▶Ep 25 · 24:09
clinicalThere is no evidence that absorbable fixation causes reduction in pain, better fixation, or improved long-term outcomes compared to permanent fixation.↗
▶Ep 25 · 24:20
clinicalIf absorbable fixation is put through a nerve, it is the neuroma that causes the problem, not the tack itself.↗
▶Ep 25 · 24:56
clinicalThere is mounting evidence that medium-weight polypropylene mesh can be placed in a contaminated field, with several series demonstrating this in ventral hernias.↗
▶Ep 25 · 27:00
clinicalFor incarcerated femoral hernias, the lacunar ligament can be released medially to gain an extra centimeter of space for reduction without destroying the inguinal floor or inguinal ligament.↗
▶Ep 25 · 28:12
opinionFor recurrent hernias, the surgeon should go where nobody has been before; if somebody has been in both places, go where you are best.↗
▶Ep 25 · 28:30
opinionFor bilateral hernias in a skilled laparoscopic surgeon, laparoscopy is the best approach.↗
▶Ep 25 · 28:40
opinionSurgeons learning laparoscopic inguinal hernia repair should avoid bilateral and recurrent hernias during their learning curve, although these patients might benefit most, they have the highest risk.↗
Inguinal Hernia With M. Rosen
▶Ep 27 · 4:40
opinionFor an 89-year-old with asymptomatic hernia, observation is appropriate because odds are in a couple years they might not develop symptoms, but in younger patients the odds are against them living the rest of their life without symptoms.↗
▶Ep 27 · 6:32
clinicalInguinal hernias can be repaired under local anesthesia in high-risk patients with severe comorbidities (cardiac disease, ascites, coagulopathy).↗
▶Ep 27 · 8:20
quoteI think that the right answer to that question would be defined based on the patient that you have in front of you. And I think equally, if not more important, based on your skill set and where you're at with the learning curve of all of these operations.↗
▶Ep 27 · 9:20
clinicalThe primary advantage of laparoscopic repair is placing mesh away from nerves, resulting in lower risk of chronic pain compared to open repair when done correctly.↗
▶Ep 27 · 9:20
quoteWith the primary reason that there is one difference in skilled surgeons' hands that seems to be consistent, is that laparoscopy, you're putting the mesh away from the nerves, and the risk of chronic pain in laparoscopic inguinal hernia repair, when done right, is lower than the risk in open inguinal hernias.↗
▶Ep 27 · 9:50
epidemiologicalChronic pain incidence in open inguinal hernia repair varies depending on measurement method: very high if detailed surveys are used, lower if only counting patients who present with complaints.↗
▶Ep 27 · 12:10
clinicalLaparoscopic repair offers approximately one week to 10 days earlier recovery compared to open repair.↗
▶Ep 27 · 12:25
clinicalThe disadvantage of laparoscopic repair is operating near intestines with risk of intestinal injury and major blood vessel injury, though this risk should be incredibly low with proper technique.↗
▶Ep 27 · 13:20
opinionIn elderly patients or those on anticoagulation requiring quick restart, open repair is preferred to avoid dissecting the retroperitoneal space.↗
▶Ep 27 · 14:26
opinionIn a 78-year-old with symptomatic hernia on one side and asymptomatic hernia discovered laparoscopically on the other side, repairing the asymptomatic side doubles anesthetic time and increases hematoma risk without clear benefit.↗
▶Ep 27 · 15:50
quoteI think you also have to remember that, and I said this before, but, you know, the benefits of laparoscopy are small for the vast majority of patients. Still worthwhile. But you have to check your minimally invasive ego at the door and make sure that you also can do opening oral hernias or in a patient who's a candidate, send it to somebody who can do opening oral hernias.↗
▶Ep 27 · 16:26
opinionPrevious lower abdominal surgery increases risk of enterotomy and OR time for laparoscopic repair; if patient has not had previous open inguinal hernia, open approach is preferred.↗
▶Ep 27 · 16:55
opinionPrevious prostate surgery creates unpredictable difficulty for laparoscopic repair, ranging from straightforward to brutal; currently managed with open repair.↗
▶Ep 27 · 17:58
clinicalThe most important part of laparoscopic repair is parietalization of the cord (stripping peritoneum off cord inferiorly and posteriorly), a principle promoted by Rene Stoppa in open preperitoneal repairs.↗
▶Ep 27 · 18:10
quoteI think the most important part of any laparoscopic repair, and it's a basic principle that Rene Stoppa promoted during open preperitoneal repairs, which is parietalization of the cord, which essentially just means stripping the peritoneum off the cord inferiorly and posteriorly.↗
▶Ep 27 · 18:40
quoteAnd the inferior dissection is the Achilles heel of any laparoscopic repair because it's awkward to view it. It's a little bit scary that you're going to start to make holes in it, and you're taking it very close off the vessels.↗
▶Ep 27 · 18:40
clinicalThe inferior dissection is the Achilles heel of laparoscopic repair because it is awkward to view, risky for creating peritoneal holes, and close to vessels.↗
▶Ep 27 · 20:30
opinionFor large direct hernias, heavier weight mesh material should be used.↗
▶Ep 27 · 21:02
clinicalHeavyweight mesh is approximately 90 grams per meter squared (Marlex or Prolene), midweight is 40-50 grams per meter squared, and lightweight (Ultrapro) is less than 30 grams per meter squared.↗
▶Ep 27 · 21:50
clinicalLightweight mesh has less foreign body and may contract less due to better ingrowth, but has half the material and is at risk for fracturing, particularly in direct hernias where it bridges and muscles never come together.↗
▶Ep 27 · 22:30
clinicalHeavier weight mesh rarely breaks but can cause chronic pain if wrinkles or buckles are present in the groin.↗
▶Ep 27 · 23:00
opinionSurgeons commonly downsize preformed meshes; for inguinal hernia repair, never use smaller than a large preformed mesh to cover the entire myopectineal orifice.↗
▶Ep 27 · 23:24
clinicalIf struggling with mesh placement during laparoscopic repair, the problem is inadequate dissection of the space, not oversized mesh; the solution is to remove mesh and dissect more widely.↗
▶Ep 27 · 23:24
quoteAnd so if you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon. It's that you didn't dissect out the space to put the mesh. And it's not because you have too big of a mesh. It's because you need to take out the mesh and dissect bigger.↗
▶Ep 27 · 24:09
clinicalThere is no evidence that absorbable fixation causes reduction in pain, provides better fixation, or improves long-term outcomes compared to permanent fixation.↗
▶Ep 27 · 24:20
clinicalIf absorbable tack is placed through a nerve, it is the neuroma that causes the problem, not the tack itself.↗
▶Ep 27 · 25:10
opinionBassini or McVay tissue repairs remain appropriate operations for contaminated fields.↗
▶Ep 27 · 25:55
clinicalFor incarcerated femoral hernia with bowel compromise, an infrainguinal vertical incision allows direct access to the hernia sac, bowel resection if needed, and reduction without dividing the inguinal ligament.↗
▶Ep 27 · 26:35
clinicalTo facilitate reduction of incarcerated femoral hernia contents, the lacunar ligament (medial to femoral space) can be released with scissors or bovie to gain an extra centimeter, avoiding destruction of the inguinal ligament.↗
▶Ep 27 · 27:20
clinicalReverse McVay repair for femoral hernia involves taking the inferior border of the inguinal ligament and sewing it down to Cooper's ligament from below, starting immediately lateral to the femoral vein to avoid impingement.↗
▶Ep 27 · 27:46
clinicalMesh plugs in femoral hernia repair can cause DVT due to irritation of the femoral vein, particularly in thin women who typically present with femoral hernias.↗
▶Ep 27 · 28:12
opinionFor recurrent hernias, operate where no prior surgery has been performed; if both spaces have been operated, choose the approach where you have the most skill.↗
▶Ep 27 · 28:30
opinionFor bilateral hernias in a skilled laparoscopic surgeon, laparoscopy is the best approach, but surgeons learning laparoscopy should avoid bilateral and recurrent hernias as these are twice as hard despite potentially offering the most benefit.↗
▶Ep 27 · 29:09
opinionLarge inguinoscrotal hernias are managed with open operation; if truly incarcerated and cannot be reduced in office, open approach is used.↗
▶Ep 27 · 29:30
clinicalFor difficult-to-reduce but not truly incarcerated hernias, patient can be put to sleep for reduction under anesthesia, then TAPP repair performed; the internal ring can be cut laparoscopically at the two o'clock position (avoiding epigastric vessels) to facilitate reduction.↗
▶Ep 27 · 30:00
clinicalIf bowel holes are made during incarcerated hernia repair, the morbidity of the operation increases unacceptably high.↗
Inguinal Hernia With M. Rosen
▶Ep 28 · 2:10
quoteI think like anybody who sent you with an inguinal hernia, first you want to do an exam and you want to confirm whether they have an inguinal hernia. I have to say that can be one of the hardest things to do because there are small hernias that on physical exam are extremely difficult to feel.↗
▶Ep 28 · 4:30
opinionFor an 89-year-old with asymptomatic hernia, observation is appropriate because in a couple years they might not have symptoms, but in younger patients the odds are against them living without it becoming symptomatic.↗
▶Ep 28 · 6:32
clinicalInguinal hernia repairs can be done under local anesthesia in patients with severe comorbidities, and it is worse for them to present with an emergency problem in the middle of the night.↗
▶Ep 28 · 8:20
quoteI think that the right answer to that question would be defined based on the patient that you have in front of you. And I think equally, if not more important, based on your skill set and where you're at with the learning curve of all of these operations.↗
▶Ep 28 · 9:20
clinicalThe primary advantage of laparoscopy in skilled hands is that mesh is placed away from nerves, and the risk of chronic pain is lower than in open inguinal hernias.↗
▶Ep 28 · 9:40
quoteI think that how do you measure chronic pain in open inguinal hernias depends. If you do a very detailed survey, you'll have a very high incidence of chronic pain. If you just wait until patients come back and present with chronic pain, it will be lower. But those patients are absolutely miserable.↗
▶Ep 28 · 10:44
quoteI think the TEP pair, it's a little bit more expensive because you need to use the balloon. It's a little bit smaller of a space, but perhaps the angles are a little bit easier to operate with. I think a TAP, you get a little bit of a better view. You get a little bit more of a working space.↗
▶Ep 28 · 11:20
quoteThe way that I look at it is it's the same room. One comes through the front door. One comes through the ceiling. Ultimately, you work in the same space, and it should be the same operation regardless.↗
▶Ep 28 · 11:53
opinionFor young, healthy, active patients with unilateral hernia who are not anesthetic risks, laparoscopic repair is preferred in experienced hands, offering about a week to 10 days earlier recovery than open repair.↗
▶Ep 28 · 12:30
clinicalDisadvantages of laparoscopic repair include operating near intestines with risk of intestinal injury and risk of injury to major blood vessels, though these risks should be incredibly low if planes are known.↗
▶Ep 28 · 13:00
opinionIn elderly patients or anyone on anticoagulation who needs to restart quickly, open operation is preferred to avoid dissecting the retroperitoneal space.↗
▶Ep 28 · 14:09
opinionIn a 78-year-old patient with symptomatic hernia on one side and asymptomatic hernia discovered laparoscopically on the other side, the asymptomatic side should not be repaired due to doubled anesthetic time and increased hematoma risk.↗
▶Ep 28 · 14:58
opinionIn younger active patients, an asymptomatic contralateral hernia discovered laparoscopically should be repaired because the chance of it becoming symptomatic is much higher.↗
▶Ep 28 · 15:50
quoteI think that you also have to remember that, and I said this before, but, you know, the benefits of laparoscopy are small for the vast majority of patients. Still worthwhile. But you have to check your minimally invasive ego at the door.↗
▶Ep 28 · 16:26
opinionPrevious lower abdominal surgery increases risk of enterotomy and OR time for laparoscopic repair; if patient hasn't had open inguinal hernia, open approach is preferred.↗
▶Ep 28 · 16:55
opinionPrevious prostate surgery cases are unpredictable laparoscopically and can be brutal; in current practice these get open inguinal hernia repair.↗
▶Ep 28 · 17:58
clinicalThe most important part of any laparoscopic repair is parietalization of the cord (stripping peritoneum off the cord inferiorly and posteriorly), a principle promoted by Rene Stoppa during open preperitoneal repairs.↗
▶Ep 28 · 18:10
quoteI think the most important part of any laparoscopic repair, and it's a basic principle that Rene Stoppa promoted during open preperitoneal repairs, which is parietalization of the cord, which essentially just means stripping the peritoneum off the cord inferiorly and posteriorly.↗
▶Ep 28 · 18:40
clinicalThe inferior dissection is the Achilles heel of any laparoscopic repair because it's awkward to view, scary to make holes, and taken very close off the vessels.↗
▶Ep 28 · 18:40
quoteAnd the inferior dissection is the Achilles heel of any laparoscopic repair because it's awkward to view it. It's a little bit scary that you're going to start to make holes in it, and you're taking it very close off the vessels.↗
▶Ep 28 · 20:40
opinionFor large direct hernias, mesh choice should change to a heavier weight material.↗
▶Ep 28 · 21:02
clinicalHeavyweight mesh is around 90 grams per meter squared (Marlex or Prolene), midweight is 40-50 grams per meter squared, and lightweight (Ultrapro) is less than 30 grams per meter squared.↗
▶Ep 28 · 21:50
clinicalAdvantage of lighter weight mesh is less foreign body and less contraction; disadvantage is half the material with risk of fracturing, particularly in direct hernias where it's a bridge.↗
▶Ep 28 · 22:30
clinicalHeavier weight mesh rarely breaks but sometimes people feel it in their groin if there are wrinkles or buckles, which can cause issues.↗
▶Ep 28 · 23:00
quoteSo if you're doing an inguinal hernia, I don't think you should ever use smaller than a large of those preformed meshes because you need to cover the whole myelope.↗
▶Ep 28 · 23:00
opinionFor inguinal hernia repair, should never use smaller than a large preformed mesh because you need to cover the whole myopectineal orifice.↗
▶Ep 28 · 23:24
quoteAnd so if you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon. It's that you didn't dissect out the space to put the mesh.↗
▶Ep 28 · 23:24
clinicalIf struggling with mesh placement during laparoscopic repair, it's not that you're not a good enough laparoscopic surgeon, it's that you didn't dissect out the space enough - you need to take out the mesh and dissect bigger.↗
▶Ep 28 · 23:53
opinionMesh should be fixed in place; options include Protack tacks, glue, or no fixation, though for big direct hernias everybody uses fixation.↗
▶Ep 28 · 24:09
clinicalThere is no evidence that absorbable fixation causes reduction in pain, better fixation, or improved long-term outcomes; permanent fixation is used because if absorbable fixation goes through a nerve, it's the neuroma that causes the problem, not the tack.↗
▶Ep 28 · 24:09
quoteNo evidence that absorbable fixation causes reduction in pain, better fixation, or improve long-term outcomes. So I use permanent fixation. And absorbable fixation, if you put it through the nerve, it's the neuroma that causes the problem, not the attack.↗
▶Ep 28 · 25:55
clinicalFor incarcerated femoral hernia with bowel compromise, make a vertical incision for vascular-type exposure, dissect onto hernia sac, bring out compromised intestine infrainguinally, resect and anastomose, then reduce.↗
▶Ep 28 · 26:32
clinicalTo reduce incarcerated femoral hernia without dividing inguinal ligament, release the lacunar ligament medially (which gives off from the inguinal ligament) to gain an extra centimeter of space.↗
▶Ep 28 · 27:10
clinicalA 'reverse McVay' repair can be performed from below for femoral hernias, taking the inferior border of the inguinal ligament and sewing it down to Cooper's ligament starting immediately lateral to the femoral vein.↗
▶Ep 28 · 27:46
clinicalMesh plugs are not preferred for femoral hernias because femoral hernias tend to occur in thin women and there have been DVTs due to irritation on the femoral vein.↗
▶Ep 28 · 28:12
opinionFor recurrent hernias, operate where nobody has been before; if both spaces have been operated, go where you're best.↗
▶Ep 28 · 28:30
opinionFor bilateral hernias in a skilled laparoscopic surgeon, laparoscopy is the best approach, but if learning, avoid bilateral and recurrent hernias laparoscopically because it makes it twice as hard despite these patients getting the most benefit.↗
▶Ep 28 · 29:09
opinionFor really big inguinal scrotal hernias that can't be reduced in office, open operation is preferred; when younger, these were done laparoscopically but now all done open.↗
▶Ep 28 · 29:40
clinicalFor incarcerated hernias, TAP approach is preferred over TEP because you want the contents out of the hernia; can laparoscopically cut the internal ring at the two o'clock position relative to epigastric vessels to help reduce.↗
Michael's statements about Low Cardiac Output150 statements
quoteI have to say that can be one of the hardest things to do because there are small hernias that on physical exam are extremely difficult to feel.↗
▶Ep 1 · 2:17
quoteI have to say that can be one of the hardest things to do because there are small hernias that on physical exam are extremely difficult to feel.↗
▶Ep 1 · 2:38
quoteJust remember that anytime somebody stands up and coughs or does a Valsalva, there's always the cord structures that are gonna be giving you an impulse, so you really wanna make sure that you actually see a bulge, and it's a true hernia.↗
▶Ep 1 · 2:38
quoteJust remember that anytime somebody stands up and coughs or does a Valsalva, there's always the cord structures that are gonna be giving you an impulse, so you really wanna make sure that you actually see a bulge, and it's a true hernia.↗
▶Ep 1 · 3:30
epidemiologicalIn the Fitzgibbons VA study of minimally symptomatic to asymptomatic inguinal hernias in patients in their 70s-80s, the risk of presenting with an emergency problem (incarceration or strangulation) requiring operation was 0.3% over 2 years.↗
▶Ep 1 · 3:30
epidemiologicalIn the Fitzgibbons VA study of minimally symptomatic to asymptomatic inguinal hernias in patients in their 70s-80s, the risk of presenting with an emergency problem (incarceration or strangulation) requiring operation was 0.3% over 2 years.↗
▶Ep 1 · 4:11
epidemiologicalIn the Fitzgibbons study, almost one-third of patients in the observation group developed symptoms requiring operation by 2 years.↗
▶Ep 1 · 4:11
epidemiologicalIn the Fitzgibbons study, almost one-third of patients in the observation group developed symptoms requiring operation by 2 years.↗
▶Ep 1 · 4:21
epidemiologicalIn long-term follow-up of the Fitzgibbons study, almost three-fifths of patients in the observation group developed symptoms requiring operation by 5 years.↗
▶Ep 1 · 4:21
epidemiologicalIn long-term follow-up of the Fitzgibbons study, almost three-fifths of patients in the observation group developed symptoms requiring operation by 5 years.↗
▶Ep 1 · 4:33
opinionFor an 89-year-old patient with an asymptomatic hernia, watchful waiting is acceptable because the odds are they may not develop symptoms over their remaining lifespan.↗
▶Ep 1 · 4:33
opinionFor an 89-year-old patient with an asymptomatic hernia, watchful waiting is acceptable because the odds are they may not develop symptoms over their remaining lifespan.↗
▶Ep 1 · 4:36
quoteThe odds are in a couple of years, they might not have any symptoms and you'll be OK, but in a younger patient, the odds are against them that they're going to live the rest of their life without this becoming symptomatic.↗
▶Ep 1 · 4:36
quoteThe odds are in a couple of years, they might not have any symptoms and you'll be OK, but in a younger patient, the odds are against them that they're going to live the rest of their life without this becoming symptomatic.↗
▶Ep 1 · 4:36
opinionFor younger patients with asymptomatic hernias, the odds are against them living the rest of their life without the hernia becoming symptomatic, so repair should be recommended when the time is right.↗
▶Ep 1 · 4:36
opinionFor younger patients with asymptomatic hernias, the odds are against them living the rest of their life without the hernia becoming symptomatic, so repair should be recommended when the time is right.↗
▶Ep 1 · 6:06
clinicalInguinal hernia repairs can be performed under local anesthesia in high-risk patients.↗
▶Ep 1 · 6:06
opinionFor symptomatic hernias in high-risk patients, it is much worse for them to present with an emergency problem in the middle of the night, which could be life-threatening, so they should still be offered repair.↗
▶Ep 1 · 6:06
quoteIt's much worse for them to present with an emergency problem in the middle of the night, which could be life threatening.↗
▶Ep 1 · 6:06
opinionFor symptomatic hernias in high-risk patients, it is much worse for them to present with an emergency problem in the middle of the night, which could be life-threatening, so they should still be offered repair.↗
▶Ep 1 · 6:06
clinicalInguinal hernia repairs can be performed under local anesthesia in high-risk patients.↗
▶Ep 1 · 6:06
quoteIt's much worse for them to present with an emergency problem in the middle of the night, which could be life threatening.↗
▶Ep 1 · 7:56
clinicalFor unilateral primary inguinal hernias, tissue repair, open mesh repair, or laparoscopic mesh repair are all acceptable approaches with ample literature support.↗
▶Ep 1 · 7:56
clinicalFor unilateral primary inguinal hernias, tissue repair, open mesh repair, or laparoscopic mesh repair are all acceptable approaches with ample literature support.↗
▶Ep 1 · 8:29
opinionThe best approach for inguinal hernia repair is what the surgeon does best, and this is supported by literature.↗
▶Ep 1 · 8:29
opinionThe best approach for inguinal hernia repair is what the surgeon does best, and this is supported by literature.↗
▶Ep 1 · 9:04
opinionFor young, healthy patients with unilateral hernias who are not anesthetic risks, laparoscopic repair is preferred by Dr. Rosen if the surgeon is past the learning curve.↗
▶Ep 1 · 9:04
epidemiologicalThe learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200-250 cases required.↗
▶Ep 1 · 9:04
opinionFor young, healthy patients with unilateral hernias who are not anesthetic risks, laparoscopic repair is preferred by Dr. Rosen if the surgeon is past the learning curve.↗
▶Ep 1 · 9:04
epidemiologicalThe learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200-250 cases required.↗
▶Ep 1 · 9:18
clinicalIn laparoscopic inguinal hernia repair, the mesh is placed away from the nerves, and the risk of chronic pain is lower than in open inguinal hernia repair when done correctly.↗
▶Ep 1 · 9:18
clinicalIn laparoscopic inguinal hernia repair, the mesh is placed away from the nerves, and the risk of chronic pain is lower than in open inguinal hernia repair when done correctly.↗
▶Ep 1 · 9:51
clinicalChronic pain after open inguinal hernia repair can occur due to technical problems or simply due to mesh laying on the nerves, and affected patients are absolutely miserable.↗
▶Ep 1 · 9:51
clinicalChronic pain after open inguinal hernia repair can occur due to technical problems or simply due to mesh laying on the nerves, and affected patients are absolutely miserable.↗
▶Ep 1 · 10:45
epidemiologicalTAPP (transabdominal preperitoneal) and TEP (total extraperitoneal) approaches have not been studied well enough to provide level-one evidence distinguishing their outcomes.↗
▶Ep 1 · 10:45
epidemiologicalTAPP (transabdominal preperitoneal) and TEP (total extraperitoneal) approaches have not been studied well enough to provide level-one evidence distinguishing their outcomes.↗
▶Ep 1 · 10:58
clinicalTEP repair requires use of a balloon dissector, which is more expensive, and provides a smaller working space but perhaps easier angles to operate with.↗
▶Ep 1 · 10:58
clinicalTEP repair requires use of a balloon dissector, which is more expensive, and provides a smaller working space but perhaps easier angles to operate with.↗
▶Ep 1 · 11:09
clinicalTAPP repair provides a better view and larger working space, and makes it easier for surgeons early in their learning curve to look intraperitoneally and confirm hernia reduction.↗
▶Ep 1 · 11:09
clinicalTAPP repair provides a better view and larger working space, and makes it easier for surgeons early in their learning curve to look intraperitoneally and confirm hernia reduction.↗
▶Ep 1 · 11:26
clinicalTAPP and TEP ultimately work in the same anatomical space—one enters through the front door, one through the ceiling—and should result in the same operation.↗
▶Ep 1 · 11:26
clinicalTAPP and TEP ultimately work in the same anatomical space—one enters through the front door, one through the ceiling—and should result in the same operation.↗
▶Ep 1 · 12:11
quoteI think that that surgical skill is critical, and you don't want to be getting an inguinal hernia in the patient's first in the surgeon's first couple laparoscopic inguinal hernia operates because there is a real learning curve.↗
▶Ep 1 · 12:11
quoteI think that that surgical skill is critical, and you don't want to be getting an inguinal hernia in the patient's first in the surgeon's first couple laparoscopic inguinal hernia operates because there is a real learning curve.↗
▶Ep 1 · 12:23
clinicalLaparoscopic inguinal hernia repair offers approximately 1 week to 10 days earlier recovery compared to open repair.↗
▶Ep 1 · 12:23
quoteThe laparoscopic repair offers you about 1 week to 10 days earlier recovery. It's not a month, it's not 3 or 4 months, but it is about 1 week to 10 days in my practice.↗
▶Ep 1 · 12:23
quoteThe laparoscopic repair offers you about 1 week to 10 days earlier recovery. It's not a month, it's not 3 or 4 months, but it is about 1 week to 10 days in my practice.↗
▶Ep 1 · 12:23
clinicalLaparoscopic inguinal hernia repair offers approximately 1 week to 10 days earlier recovery compared to open repair.↗
▶Ep 1 · 12:45
clinicalLaparoscopic inguinal hernia repair carries a risk of intestinal injury and injury to major blood vessels because the operation is performed near these structures, but this risk should be incredibly low if the surgeon knows the planes and operates safely.↗
▶Ep 1 · 12:45
clinicalLaparoscopic inguinal hernia repair carries a risk of intestinal injury and injury to major blood vessels because the operation is performed near these structures, but this risk should be incredibly low if the surgeon knows the planes and operates safely.↗
▶Ep 1 · 13:06
quoteThe consequence of chronic pain, which is starting to become one of the most common things that I see in my clinic with open mesh repairs, it is not worth that risk in a young, healthy, active patient.↗
▶Ep 1 · 13:06
quoteThe consequence of chronic pain, which is starting to become one of the most common things that I see in my clinic with open mesh repairs, it is not worth that risk in a young, healthy, active patient.↗
▶Ep 1 · 13:28
opinionIn elderly patients with any anesthetic risk or anyone on anticoagulation who needs to restart quickly, Dr. Rosen prefers open repair because he does not want to dissect the retroperitoneal space in these patients.↗
▶Ep 1 · 13:28
opinionIn elderly patients with any anesthetic risk or anyone on anticoagulation who needs to restart quickly, Dr. Rosen prefers open repair because he does not want to dissect the retroperitoneal space in these patients.↗
▶Ep 1 · 14:10
opinionIn a 78-year-old patient with a symptomatic hernia on one side and an asymptomatic hernia discovered laparoscopically on the other side, Dr. Rosen does not fix the asymptomatic side, citing concerns about doubling anesthetic time and increasing hematoma risk.↗
▶Ep 1 · 14:10
opinionIn a 78-year-old patient with a symptomatic hernia on one side and an asymptomatic hernia discovered laparoscopically on the other side, Dr. Rosen does not fix the asymptomatic side, citing concerns about doubling anesthetic time and increasing hematoma risk.↗
▶Ep 1 · 15:17
clinicalPneumoperitoneum is rarely a problem in patients with reduced cardiac capacity as long as insufflation is done slowly, pressures are kept low, and the patient is positioned in Trendelenburg to help cardiac return.↗
▶Ep 1 · 15:17
clinicalPneumoperitoneum is rarely a problem in patients with reduced cardiac capacity as long as insufflation is done slowly, pressures are kept low, and the patient is positioned in Trendelenburg to help cardiac return.↗
▶Ep 1 · 15:39
opinionThe benefits of laparoscopy for inguinal hernia repair are small for the vast majority of patients, though still worthwhile.↗
▶Ep 1 · 15:39
opinionThe benefits of laparoscopy for inguinal hernia repair are small for the vast majority of patients, though still worthwhile.↗
▶Ep 1 · 15:55
quoteYou have to check your minimally invasive ego at the door and make sure that you also can do opening oral hernias or in a patient who's a candidate, send it to somebody who can do opening oral hernias.↗
▶Ep 1 · 15:55
quoteYou have to check your minimally invasive ego at the door and make sure that you also can do opening oral hernias or in a patient who's a candidate, send it to somebody who can do opening oral hernias.↗
▶Ep 1 · 15:55
opinionSurgeons must check their minimally invasive ego at the door and ensure they can also perform open inguinal hernias or refer to someone who can, rather than pushing laparoscopy in sick comorbid patients simply because it is their go-to approach.↗
▶Ep 1 · 15:55
opinionSurgeons must check their minimally invasive ego at the door and ensure they can also perform open inguinal hernias or refer to someone who can, rather than pushing laparoscopy in sick comorbid patients simply because it is their go-to approach.↗
▶Ep 1 · 16:24
opinionPrevious lower abdominal surgery is a contraindication to laparoscopic inguinal hernia repair in Dr. Rosen's practice because it increases the risk of enterotomy and OR time.↗
▶Ep 1 · 16:24
opinionPrevious lower abdominal surgery is a contraindication to laparoscopic inguinal hernia repair in Dr. Rosen's practice because it increases the risk of enterotomy and OR time.↗
▶Ep 1 · 16:42
opinionPrevious prostate surgery makes laparoscopic inguinal hernia repair unpredictable—sometimes straightforward, sometimes brutal—and Dr. Rosen now performs these as open repairs.↗
▶Ep 1 · 16:42
opinionPrevious prostate surgery makes laparoscopic inguinal hernia repair unpredictable—sometimes straightforward, sometimes brutal—and Dr. Rosen now performs these as open repairs.↗
▶Ep 1 · 17:52
clinicalBasic tenets of laparoscopic inguinal hernia repair include achieving a wide dissection plane, with parietalization of the cord (stripping peritoneum off the cord inferiorly and posteriorly) being the most critical element.↗
▶Ep 1 · 17:52
clinicalBasic tenets of laparoscopic inguinal hernia repair include achieving a wide dissection plane, with parietalization of the cord (stripping peritoneum off the cord inferiorly and posteriorly) being the most critical element.↗
▶Ep 1 · 18:15
clinicalParietalization of the cord is a basic principle promoted by René Stoppa during open preperitoneal repairs.↗
▶Ep 1 · 18:15
clinicalParietalization of the cord is a basic principle promoted by René Stoppa during open preperitoneal repairs.↗
▶Ep 1 · 18:27
clinicalThe length of parietalization is critical because it prevents the peritoneum from coming under the mesh and going back out to the defect, which is the mechanism of recurrence.↗
▶Ep 1 · 18:27
clinicalThe length of parietalization is critical because it prevents the peritoneum from coming under the mesh and going back out to the defect, which is the mechanism of recurrence.↗
▶Ep 1 · 18:53
clinicalThe inferior dissection is the Achilles heel of any laparoscopic inguinal hernia repair because it is awkward to view, surgeons fear making holes in the peritoneum, and it requires dissection very close to the vessels.↗
▶Ep 1 · 18:53
clinicalThe inferior dissection is the Achilles heel of any laparoscopic inguinal hernia repair because it is awkward to view, surgeons fear making holes in the peritoneum, and it requires dissection very close to the vessels.↗
▶Ep 1 · 18:56
quoteThe inferior dissection is the Achilles heel any laparoscopic repair because it's awkward to view it. It's a little bit scary you're gonna start to make holes in it and you're taking it very close off the vessels.↗
▶Ep 1 · 18:56
quoteThe inferior dissection is the Achilles heel any laparoscopic repair because it's awkward to view it. It's a little bit scary you're gonna start to make holes in it and you're taking it very close off the vessels.↗
▶Ep 1 · 19:03
clinicalWhen surgeons do not take the peritoneum far enough back inferiorly, they tend to use a smaller piece of mesh, which is problematic.↗
▶Ep 1 · 19:03
clinicalWhen surgeons do not take the peritoneum far enough back inferiorly, they tend to use a smaller piece of mesh, which is problematic.↗
▶Ep 1 · 19:30
clinicalAll mesh contracts to some degree and can move.↗
▶Ep 1 · 19:30
clinicalAll mesh contracts to some degree and can move.↗
▶Ep 1 · 19:40
quoteIf you go back and read Stopa's original descriptions, his description, if you were doing a unilateral inguinal hernia was to never use less than a 15 by 15 centimeter piece of mesh or a 6 by 6 inch piece of mesh, which is much bigger than the vast majority of laparoscopic pre-formed meshes or or meshes that are being placed.↗
▶Ep 1 · 19:40
clinicalAccording to Stoppa's original descriptions, for a unilateral inguinal hernia, surgeons should never use less than a 15 by 15 centimeter (6 by 6 inch) piece of mesh, which is much bigger than the vast majority of laparoscopic pre-formed meshes being placed.↗
▶Ep 1 · 19:40
quoteIf you go back and read Stopa's original descriptions, his description, if you were doing a unilateral inguinal hernia was to never use less than a 15 by 15 centimeter piece of mesh or a 6 by 6 inch piece of mesh, which is much bigger than the vast majority of laparoscopic pre-formed meshes or or meshes that are being placed.↗
▶Ep 1 · 19:40
clinicalAccording to Stoppa's original descriptions, for a unilateral inguinal hernia, surgeons should never use less than a 15 by 15 centimeter (6 by 6 inch) piece of mesh, which is much bigger than the vast majority of laparoscopic pre-formed meshes being placed.↗
▶Ep 1 · 20:26
opinionFor large direct inguinal hernias, mesh choice should change and surgeons should use a heavier weight material.↗
▶Ep 1 · 20:26
opinionFor large direct inguinal hernias, mesh choice should change and surgeons should use a heavier weight material.↗
▶Ep 1 · 21:37
clinicalHeavyweight mesh is approximately 90 grams per meter squared (e.g., Marlex or Prolene).↗
▶Ep 1 · 21:37
clinicalMesh weight categories (heavyweight, midweight, lightweight) were defined by marketing companies, not based on science.↗
▶Ep 1 · 21:37
clinicalHeavyweight mesh is approximately 90 grams per meter squared (e.g., Marlex or Prolene).↗
▶Ep 1 · 21:37
clinicalMesh weight categories (heavyweight, midweight, lightweight) were defined by marketing companies, not based on science.↗
▶Ep 1 · 21:57
clinicalMidweight mesh is between 40 to 50 grams per meter squared.↗
▶Ep 1 · 21:57
clinicalLightweight mesh (Ultrapro) is less than 30 grams per meter squared, starting heavier but degrading over time to about 28 grams per meter squared.↗
▶Ep 1 · 21:57
clinicalLightweight mesh (Ultrapro) is less than 30 grams per meter squared, starting heavier but degrading over time to about 28 grams per meter squared.↗
▶Ep 1 · 21:57
clinicalMidweight mesh is between 40 to 50 grams per meter squared.↗
▶Ep 1 · 22:16
clinicalAdvantages of lighter weight mesh include less foreign body, less palpability, and potentially less contraction because it ingrows more.↗
▶Ep 1 · 22:16
clinicalAdvantages of lighter weight mesh include less foreign body, less palpability, and potentially less contraction because it ingrows more.↗
▶Ep 1 · 22:23
clinicalDisadvantages of lightweight mesh include having half the material, and in direct hernias where the mesh bridges and muscles never come together, the mesh is at risk for fracturing, with reports now showing central mesh failures.↗
▶Ep 1 · 22:23
clinicalDisadvantages of lightweight mesh include having half the material, and in direct hernias where the mesh bridges and muscles never come together, the mesh is at risk for fracturing, with reports now showing central mesh failures.↗
▶Ep 1 · 22:42
clinicalHeavier weight mesh rarely breaks, but patients sometimes feel it in their groin if there are wrinkles or buckles, which can cause issues.↗
▶Ep 1 · 22:42
clinicalHeavier weight mesh rarely breaks, but patients sometimes feel it in their groin if there are wrinkles or buckles, which can cause issues.↗
▶Ep 1 · 22:51
clinicalPre-formed meshes for inguinal hernia anatomy are technically easier to place but surgeons commonly downsize to a much smaller piece of mesh, which is problematic.↗
▶Ep 1 · 22:51
clinicalPre-formed meshes for inguinal hernia anatomy are technically easier to place but surgeons commonly downsize to a much smaller piece of mesh, which is problematic.↗
▶Ep 1 · 23:08
opinionFor laparoscopic inguinal hernia repair, surgeons should never use smaller than a large pre-formed mesh because the entire myopectineal orifice needs to be covered.↗
▶Ep 1 · 23:08
opinionFor laparoscopic inguinal hernia repair, surgeons should never use smaller than a large pre-formed mesh because the entire myopectineal orifice needs to be covered.↗
▶Ep 1 · 23:24
clinicalIf the mesh is too big during laparoscopic inguinal hernia repair, the problem is not the mesh size but inadequate dissection of the space.↗
▶Ep 1 · 23:24
quoteIf you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon, it's that you didn't dissect out the space to put the mesh.↗
▶Ep 1 · 23:24
quoteIf you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon, it's that you didn't dissect out the space to put the mesh.↗
▶Ep 1 · 23:24
clinicalIf the mesh is too big during laparoscopic inguinal hernia repair, the problem is not the mesh size but inadequate dissection of the space.↗
▶Ep 1 · 23:53
opinionDr. Rosen believes mesh should be fixed in laparoscopic inguinal hernia repair and uses ProTack, though some surgeons use glue or no fixation.↗
▶Ep 1 · 23:53
opinionDr. Rosen believes mesh should be fixed in laparoscopic inguinal hernia repair and uses ProTack, though some surgeons use glue or no fixation.↗
▶Ep 1 · 23:59
clinicalEven surgeons who advocate no fixation will selectively use fixation for large direct hernias.↗
▶Ep 1 · 23:59
clinicalEven surgeons who advocate no fixation will selectively use fixation for large direct hernias.↗
▶Ep 1 · 24:10
epidemiologicalThere is no evidence that absorbable fixation causes reduction in pain, provides better fixation, or improves long-term outcomes compared to non-absorbable fixation.↗
▶Ep 1 · 24:10
epidemiologicalThere is no evidence that absorbable fixation causes reduction in pain, provides better fixation, or improves long-term outcomes compared to non-absorbable fixation.↗
▶Ep 1 · 24:22
clinicalIf a tack is placed through a nerve, it is the neuroma that causes the problem, not the tack itself.↗
▶Ep 1 · 24:22
quoteIf you put it through the nerve, it's the neuroma that causes the problem, not the attack.↗
▶Ep 1 · 24:22
clinicalIf a tack is placed through a nerve, it is the neuroma that causes the problem, not the tack itself.↗
▶Ep 1 · 24:22
quoteIf you put it through the nerve, it's the neuroma that causes the problem, not the attack.↗
▶Ep 1 · 24:30
opinionDr. Rosen performs Lichtenstein repair as his preferred open inguinal hernia technique.↗
▶Ep 1 · 24:30
opinionDr. Rosen performs Lichtenstein repair as his preferred open inguinal hernia technique.↗
▶Ep 1 · 24:56
epidemiologicalThere is mounting evidence that medium weight polypropylene mesh can be placed in a contaminated field, with several series in ventral hernias supporting this.↗
▶Ep 1 · 24:56
epidemiologicalThere is mounting evidence that medium weight polypropylene mesh can be placed in a contaminated field, with several series in ventral hernias supporting this.↗
▶Ep 1 · 25:01
opinionDepending on the level of contamination and indication, it is also appropriate to perform a Bassini or McVay repair without mesh in contaminated fields.↗
▶Ep 1 · 25:01
opinionDepending on the level of contamination and indication, it is also appropriate to perform a Bassini or McVay repair without mesh in contaminated fields.↗
▶Ep 1 · 25:55
opinionFor incarcerated femoral hernias with bowel compromise, Dr. Rosen makes a vertical incision (vascular exposure), dissects onto the hernia sac, and can resect compromised bowel infrainguinally without dividing the inguinal ligament.↗
▶Ep 1 · 25:55
opinionFor incarcerated femoral hernias with bowel compromise, Dr. Rosen makes a vertical incision (vascular exposure), dissects onto the hernia sac, and can resect compromised bowel infrainguinally without dividing the inguinal ligament.↗
▶Ep 1 · 26:36
clinicalTo gain space for reducing femoral hernia contents without dividing the inguinal ligament, surgeons can release the lacunar ligament medially (which gives off from the inguinal ligament and goes to the pectineal line) to gain an extra 1 centimeter.↗
▶Ep 1 · 26:36
clinicalTo gain space for reducing femoral hernia contents without dividing the inguinal ligament, surgeons can release the lacunar ligament medially (which gives off from the inguinal ligament and goes to the pectineal line) to gain an extra 1 centimeter.↗
▶Ep 1 · 27:19
opinionDr. Rosen performs a 'reverse McVay' repair for femoral hernias from the infrainguinal approach, sewing the inferior border of the inguinal ligament down to Cooper's ligament starting medially to avoid impinging on the femoral vein.↗
▶Ep 1 · 27:19
opinionDr. Rosen performs a 'reverse McVay' repair for femoral hernias from the infrainguinal approach, sewing the inferior border of the inguinal ligament down to Cooper's ligament starting medially to avoid impinging on the femoral vein.↗
▶Ep 1 · 27:44
opinionDr. Rosen does not use mesh plugs in femoral hernia repair because femoral hernias tend to occur in thin women and he has had a DVT occur due to irritation of the femoral vein from the plug.↗
▶Ep 1 · 27:44
opinionDr. Rosen does not use mesh plugs in femoral hernia repair because femoral hernias tend to occur in thin women and he has had a DVT occur due to irritation of the femoral vein from the plug.↗
▶Ep 1 · 28:12
opinionFor recurrent inguinal hernias, surgeons should approach from where nobody has been before, or if both spaces have been operated, go where they are most skilled.↗
▶Ep 1 · 28:12
opinionFor recurrent inguinal hernias, surgeons should approach from where nobody has been before, or if both spaces have been operated, go where they are most skilled.↗
▶Ep 1 · 28:31
opinionFor known bilateral inguinal hernias in a skilled laparoscopic surgeon's hands, laparoscopy is the preferred approach.↗
▶Ep 1 · 28:31
opinionFor known bilateral inguinal hernias in a skilled laparoscopic surgeon's hands, laparoscopy is the preferred approach.↗
▶Ep 1 · 28:36
opinionSurgeons learning laparoscopic inguinal hernia repair should avoid bilateral and recurrent hernias during their learning curve, even though these patients might benefit most from laparoscopy, because these cases are twice as hard.↗
▶Ep 1 · 28:36
opinionSurgeons learning laparoscopic inguinal hernia repair should avoid bilateral and recurrent hernias during their learning curve, even though these patients might benefit most from laparoscopy, because these cases are twice as hard.↗
▶Ep 1 · 29:10
opinionFor large inguinoscrotal hernias, Dr. Rosen now performs all repairs open, whereas when he was younger he did them laparoscopically.↗
▶Ep 1 · 29:10
opinionFor large inguinoscrotal hernias, Dr. Rosen now performs all repairs open, whereas when he was younger he did them laparoscopically.↗
▶Ep 1 · 29:23
opinionFor incarcerated hernias that are difficult to reduce, Dr. Rosen puts patients to sleep and reduces the hernia under general anesthesia, then can proceed with TAPP repair.↗
▶Ep 1 · 29:23
opinionFor incarcerated hernias that are difficult to reduce, Dr. Rosen puts patients to sleep and reduces the hernia under general anesthesia, then can proceed with TAPP repair.↗
▶Ep 1 · 29:30
opinionFor truly incarcerated hernias, TEP repair is not a good idea because surgeons want the hernia contents out of the sac; TAPP is preferred.↗
▶Ep 1 · 29:30
opinionFor truly incarcerated hernias, TEP repair is not a good idea because surgeons want the hernia contents out of the sac; TAPP is preferred.↗
▶Ep 1 · 29:43
clinicalSurgeons can laparoscopically cut the internal ring at the 2 o'clock position while watching the epigastric vessels to help reduce an incarcerated hernia.↗
▶Ep 1 · 29:43
clinicalSurgeons can laparoscopically cut the internal ring at the 2 o'clock position while watching the epigastric vessels to help reduce an incarcerated hernia.↗
▶Ep 1 · 29:53
opinionIf an incarcerated hernia cannot be reduced laparoscopically, it should be done open, because making holes in the bowel increases the morbidity of the operation unacceptably high.↗
▶Ep 1 · 29:53
opinionIf an incarcerated hernia cannot be reduced laparoscopically, it should be done open, because making holes in the bowel increases the morbidity of the operation unacceptably high.↗
Michael's statements about Upper Gastrointestinal & Foregut Surgery56 statements
clinicalSurgery for gastroesophageal reflux disease should be far down the treatment line after appropriate medical management and workup↗
▶Ep 6 · 1:38
quoteI think when you see a patient like that, particularly as a surgeon, if you're seeing them the first time and they really haven't had any workup, I, I think that surgery should be looked at and disease of gastroesophageal reflux is very far down on the treatment line.↗
▶Ep 6 · 2:27
clinicalInitial trial of 20 mg daily Prilosec (omeprazole) for 6 weeks is appropriate first-line therapy for GERD symptoms↗
▶Ep 6 · 3:34
clinicalThere is mounting data that a lifetime of proton pump inhibitors has consequences associated with it↗
▶Ep 6 · 3:34
quoteI certainly think there's mounting data that a lifetime of proton pump inhibitors, it has consequences associated with it.↗
▶Ep 6 · 4:06
clinicalEndoscopy is needed at minimum to assess esophagitis and in particular to rule out Barrett's esophagus in patients with persistent reflux symptoms↗
▶Ep 6 · 4:26
quoteAt a minimum, to assess the esophagitis and in particular to rule out Barrett's.↗
▶Ep 6 · 5:02
opinionIn 2016, for a patient without esophagitis, hiatal hernia, or Barrett's, more workup is warranted before keeping them on PPIs indefinitely, especially in young active persons due to concerns about osteoporosis and other issues↗
▶Ep 6 · 5:33
clinicalA pH study is needed to confirm the diagnosis of gastroesophageal reflux disease when endoscopy does not show evidence of esophagitis↗
▶Ep 6 · 6:19
clinicalThe Bravo test should be done off PPIs to provide symptom correlation, which is important for setting patient expectations about what surgery will improve↗
▶Ep 6 · 6:26
quoteI like the Bravo test to tell me symptom correlation.↗
▶Ep 6 · 6:51
clinicalManometry is essential before any surgical discussion and should be part of the preoperative workup for patients potentially going down the operative road↗
▶Ep 6 · 11:19
clinicalThe basic reason for manometry is number one to rule out achalasia, because wrapping someone with achalasia destroys their esophageal function↗
▶Ep 6 · 11:31
quoteBecause if you wrap somebody with ankylasia, you have really destroyed their esophageal function.↗
▶Ep 6 · 12:25
clinicalManometry findings consistent with reflux include total relaxation of the lower esophageal sphincter with swallowing and low resting pressure of the LES↗
▶Ep 6 · 12:38
clinicalDistal esophageal amplitudes on manometry can be used to tailor the fundoplication, with discussion about the difference between a floppy Nissen and a Toupet based on esophageal motility↗
▶Ep 6 · 13:27
clinicalA patient with normal peristalsis (amplitude of 30 mmHg or higher), total LES relaxation, DeMeester score of 28, and a 2 cm hiatal hernia should receive a full Nissen fundoplication↗
▶Ep 6 · 14:20
clinicalOne disadvantage of laparoscopic fundoplication is that it does not create much scar tissue; full mediastinal dissection helps reduce recurrences by creating ability for the area to scar down and provides more esophageal length↗
▶Ep 6 · 14:20
quoteI actually think when you do this laparoscopically, one of the disadvantages of laparoscopy, Is we don't get a lot of scar tissue, and I think one of the ways to reduce recurrences is to actually do a full mediastinal dissection and create ability for that area to scar down and you also get more length on the esophagus.↗
▶Ep 6 · 14:38
clinicalTaking down the short gastric vessels makes it easier to avoid twisting the wrap and to see exactly what is being brought around during fundoplication↗
▶Ep 6 · 14:55
quoteI think the way that a Nissan is created is, is highly variable, and one of the downsides of this operation that makes it hard to reproduce the data is everybody does it just a little bit differently, and there's not really great standardization↗
▶Ep 6 · 14:55
opinionThe way a Nissen is created is highly variable and one of the downsides of this operation is lack of standardization, making it hard to reproduce data↗
▶Ep 6 · 16:19
quoteone of the common mistakes I would make was that I thought I have all this intraabdominal esophageal length and I would feel the need to wrap all of that and I think one of the mistakes that people make is they make the wrap too long, uh, and it adds to dysphagia.↗
▶Ep 6 · 16:19
clinicalA common mistake is making the Nissen wrap too long, which adds to dysphagia; the wrap should be about 2 centimeters with typically 3 sutures↗
▶Ep 6 · 16:43
clinicalThe first stitch in a Nissen should be stomach to stomach so the knot can be used to move the wrap and ensure proper positioning before placing additional sutures↗
▶Ep 6 · 17:42
clinicalA bougie is not routinely needed during crural closure in experienced hands; the esophagus should have a little V-shaped triangle of air below it↗
▶Ep 6 · 19:05
quoteI think in those type of patients, uh, I think the key is to have a clear discussion of, uh, we don't want to cure one problem to create another disease.↗
▶Ep 6 · 19:05
clinicalIn patients with weak peristalsis (amplitude below 20 mmHg) and weak LES, the best operation to prevent reflux is still a Nissen, but the esophageal pump does not work well enough to overcome that barrier, necessitating a Toupet to avoid creating dysphagia↗
▶Ep 6 · 19:14
quoteThe best operation we have to prevent reflux is a Nissen fundoplication. And while it's a very good operation to let the acid not go back up, the pump of your esophagus doesn't work good enough to make it past that barrier.↗
▶Ep 6 · 19:44
clinicalA Toupet fundoplication is a posterior 270-degree wrap that is about 2.5 to almost 3 centimeters long with 3 sutures on either side through esophagus to stomach↗
▶Ep 6 · 21:33
opinionThe hardest transition of becoming an attending doing foregut surgery is managing patient satisfaction after fundoplication and realizing patients come back with complaints and issues↗
▶Ep 6 · 21:33
quoteI would say the hardest transition of becoming and attending 12 years ago and doing for gut surgery. Was managing patient satisfaction after this operation and realizing when you don't go off service and you don't leave after you do 20 Nissans that people come back with complaints.↗
▶Ep 6 · 22:03
clinicalFundoplication changes the way patients swallow, the way their stomach works, and the way acid moves from their body; patients must be counseled preoperatively about these changes↗
▶Ep 6 · 22:03
quotethis operation changes things. It's going to change the way you swallow. It's going to change the way your stomach works, and it's going to change the way acid moves from out your body.↗
▶Ep 6 · 22:17
quotethis operation is its tightest right after surgery and it's going to get looser over time.↗
▶Ep 6 · 22:17
clinicalThe fundoplication is tightest right after surgery and gets looser over time; early dysphagia is expected and the patient who has no dysphagia at 2 weeks likely has a wrap that is too loose↗
▶Ep 6 · 22:30
quotethe person I worry about the most is the person who shows up two weeks after innocent and says they've been eating everything they want and they don't have any dysphagia because you know you made it too loose and you're in trouble, uh, long term.↗
▶Ep 6 · 22:48
clinicalDysphagia should not be a concern for the first 6 weeks postoperatively, even if the patient maintains a liquid diet, and endoscopic intervention should not be considered until 3 months with no progression and inability to tolerate anything besides liquids↗
▶Ep 6 · 23:17
clinicalFor persistent dysphagia at 6-8 months, workup should include upper GI to rule out hernia recurrence and look for anatomic causes, followed by endoscopy with dilation if the wrap appears too tight↗
▶Ep 6 · 24:06
clinicalPseudoachalasia after fundoplication presents with dilated esophagus, retained fluid, tight GE junction on endoscopy, and manometry showing lack of peristalsis and non-relaxing LES; this likely occurs when the wrap is too tight and prolonged dysphagia causes the esophagus to burn out↗
▶Ep 6 · 24:57
clinicalFor pseudoachalasia, nutrition should be optimized before reoperation, with consideration of PEG tube feeding if needed↗
▶Ep 6 · 26:40
clinicalFor complex reoperative foregut surgery, the best approach is to plan to start over and take down the entire wrap, though sometimes dividing it and leaving half a wrap (Toupet) may be acceptable if the wrap cannot be fully taken down↗
▶Ep 6 · 26:40
quoteI think for complex reoperative foregut surgery. You have to start over because dysphagia, was it twisted a little bit? All those things get hard to sort out.↗
▶Ep 6 · 27:36
clinicalFor morbidly obese patients with BMI over 35 and reflux, gastric bypass should be considered instead of fundoplication as the primary operation because Nissen does not work well in morbidly obese patients↗
▶Ep 6 · 28:17
clinicalFor symptomatic herniated wrap, reevaluation should include 48-hour Bravo study for symptom correlation, repeat manometry, and gastric emptying study especially if nausea and vomiting are prominent symptoms↗
▶Ep 6 · 29:02
clinicalNausea and vomiting as a large component of foregut patients' complaints are red flags to put the brakes on rushing to surgery and to understand what is going on, particularly regarding gastric emptying↗
▶Ep 6 · 29:08
quotenausea and vomiting is a large component. Of my 4 gut patients' complaints, I am putting the brakes on rushing to do this and and really wanna understand what's going on.↗
▶Ep 6 · 30:18
quotethe first kind of goal of my operation is to get me to the right crew. I think that's the most important part of the operation simply because then I know where the cava is and where you can get in big trouble.↗
▶Ep 6 · 30:18
clinicalIn reoperative fundoplication, the first goal is to reach the right crus to identify where the cava is and avoid injury; the liver and wrap often obliterate the right crus and drifting off the wrap can lead to caval injury↗
▶Ep 6 · 30:44
clinicalWhen taking the liver off the wrap in reoperative surgery, sharp dissection with hook or scissors accepting bleeding is preferred over harmonic to avoid injuring the wrap that will be used later↗
▶Ep 6 · 31:11
clinicalMost surgeons do not take the dissection low enough to the base of the crus; getting the crus at the base provides a choice of going right or straight up with known anatomy to avoid the cava↗
▶Ep 6 · 31:33
quotethe reason why a lot of these things come back is there's just not scar tissue in the chest.↗
▶Ep 6 · 31:33
clinicalMany fundoplications recur because there is not enough scar tissue in the chest; if struggling with dissection below, getting up in the chest and working back down is a useful strategy↗
▶Ep 6 · 32:01
clinicalIn reoperative surgery, the key is identifying named structures and digging them out in a systematic fashion rather than trying to make a space without proper dissection, or the surgeon will get lost quickly↗
▶Ep 6 · 32:01
quotethe key, and where I've seen young people get in trouble, and what I've been in trouble myself in this is where you try to make a space and not do a dissection. So this has to be identifying name structures, digging them out in a very systematic fashion and not being erratic or you get lost quick.↗
▶Ep 6 · 32:36
clinicalIf the anterior vagus nerve is injured during reoperative fundoplication but the posterior vagus is intact, no acute intervention is needed in the operating room; postoperative upper GI on day 1 or 2 should assess gastric emptying, and early Botox of the pylorus is preferred over pyloroplasty if delayed emptying is a concern↗
Summaries Michael gave as host
· 28 summaries
Recaps of other experts' statements, not Michael's own clinical position.
host summaryMichael Rosen summarizing a resource: In the Fitzgibbons VA study of minimally symptomatic to asymptomatic hernias in patients in their 70s-80s, the risk of presenting with an emergency problem (incarceration/strangulation) requiring operation was less than 1% (actually one-third of 1%) over the initial study period.↗
▶Ep 4 · 4:00
host summaryMichael Rosen summarizing a resource: In the Fitzgibbons study, almost one-third of observed patients developed symptoms requiring operation within two years, and by five years almost three-quarters developed symptoms.↗
▶Ep 4 · 4:20
host summaryMichael Rosen summarizing a resource: Patients who developed symptoms during observation in the Fitzgibbons study did not do any worse with their eventual operation compared to immediate repair.↗
▶Ep 4 · 8:40
host summaryMichael Rosen summarizing a resource: I think that ultimately, it's been shown in the literature that the best approach is what you do best.↗
▶Ep 4 · 9:00
host summaryMichael Rosen summarizing a resource: The learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200-250 cases required.↗
▶Ep 4 · 19:05
host summaryMichael Rosen summarizing a resource: Inadequate inferior peritoneal dissection leads to use of smaller mesh, but Stoppa's original description for unilateral inguinal hernia specified never using less than 15×15 cm (6×6 inch) mesh, which is larger than most laparoscopic meshes being placed.↗
▶Ep 4 · 19:30
host summaryMichael Rosen summarizing a resource: If you go back and read stopa's original descriptions, his description, if you were doing a unilateral inguinal hernia, was to never use less than a 15 by 15 centimeter piece of mesh or a 6 by 6 inch piece of mesh, which is much bigger than the vast majority of laparoscopic preform meshes or meshes that are being placed.↗
▶Ep 4 · 24:56
host summaryMichael Rosen summarizing a resource: There is mounting evidence that medium-weight polypropylene mesh can be placed in contaminated fields, with several series in ventral hernias supporting this.↗
Inguinal Hernia With M. Rosen
▶Ep 5 · 3:22
host summaryMichael Rosen summarizing a resource: In the Fitzgibbon VA study of minimally symptomatic to asymptomatic hernias in patients in their 70s-80s, the risk of presenting with an emergency problem requiring operation due to incarceration or strangulation was less than 1% (actually one-third of 1%).↗
▶Ep 5 · 4:00
host summaryMichael Rosen summarizing a resource: In the Fitzgibbon study over two years, almost one-third of observed patients went on to develop symptoms and need an operation, and by five years almost three-quarters developed symptoms.↗
▶Ep 5 · 4:00
host summaryMichael Rosen summarizing a resource: So it's safe to watch people. But the problem with this study is this study was over two years. Almost a third of the patients went on to develop symptoms and need an operation.↗
▶Ep 5 · 9:00
host summaryMichael Rosen summarizing a resource: There is a real learning curve to laparoscopic inguinal hernia repair, with some studies showing 200 to 250 cases required.↗
▶Ep 5 · 19:10
host summaryMichael Rosen summarizing a resource: According to Stoppa's original descriptions, for unilateral inguinal hernia repair, never use less than a 15 by 15 centimeter (6 by 6 inch) piece of mesh, which is much bigger than the vast majority of laparoscopic meshes being placed.↗
▶Ep 5 · 24:56
host summaryMichael Rosen summarizing a resource: There is mounting evidence that medium-weight polypropylene can be placed in a contaminated field, with several series in ventral hernias supporting this.↗
Summaries Michael gave as host · Inguinal Hernia14 summaries
host summaryMichael Rosen summarizing a resource: In the Fitzgibbons VA study of minimally symptomatic to asymptomatic hernias in patients in their 70s-80s, the risk of presenting with an emergency problem (incarceration/strangulation) requiring operation was less than 1% (actually one-third of 1%) over the initial study period.↗
▶Ep 27 · 4:00
host summaryMichael Rosen summarizing a resource: In the Fitzgibbons study, almost one-third of observed patients developed symptoms requiring operation within two years, and by five years almost three-quarters developed symptoms.↗
▶Ep 27 · 4:20
host summaryMichael Rosen summarizing a resource: Patients who developed symptoms during observation in the Fitzgibbons study did not do any worse with their eventual operation compared to immediate repair.↗
▶Ep 27 · 8:40
host summaryMichael Rosen summarizing a resource: I think that ultimately, it's been shown in the literature that the best approach is what you do best.↗
▶Ep 27 · 9:00
host summaryMichael Rosen summarizing a resource: The learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200-250 cases required.↗
▶Ep 27 · 19:05
host summaryMichael Rosen summarizing a resource: Inadequate inferior peritoneal dissection leads to use of smaller mesh, but Stoppa's original description for unilateral inguinal hernia specified never using less than 15×15 cm (6×6 inch) mesh, which is larger than most laparoscopic meshes being placed.↗
▶Ep 27 · 19:30
host summaryMichael Rosen summarizing a resource: If you go back and read stopa's original descriptions, his description, if you were doing a unilateral inguinal hernia, was to never use less than a 15 by 15 centimeter piece of mesh or a 6 by 6 inch piece of mesh, which is much bigger than the vast majority of laparoscopic preform meshes or meshes that are being placed.↗
▶Ep 27 · 24:56
host summaryMichael Rosen summarizing a resource: There is mounting evidence that medium-weight polypropylene mesh can be placed in contaminated fields, with several series in ventral hernias supporting this.↗
Inguinal Hernia With M. Rosen
▶Ep 28 · 3:22
host summaryMichael Rosen summarizing a resource: In the Fitzgibbon VA study of minimally symptomatic to asymptomatic hernias in patients in their 70s-80s, the risk of presenting with an emergency problem requiring operation due to incarceration or strangulation was less than 1% (actually one-third of 1%).↗
▶Ep 28 · 4:00
host summaryMichael Rosen summarizing a resource: So it's safe to watch people. But the problem with this study is this study was over two years. Almost a third of the patients went on to develop symptoms and need an operation.↗
▶Ep 28 · 4:00
host summaryMichael Rosen summarizing a resource: In the Fitzgibbon study over two years, almost one-third of observed patients went on to develop symptoms and need an operation, and by five years almost three-quarters developed symptoms.↗
▶Ep 28 · 9:00
host summaryMichael Rosen summarizing a resource: There is a real learning curve to laparoscopic inguinal hernia repair, with some studies showing 200 to 250 cases required.↗
▶Ep 28 · 19:10
host summaryMichael Rosen summarizing a resource: According to Stoppa's original descriptions, for unilateral inguinal hernia repair, never use less than a 15 by 15 centimeter (6 by 6 inch) piece of mesh, which is much bigger than the vast majority of laparoscopic meshes being placed.↗
▶Ep 28 · 24:56
host summaryMichael Rosen summarizing a resource: There is mounting evidence that medium-weight polypropylene can be placed in a contaminated field, with several series in ventral hernias supporting this.↗
