161. Teaching Hernia Surgery

This week, the topic of discussion was:
- Residency
- Surgical Education
- Skills Lab
- Robotic Surgery
- Open Surgery
- Mesh Placement
- Hernia Specialty
- Obesity
- Mesh Fixation
- MRI Hernia Protocol

Welcome to HerniaTalk LIVE, a Q&A hosted by Dr. Shirin Towfigh, hernia and laparoscopic surgery specialist who practices at the Beverly Hills Hernia Center. This is the only Q&A of its kind, aimed at educating and empowering patients about all things related to hernias and hernia-related complications. For a personal consultation with Dr. Towfigh, call +1-310-358-5020 or email info@beverlyhillsherniacenter.com.

Guest Panelist: Dr Jacob Greenberg, Hernia Specialist at Duke University in North Carolina

If you find this content informative, please LIKE, SHARE, and SUBSCRIBE to the HerniaTalk Live channel and visit us on HerniaTalk.com.

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Transcript

Speaker 1 (00:00:10):

Hi everyone. Welcome to Hernia Talk Live. We’re here on another Tuesday. We call them Hernia Talk Tuesdays. I’m your host, Dr. Shirin Towfigh. I’m your hernia and laparoscopic surgery specialist. You can follow me on Twitter at Hernia doc. Same on Instagram and hernia Doc. Many of you are joining me today as of Facebook Live at Dr. Towfigh. And thanks for those of you that are logged in. I see many of you already on Zoom, and as you know, this episode and all prior episode, I think we’re up to 160 by now, will be available to you to watch, review, share on my YouTube channel also at Hernia Doc. And if you’re like me and you actually enjoy podcasts, then you can just listen while you’re driving because we also have it as a podcast at Hernia Talk Live. So all those are available and I’m really excited because we have a guest, I think you’re our first guest of the year, Jake, Dr. Jacob Greenberg. He’s awesome. One of my favorite people in the world, and you’ll learn why once you kind of go to the next hour. He is currently a big deal surgeon, hernia surgeon specialist, but he does so much more at Duke Hospital in North Carolina. You can follow him on Twitter at Duke hernia, which is an appropriate moniker. So welcome Jake. Thanks so much for accepting to be a guest.

Speaker 2 (00:01:30):

Oh, thank you so much for the invitation. Anytime I get a chance to hang out with you for an hour, it’s always fun. So this,

Speaker 1 (00:01:35):

You’re so sweet.

Speaker 2 (00:01:36):

Yes.

Speaker 1 (00:01:38):

So Jake’s been great. He is held many different positions. You do minimally invasive surgery, bariatric surgery, weight loss surgery. Your current role in Duke, I believe is also in charge of their educational program, is that right?

Speaker 2 (00:01:53):

So division chief of Minimally invasive Surgery.

Speaker 1 (00:01:56):

Okay, great. And you have fellows that you have to teach

Speaker 2 (00:02:01):

Residents? We have 3 MIS bariatric fellows who are Oh, sweet.

Speaker 1 (00:02:05):

That’s a big program,

Speaker 2 (00:02:06):

A fantastic group. And that’s led by our wonderful program director, Kunoor Jain-Spangler, MD, who’s a bariatric surgeon who

Speaker 1 (00:02:13):

Wow straight. And how much of what you teach clinically is Hernia related?

Speaker 2 (00:02:19):

So my practice has now really kind of moved almost entirely to Hernia.

Speaker 1 (00:02:24):

I mean, why shouldn’t it be? It’s the most, it’s

Speaker 2 (00:02:25):

So much more fun,

Speaker 1 (00:02:27):

So much better than other specialties.

Speaker 2 (00:02:31):

I like everything MIS, I like bariatric, I love benign Foregut and Flex Endo and Hernia. But the hernia stuff is just, to me is like it’s the passion. It’s the thing that’s the most fun to do. And so we have a lot of great surgeons at Duke who all like to do a lot of great things and there’s a big really fantastic group in bariatrics and my contributions can be much more on the hernia side, which works out perfectly

Speaker 1 (00:02:58):

For me. Oh, that’s nice. So you have a close relationship between weight loss surgeons and hernias. You kind of need that.

Speaker 2 (00:03:05):

We do. And so our hernia center and our weight loss program are all housed within the same clinic and there’s a lot of free flow between the two, which makes a ton of sense. That’s great. Yeah,

Speaker 1 (00:03:15):

We had JB at Bitner on I think a year ago or a year and a half ago. So yeah, he was able to also bring us that vision of a Hernia surgeon that does bariatric surgery, understanding how the two are somewhat interlinked.

Speaker 2 (00:03:32):

Yeah, I mean I think so much of what we do is predicated and dependent on how well patients are prepared for that surgery and patients who are smokers who are obese or suffer from or diabetics that the more that we can get those things under control before surgery, the better the patients do. And so seeing a lot of patients with a lot of those comorbidities, you can help guide them through their care in a much more meaningful way and be involved in them from sort of the start to finish. So it’s a great combination.

Speaker 1 (00:04:03):

So our group is also MIS bariatrics, so the Cedar-Sinai, MIS bariatric. We used to have two fellows. We went down to one, but we’ve maintained the good balance of both MIS and bariatric education. But yeah, so when we do journal clubs every so often they throw in a Hernia article. And because they do so much bariatric, it’s like a Hernia in the obese population or hernia in the bariatric population. And it’s so interesting how the minute you bring those two topics together, everyone’s like, everyone goes nuts. It’s as if there’s no standard. They just have their own ideas. And to me it’s very clear. I mean it’s not very clear, but I kind of have an algorithm in my mind. But if you don’t do a lot of hernias and just bariatrics when you throw in the Hernia part, some people don’t understand how to balance the Hernia repair with the bariatric surgery and vice versa.

Speaker 2 (00:05:05):

It’s really, really interesting too when you read the literature, and it all depends on whose perspective it’s written by.

Speaker 1 (00:05:11):

Yeah, exactly.

Speaker 2 (00:05:13):

Surgeons writing it, it’s pretty clear that the outcomes of hernia surgery are actually, they’re okay in obese and morbidly obese patients. They can do okay. They clearly do better if they are on the lower end of the weight scale. But when you look at the outcomes in bariatric surgery for patients who have hernias and concomitant bariatric surgery, like their bariatric outcomes, the outcomes of the procedure are a little bit worse because the comorbidities are usually higher and then the morbidity and the potential mortality a little bit higher. So from a bariatric standpoint, it really doesn’t make a lot of sense to do hernia repairs at the time of bariatric surgery. Do as little as you can get

Speaker 1 (00:05:50):

Out. Yeah, it’s totally okay. People call me all the time either during their surgery or before as they’re planning and they’re like, I have this big operation. Let’s say they’re taking out a big tumor or cancer or infection or whatever, but the patient has a Hernia, what do I do with it? I’m like, don’t do anything with it. And they’re like, what do you mean? They feel like just because the Hernia in their face, they have to fix it. I’m like, no, don’t screw it up. Do the lifesaving procedure and then come back when there’s time to do a good job, do a good hernia repair.

Speaker 2 (00:06:25):

There are definitely times where I think it makes sense to do them both together. Certainly like ostomy take down things like where you can actually intervene and fix the problem, but when you’re there for some other reason and there happens to be yeah,

Speaker 1 (00:06:36):

Don’t

Speaker 2 (00:06:38):

Or close ’em primarily, right. Don’t make anything more complicated than it needs and just come back and fight another day. It’s always,

Speaker 1 (00:06:44):

Yeah, I agree. So that’s where the education comes in. Often the residents call me and I think it’s great that you’re group is also kind of intermingled that way because ultimately we’re teaching the residents, we’re kind of teaching our own colleagues too, but we’re teaching the residents because for them they need to be able to have a system of, it’s not random how we provide Hernia care. There’s a system and there’s an algorithm that goes through each of our minds.

Speaker 2 (00:07:16):

So

Speaker 1 (00:07:17):

Do you have hernia journal clubs and you have people doing research with you? What kind of educational programs are part of your residency and fellowship?

Speaker 2 (00:07:28):

So we call it First Friday. So every first Friday we have a lot of education for our fellows and the residents that are on the team. One hour of that in the morning is our complex hernia conference. So it’s a system-wide conference. Usually our plastic surgeons, a lot of our community surgeons and a lot of the MIS bariatric and hernia folks there, we present cases. Everyone pulls the most sort of complex stuff that they’ve seen in clinic. And it’s a great way to sort of vet the cases with everyone who’s interested, if anyone has any good ideas or thoughts. a lot of times it’s a lot of really super complex patients who may be surgery actually isn’t the best thing for, and at least then everyone together to sort of come to that consensus, which is good. And so then usually we have a full day of education that extends beyond that. So our fellows tend to lead it. Oftentimes it’s focused on bariatric. We still are mostly primarily a bariatric fellowship, but they’ll also talk about all the other aspects of an MIS bariatric fellowship. And it’s just a great educational day that’s usually fun. We’re all kind of sitting around in this one communal space in our clinic and it is just a nice time to get the whole team together and do a lot of education around this. So

Speaker 1 (00:08:40):

I think you’re significantly younger than I am, but I think training wise we’re probably the same generation where hernias were not cool when we were training. No, it was not what people wish to do. Or even definitely there was no hernia specialty discussion back then, but now there is

Speaker 2 (00:08:59):

And it’s great. And now the fellowship council is opening a designation for hernia and abdominal surgery fellowships. And there are a lot of people that have seen surgeons like you who they, I love it as role models and that’s what they want to be and I think that’s great.

Speaker 1 (00:09:15):

Yeah, they love it.

Speaker 2 (00:09:18):

I totally, I made every wrong decision in probably life, but definitely in residency I was supplying in colorectal. I really liked laparoscopic colon surgery. And thankfully my wife who and who’s also certain you’re applying in the wrong fellowship, you don’t like that. She’s like, you just like MIS. She’s like, you’ve home happy after days where you’ve done lap choles, lap inguinal hernias lap, ventral hernias, lap colon. She’s like, you just like laparoscopy.

Speaker 1 (00:09:45):

Yeah, that was my life before,

Speaker 2 (00:09:46):

So you should just do that. And I was like, eye captain, that sounds a good plan. And in fellowship, my fellowship at UMass was largely bariatric and I did a little bit of the complex hernia stuff because they were the ones doing the endoscopic external oblique releases at the time. Yeah.

Speaker 1 (00:10:03):

Alright.

Speaker 2 (00:10:04):

Then when I got into practice, I just sort of said, oh, I love inguinal hernias. I like ventral. I’ll happily see everyone. And then the floodgates just open and it just becomes your practice. And I fell in love with it.

Speaker 1 (00:10:18):

The residents always like, how’d you get into this? And it’s like, it wasn’t a straight path, but I love what I do and they see that. So I think people that come to you and they see are so happy with what you’re doing that they start thinking, oh, maybe this is a good specialty to do. We some, we

Speaker 2 (00:10:37):

Make people better. They come in, you make them better, and then they’re happy and they go forward and they don’t have a bad terminal diagnosis or something that’s really awesome. They have a problem that we can fix and we can then help. So

Speaker 1 (00:10:53):

Our audience is asking some questions that are a little bit off our topic, which is totally fine. So maybe you answer some of them and I’ll answer some of them if you know what. Okay. So we’ll give you question number one. I’m being evaluated for groin pain and possibly an occult angle hernia, a CT scan and ultrasound showed nothing. We know what that means. I’ll likely have an MRI. Next question, is your MRI protocol standard? If not, how do I advocate for that protocol? And would such an MRI capture possible other causes such as hip or low back pain? So they’re referring to the MRI hernia protocol, which I sat down and made up with our radiologist and it’s been so helpful because it’s not really a hip protocol, it’s not really a pelvic protocol, it’s not really a sports hernia protocol. It’s really based on Valsalva and getting the right pictures for hernias. And I do get pushback from different radiologists outside of my region. They either don’t have that protocol or they don’t want to do it. It’s extra work. It’s not their own protocol. Have you had experience with the same MRIs for hernias?

Speaker 2 (00:12:03):

So I think it’s very institution dependent as most institutions. It’s been protocolized by the radiologists who I think really are trying to do what they view as being the best thing for the spectrum of disease that they see. Most of the places that I’ve been, any groin MRI that’s looking for something is usually protocolized for a sports Hernia. That’s been the most common thing that I’ve seen by far and ours. I’ve never been at a place where the groin and hip are sort of in the same protocol. It’s usually two separate ones looking for labral hip tears, femoral acetabular impingement or looking more at the groin for sports hernias, osteitis pubis and that spectrum of problem. So I haven’t been at a place where it’s been protocol to look at the two. To me, that makes a ton of sense because there’s so much overlap in that spectrum of disease. But I haven’t been at a place where that’s been the case.

Speaker 1 (00:12:56):

So the MRI protocol, it’s free. I saw my website, you can download it. I always have the patients print it because it has radiology language on it to take it to their radiology group and see if they can replicate it. But it’s basically an MRI pelvis with no contrast. It will look at the hip and the lower back though it’s not intended for that use. So it’s not the best study for spine or hip, but you can still see it. And yeah, there’s still ways of encouraging a radiology group to use that protocol because some of the sports hernia protocols, which may be standardized in an institution, they really focus on inflammation and tears. They don’t include Valsalva for example, which for a little hernia or occult hernia, especially if said you’re laying flat, it would be helpful. But yeah, you can just print it out. You can even call my office. They can give you a copy, but if you just google MRI hernia protocol, it should show up. That’s one of the That’s awesome. Yeah. Yeah. We have it at the IHC too. Yeah, it’s easy. Next. Oh, this is a good one for you. How do you manage omentum severely enlarged by fat when doing a laparoscopic Hernia? So fatty, large omentum, maybe in a hernia or something?

Speaker 2 (00:14:29):

I think it all depends on if it’s in the defect or not, right? Yeah. One, I think obviously usually getting a little bit of preoperative weight loss to try and decrease both visceral and peripheral fat is always helpful. Historically. I think that was always a really challenging thing. Diet and exercise, they’re tough. It’s really hard to lose weight, period. The medications nowadays are much more effective than they have been in the past. They’re hard to get.

Speaker 1 (00:15:00):

Yeah. Do the medications reduce visceral fat the same as overall fat?

Speaker 2 (00:15:08):

I haven’t seen anything that has definitively said that. I think it reduces overall fat. It also clearly reduces muscle, right? I think there’s some muscle loss associated with that too. But it is, I mean they’re pretty good now. The GLP one inhibitors, the semaglutide tirzepatide, they’re effective in a way that we really haven’t had in the armamentarium in the past. They’re just a challenging thing to find now and get covered for insurance for some patients. Yeah,

Speaker 1 (00:15:38):

That’s true.

Speaker 2 (00:15:40):

So if you can do that, that’s great. Obviously I’m biased as someone who’s always done bariatric surgery as part of their practice. I mean, I still think that’s, to me the gold standard. It just is incredibly effective in a really good way for patients to lose weight and improve their overall health. So I think those strategies beforehand are great if you’re in the operating room and having to deal with that. I would try and as much as possible, just not have to deal with it. Try and if we’re doing especially a minimally invasive approach, reduce whatever omentum that we need to reduce, let it lay down on the floor of the abdomen and deal with whatever’s on the, just leave

Speaker 1 (00:16:20):

It. And I think the other part of that question is when you go in there laparoscopically, you need space to work in. But in someone who’s morbidly obese, a lot of that space may be taken up by a big chunky mental fat. So you can’t do much about that, right?

Speaker 2 (00:16:41):

Usually you still have enough room to work. a lot of it depends on our patient’s body habit. So there are patients where their fat is distributed throughout their bodies, and when you lay down on a bed or lay down on a table, you can feel their rib cage and their abdomen’s actually fairly easy to access and they don’t have as much intraabdominal or visceral fat. And there are those that have skinny arms, skinny legs, and just a big belly where it’s all central obesity. And that is definitely much more challenging. And so for sure, I think for those latter patients, trying to get some preoperative weight loss is critically important. I’ve never been a big believer or fan of neurectomies during the time of repair to try and get more space. I don’t want to take anything out, I just want to fix the hole. And so I think really more importantly, preparing patients adequately for surgery with preoperative weight loss is probably the right strategy.

Speaker 1 (00:17:42):

Going back to the hernia protocol, the follow-up answer or question is, thanks so much for the answer. Regarding the Hernia protocol, the surgeon I consulted with is skeptical of an MRI showing anything. If a CAT scan or ultrasound shows nothing, of course our study shows exact opposite. So CAT scan is shown to be the worst for looking at inguinal hernias in general, especially the smaller ones, ultrasounds pretty good. So if it’s a positive ultrasound, it’s almost always correct. But if it’s a negative ultrasound, it’s correct about half the time. And then MRI has the most sensitivity and specificity, specifically looking at occult hernias and so on. So what are your thoughts about people that are like, oh, because seen people clearly have clinical symptoms of a hernia, inal, Hernia, ultrasound shows a hernia. Surgeon’s like we got to get a CAT scan, so the surgeon gets a CAT scan and it doesn’t show a Hernia. Well, it probably does show a Hernia, but it was reported as not being a hernia probably incorrectly. And then they’re like, you don’t have a hernia. So what are your thoughts on that? I’m sure you’ve heard similar stories.

Speaker 2 (00:18:56):

Yeah, I mean, I tend to think that we try to reinforce our own bias of what we’ve seen with whatever information is going to make us feel more comfortable about it. Right. Yeah.

Speaker 1 (00:19:06):

I think surgeons are so comfortable with CAT scan.

Speaker 2 (00:19:08):

Yeah. So I personally like ultrasound for the occult Hernia for a couple. One, I think it’s a cheaper study in general. Two, it’s more dynamic. Patients can Valsalva, they can move, and if you ultra sonographers are really good, they can see stuff moving that you just don’t necessarily pick up on CTs which are more static. I’ve generally tended much more towards the use of ultrasound. And for me, if I can’t feel the hernia in clinic, my first step is an ultrasound. If the ultrasound shows a hernia, I’ll usually go forward with that, leave

Speaker 1 (00:19:43):

It right. If the story makes sense. And then you have self imaging to support it.

Speaker 2 (00:19:51):

I don’t know how you were as a resident. I hated going to clinic as a resident, so I never went and I never knew how to do a good hernia exam until I was a fellow or a junior attending. And still to this day I’m pretty good, but there are clearly patients where I have not felt one at all and I’ve been like, it’s going to be negative in the ultrasound. You can clearly see it. So we’re certainly not perfect on physical exam. And for those patients where the story fits, the ultrasound shows it. I just go,

Speaker 1 (00:20:17):

I hate to admit my residency bent, I hated hernias. So at the county clinic, do you remember there were these paper charts and then they were, as the patient came in, they put the paper charts in, so you pick the first one that’s the next patient. If it was a Hernia, I’d put it in the back, take the next patient, hoping the other resident would pick up the hernia and I’ll just do the gallbladder consult. That’s perfect. I hated it. I don’t know why. I think I was uncomfortable with the examination. I was a junior resident, so I didn’t really appreciate, I understood gallbladder disease better than hernias at that time. I still feel guilty because the hernia patients probably waited longer.

Speaker 2 (00:21:01):

I think

Speaker 1 (00:21:02):

It’s fine. Whatever. I was in clinic,

Speaker 2 (00:21:03):

I think it’s probably fine. No, I don’t know what it’s like for you nowadays. I also see many, many more patients coming in with unnecessary radiology studies. I don’t know if you’re seeing the same thing. We see a ton of patients who tons have a clearly palpable inguinal hernia. And to me, if you can feel it, the ultrasound isn’t going to change anything that I’m do for that patient. So you feel it. And they’ve come to you already from their primary care doctor who’s trying to do their best job and they’ve gotten either an ultrasound or a CT that probably they didn’t need because they just could have come. Yeah,

Speaker 1 (00:21:37):

They had a typical hernia. They don’t need imaging for that.

Speaker 2 (00:21:39):

And so I kind of feel like that’s, I don’t know what’s led to that change, but I feel like probably a surgeons maybe we’re partially responsible because for saying, well, you sent them without any imaging. Get the imaging for. Yeah. But there are definitely patients paying for procedures and for interventions and studies that they probably don’t need.

Speaker 1 (00:21:57):

So do you have a good ultrasonographer at Duke?

Speaker 2 (00:22:00):

We do.

Speaker 1 (00:22:01):

Oh, that’s really important.

Speaker 2 (00:22:02):

Great.

Speaker 1 (00:22:03):

Yeah,

Speaker 2 (00:22:04):

Helpful.

Speaker 1 (00:22:05):

Right around the corner, there’s a private radiology group of three radiologists that do hernia ultrasounds, and one of ’em is like the eldest one. I wish he literally called me and he’s like, I heard you like hernias. I’m like, I do. He is like, I like them too. Send your hernia ultrasounds. I was like, really? You want that patient population? He loves it. He talks with the patient, moves them around. His reports are perfect. I hope he never retires because it’s so hard to find a good ultrasound. Ultrasound. He’s a radiologist himself, does it, not the tech. That’s

Speaker 2 (00:22:40):

Great. That’s so helpful.

Speaker 1 (00:22:45):

Okay, here’s a question. It really relates to the mesh plugs. Do you think there should be a band of Mesh plugs or what are your thoughts on mesh plugs? I guess

Speaker 2 (00:22:56):

So I have a conflicted thought on mesh plugs. So I remember as a resident training in the time where plug and patch was kind of taking off in popularity,

Speaker 1 (00:23:07):

You are younger than me, it came after my residency.

Speaker 2 (00:23:13):

I put in a lot of plug and patches. And I remember as a resident, because you don’t really follow up patients as a resident, you see them for that snippet in time and you’re done. I thought it made sense and it was good. And then as an attending and faculty member, the overwhelming majority of my interactions with plugs is removing them for pain. So I think once you learn, once I learned how to do a really good Lichtenstein, you recognize that the plug probably isn’t really supplementing anything to that repair. And so for an opening little Hernia repair, your high ligation of the cord is going to take care of the indirect problem, and then your mesh reinforcement’s going to take care of any direct problems. And so the plug probably isn’t helping for femorals for the most part one, as an MIS surgeon, I am biased way more towards minimally invasive approaches. I just think that

Speaker 1 (00:24:09):

And simple flat meshes. Yeah,

Speaker 2 (00:24:11):

Right. So a simple flat mesh that covers the whole three areas where hernias can form in the groin, in the femoral and the inguinal spaces, to me just makes much more sense than rolling up a piece of mesh and shoving it into a hole, not knowing where it’s going on the other side of that hole. It’s true. So I really think that for every hernia that’s amenable to it, the MIS approach tends to be a much better way to just fix things. I always kind go back to if you blow a tire, you patch the tire from the inside, not the outside. And I don’t know,

Speaker 1 (00:24:46):

We’ve had urologists that put in plugs robotically even the opposite way. It’s just the weirdest thing. A good idea. Obviously.

Speaker 2 (00:24:55):

I’m sure that, I’m sure there’s, there’s probably a huge number of patients out there with plugs that are perfectly fine.

Speaker 1 (00:25:02):

Yes, there are.

Speaker 2 (00:25:03):

I really think there are. And so we see a numerator of the denominator. We see part of that fraction and we don’t see the whole thing, but the part that we see hurt by it, I think gives us our perspective on what we feel as surgeons is the right thing. And so to me, I think a flat piece of mesh that covers all those holes makes much more sense than something shoved into one.

Speaker 1 (00:25:26):

Well, we looked at our data, we published our data on mesh removal, and I totally thought that mesh plug would be top on the list, probably hernia system and then flat mesh. And it wasn’t. I was taking out flat Mesh more often. I think meshoma specifically meshoma is more common with the plug. So maybe in that case small category, but in the overall mesh removals, whether it’s for infection or nerve entrapment or something, it’s not necessarily, at least in my practice, I thought it would be the plug. But looking at the numbers it, I

Speaker 2 (00:26:09):

Think that’s one of the reasons why people like you and David Chen and people that see a lot of the chronic groin pain patients are so important because just the majority of surgeons, I think don’t have that experience to really and to see what they see. And so for you guys to see it, think about it, write about it, take care of it, it’s incredibly helpful to us that don’t see as much.

Speaker 1 (00:26:33):

Yeah. So tell me a little bit more about your hernia education program. Do you take the juniors through opens or the seniors through opens? How much of it is lap or robotic? Do you feel like they’re getting good enough range of education before they graduate?

Speaker 2 (00:26:52):

I think we have a good mix. One, we have a phenomenal, it’s called our SEAL program. It’s essentially our inanimate training program. So we do a lot of lab-based work, and that does include some horse sign models, so some pig surgery where they get to do a bunch of different hernia repairs in pigs, which is great. It’s an opportunity for them to practice when it’s outside of patients. So they get really good exposure to stuff in an inanimate setting, in inanimate setting, in an animal lab. And then obviously a ton of the different procedures that we get to do with them in patients. So we have, on our service, we have the three fellows. We have essentially a PGY3 resident, and then we have interns on the service as well. The interns are frequently involved in a lot of the opening inguinal hernia repairs in the umbilical hernia repairs. In the smaller cases, the mid-level residents are doing a lot of the sort of lap umbilicals, lap ventral as our fellows. And then the fellows and the residents also get to do a mix of the bigger, more complex stuff, including eTEP, roboTAR, open transverse abdominus releases, bigger Ab wall recon, so they get a good exposure to kind of everything, which is nice.

Speaker 1 (00:28:19):

That’s really cool. I do the education too for hernias, and one thing I tell them is a tidbit, which is first of all, no matter how simple a hernia is, it’s very important that they understand it. It’s kind cute to do these big reconstructions and so on, but a good simple inguinal hernia or a little umbilical hernia, understanding the intricacies of that is also super important. But did you know this, the number one most failed question on the oral boards is the Hernia question.

Speaker 2 (00:28:55):

Which one? Is it inguinal or is it ventral?

Speaker 1 (00:28:58):

Inguinal. Inguinal one. Really? Yeah.

Speaker 2 (00:29:02):

Have you had to do your two year recertification thing yet?

Speaker 1 (00:29:04):

Yeah. Yeah.

Speaker 2 (00:29:06):

So I did my first one, I can’t remember, three or four years ago, and I sat down and I was going through questions. I got the first four and the fifth question was a patient with inguinal hernia.

Speaker 1 (00:29:18):

Yeah, I got that one wrong. I

Speaker 2 (00:29:19):

Got it wrong. And I was like, man, how did I possibly was wrong? And I was so angry. I went through the whole rest of the test and I had to go back and yeah,

Speaker 1 (00:29:29):

I, I mean I passed it, but you’re right, the hernia questions was like, oh, I know this answer and

Speaker 2 (00:29:40):

Wrong. My first wrong.

Speaker 1 (00:29:42):

I dunno if I was reading the question wrong or

Speaker 2 (00:29:44):

Elderly female patient with an inguinal hernia and I did the wrong thing.

Speaker 1 (00:29:48):

I think I know too much.

Speaker 2 (00:29:49):

Yeah,

Speaker 1 (00:29:50):

Maybe that’s what it is. Okay. Here’s another question. What type of scan or ultrasound would you need to show nerve entrapment in an incisional hernia? I have two lots of mesh, one on top of the other priatex and prolene mesh. Why are you looking for nerve entrapment? Is what I want to know.

Speaker 2 (00:30:07):

Yeah, that’s not usually that’s good enough to determine that in and of itself. Usually

Speaker 1 (00:30:17):

CAT scan for abdominal wall CAT scans perfectly good.

Speaker 2 (00:30:20):

They’re good, but I don’t know that they can necessarily see if it’s entrapped. Right. I mean, I think to me,

Speaker 1 (00:30:25):

Why would you have a nerve entrapped in a ventral hernia like laterally if they put stitches

Speaker 2 (00:30:31):

Where they put it or how they fixated it.

Speaker 1 (00:30:35):

I guess that’s possible.

Speaker 2 (00:30:37):

I think a lot of it is still kind of a clinical diagnosis. And then you use the ancillary studies to help support it.

Speaker 1 (00:30:46):

Like injections and stuff? Yeah,

Speaker 2 (00:30:48):

Exactly.

Speaker 1 (00:30:48):

Or anatomy. Just plain anatomy.

Speaker 2 (00:30:51):

And so if they have neuropathic or dermatome type pain and then using the CT and potentially targeting specific nerves to try and inject, make a ton of sense. But I think it would start off with the clinical picture.

Speaker 1 (00:31:04):

Here’s a question directed at you, Dr. Greenberg. Do your trainees get experience removing mesh for a variety of indications?

Speaker 2 (00:31:11):

So it is very dependent on sort of, I guess not to say luck, right? No one’s lucky when we’re having to take out mesh, but a lot of it is the timing of when they’re on the service. So we have seven or about to be eight residents a year that rotate through the service. And so the mesh removal cases are certainly not daily or weekly things. They’re a little bit more infrequent. And so it depends on if they’re on service or not. The fellows who tend to stay on service even they rotate between us as a group of attendings so they can potentially see some or miss some. So everyone gets sort of variable exposure, I would say.

Speaker 1 (00:31:54):

I think some of the goals of residency is not necessarily to make sure they’re experts at being able to remove the mesh, but understand that this patient maybe needs to have the mesh removed and then I can send them to someone to get the appropriate care. Whereas if you’re not aware that that’s an opportunity or an indication, then you may say, oh, your heart repair looks fine. Like this one patient that’s talking about nerve pain after having priatexx and prolene mesh on top of each other. Usually mesh on mesh is not a good idea to begin with, but they may get a CAT scan and be like, you have no Hernia go home. I have nothing. Whereas someone who’s seen mesh complications or a mesh removal surgery can say, okay, maybe I don’t do it, but I can refer you to someone who I know at least help the patient out a little bit.

Speaker 2 (00:32:47):

To me, I think the goal of residency should actually be to get them to put in mesh. Well really well do that well and then identify when it doesn’t go well, what they need to do to either work it up or send them to someone else. I think that’s the key, right? I think so many of our, duke is an incredible institution, but we put a ton of residents into transplant CT search junk really complex in different fields. And for them, they probably don’t need to know how to take out mesh or even how to put it in. They need to know how to sew on a heart valve much more. And so I think getting them exposure to sort of the bread and butter aspects of general surgery and the key technical skills that translate into what they’re going to do down the road is definitely the most important thing. And then more nuanced stuff, I think is what you pick up as a fellow. And then honestly a lot in practice when you become the person that these patients start to see.

Speaker 1 (00:33:48):

Here’s another question. What is your input on doctors who tell patients that a CAT scan is the only way to show a hernia? Do you think there could be updated training for even ER docs to prevent this misinformation to patients that tend to cause misdiagnosis? That’s a allergic legit question.

Speaker 2 (00:34:03):

I think it’s a great question. So one, I’m a big fan of always more education. Things keep changing in our field and it’s hard to keep up. So I think that figuring out ways that surgeons and physicians outside of training where they are dedicated to education and to learning new things, get exposed to new techniques, new materials, new, everything like that, that’s critical for our development. I think the world of imaging is going to change dramatically with AI and with everything else that’s happening. These computer algorithms might become really, really good at figuring out.

Speaker 1 (00:34:40):

We’re hoping so

Speaker 2 (00:34:42):

They should at detecting early cancers, at doing all these things that the naked eye or the human eye might miss because you’re looking at it as sort of an N of one versus a computer that’s looked at every CT scan that’s ever been taken in every patient and figuring out is that things are going to change. But I

Speaker 1 (00:35:03):

Do think I approached by a company that was going to do that. They’re like, you’ve done all this imaging research, I have all the images still they’re stored and I’ve personally review all of them and write my evaluation. So he’s like, why don’t you kind of feed all that information to our system? But he wanted me to sit down and do it all mainly myself. And I was like, okay, that’s a lot of work.

Speaker 2 (00:35:25):

That’s a lot of work.

Speaker 1 (00:35:27):

It needs to be done. I think that you’re right, we need to feed that kind of good information and then have the machine learn to adapt to all that.

Speaker 2 (00:35:37):

I still think it’s going to take, in my heart of hearts, still believe it’s going to take us as humans and physicians to put it all together. But I do think imaging technology and stuff is going to change a ton. And so I think that we’ll have

Speaker 1 (00:35:49):

Good answer. Yeah,

Speaker 2 (00:35:51):

Help with CTs and ultrasounds that we haven’t necessarily had in the past, but we can always all learn for

Speaker 1 (00:35:59):

Sure. Here’s another question for you that was submitted before today. What are the benefits for a patient to choose a surgeon who is accurately involved in teaching? That’s a great question.

Speaker 2 (00:36:16):

One, it’s an excellent question. So it’s hard for me to give that answer. I’ve never not been involved in teaching. Almost every case I’ve ever done in my entire career has been alongside a trainee.

Speaker 1 (00:36:29):

Exactly.

Speaker 2 (00:36:31):

But

Speaker 1 (00:36:32):

Surgeons who don’t train,

Speaker 2 (00:36:33):

I know surgeons who don’t train. And I also know that they are outstanding and they do so many of those cases and they’ve done them all themselves for years and years and years. They are really good at it. So I think to me, it’s all about your comfort level. I am very comfortable operating on patients and having trainees operate on patients under my supervision because it’s just what I’ve done forever. And anytime that my own internal alarm is going off that this trainee is not able to do whatever it is we need them to do, I take open and do that portion and then when it’s safe, I can give it back. I give it back. So to me, operating with a trainee has always been still sort of me operating because it’s me talking relentlessly about what to do and how to do it.

Speaker 2 (00:37:24):

And if they can do it great and we move forward. And if they can’t, then it’s me doing it. Surgeons who don’t have trainees, they’re often still operating with a partner or with a first assist or a nurse or an A PP or someone else. And I’ve had surgeons that I’ve coached that have done that, and I’ve watched your videos and they do absolutely beautiful hernia repairs. So I think it’s more about your own personal comfort is a patient with your surgeon. And so to me that’s having a conversation with him or her and figuring out if it’s a good fit. I think,

Speaker 1 (00:38:00):

Yeah, I think it’s very humbling to teach because they always ask questions and sometimes the residents are curious or they kind of challenge you in certain things. You’re like, oh, I didn’t think about that. Or they bring up a different way of thinking or approaching things where you may want to be open to that. I really like that. Plus I feel every so often I don’t have a resident. It’s uncommon, mostly because it’s mandated by the residency that they scrub in with me. I’m not allowed not to have a resident because it’s considered good for their education. But if I’m so used to being on the other side of the table and I’m used to, my view is different, what I do is different. So yeah, I like always having a resident trainee and I fear that if I didn’t always have a trainee that I would fall behind. I wouldn’t be up to date with things. I wouldn’t be challenged enough. But yeah, you’re right. There are tons of really amazing surgeons that either operate themselves or operate with their partner, two surgeons that just do amazing things.

Speaker 2 (00:39:14):

I remember, I think I was a senior resident, I was operating with my program director. So the person who was in charge of me is a resident, and he said something to the effect of Within five to 10 years you’ll be bored. And I was like, that doesn’t make any sense to me. I’m spending my late twenties and early thirties trying this thing. You’re telling me in five years of doing it, I’m going to be bored of doing it. And what am I going to do for my life for the next 20 to 30 years

Speaker 1 (00:39:46):

For the rest of my life? Yeah,

Speaker 2 (00:39:47):

Yeah. I now, I think I understand what he means. It does get less challenging in the beginning of surgery, everything else, everything feels hard and new and challenging. But when you’re doing your thousandth case, 1500th case, 2000th case, it does become more routine. It, it’s not as important or different for every individual patient. Everyone you’re taking care of is an N of one. And it’s always important, but it does a gallbladder for the most part when they’re straightforward is a gallbladder. And then hernia is generally the same operation for a lot of things. And so it’s become much more automatic. And the mental energy that you spend as a surgeon kind of dealing with it becomes less and less and it just becomes in your hands. You just can do it like a musician can play or an athlete can play. And so to me, the challenge in the fun of it is getting someone else to do it as well as you can. And to me, the thing that’s true

Speaker 1 (00:40:42):

Brings

Speaker 2 (00:40:43):

Me a lot of joy and is in many ways I think sometimes more challenging than doing the operation.

Speaker 1 (00:40:51):

So my take on that is if I had a job where I was doing, let’s say 10 to 15 hernias straight, one after another routine, not too challenging, but good hernias, I would definitely be bored. But I’ve always been that kind of puzzle solver person, even as a kid. So I dunno if I attract it or if I just enjoy it, but every patient has their own story and their own complexity that I need to try and figure out why do they have this pain? Why are they having symptoms? And then that whole process to me is very fun. And then going to the OR and proving your theory in the OR and then seeing how they do afterwards, that to me has kept it very fun.

Speaker 2 (00:41:45):

Yeah. Have you ever heard of the concept of flow,

Speaker 1 (00:41:50):

Like patient flow?

Speaker 2 (00:41:52):

No, it’s a operation

Speaker 1 (00:41:54):

Flow,

Speaker 2 (00:41:55):

Psychological principle called flow.

Speaker 1 (00:41:57):

Oh no, tell me.

Speaker 2 (00:41:59):

Flow is, it’s essentially like the psychology of optimal experience or in general professional happiness. So you’ll know exactly what I’m talking about. So think put yourself into the first time you were maybe in an operating room or in an experience where everything was just clicking the world around you is working perfectly. An hour passes in a second. That experience where everything is just awesome and you’re super happy and you’re completely focused on the thing that you’re doing, and time passes in like an instant.

Speaker 2 (00:42:32):

We get that in the operating room. We do. That’s this theory called flow. And there’s a bunch of different things that have to happen for you to achieve that flow state. And part of is that if you look at a graph, your skill and the challenge of whatever you have to do have to line up. Because if your skill is so high and the challenge is low, you’re kind of just bored. Versus if the challenge is super high and your skill is low, you’re anxious, right? You’re under performing and you’re really anxious about how you are. But as your skill increases, you have to take on increasingly challenging things. And so you’ve done exactly that. You take on.

Speaker 1 (00:43:12):

Interesting. I’m going to look that up and read more about it tonight.

Speaker 2 (00:43:17):

There’s a book on it called Flow by a psychologist named Mihaly Csikszentmihalyi. It’s an impossibly spelled name.

Speaker 1 (00:43:23):

Okay.

Speaker 2 (00:43:25):

It’s, it’s a little bit of a tough read, but it’s an interesting theory and concept, and he’s totally right. As you get better and better at whatever you’re doing, you have to keep challenging yourself, otherwise end up just same thing in your board. And so for you taking on the puzzle people and the challenging complex people much, I love it

Speaker 1 (00:43:45):

Moving forward. I absolutely love it. I have friends that come and visit me in the office. The surgery center is right next door, so it’s perfectly positioned office. So if you look at my desk, we’re a paperless office, but patients come in with several inch stack of old records and their op reports and their pictures of themselves and then their summaries, and then 10 CDs of different images and all that. And I get all excited like, okay, here’s my new puzzle. And my friends come in, they’re like, I would run away if I saw that because for them, that’s difficult, scary, whatever my endorphins that go up, I love that stuff. I don’t know, maybe I’m weird.

Speaker 2 (00:44:32):

No, I think you just know what drives you and you know what brings your satisfaction and joy,

Speaker 1 (00:44:38):

My flow,

Speaker 2 (00:44:40):

And you take on the stuff that other people don’t want to take on, which does a great service to patients. So I think it’s fantastic.

Speaker 1 (00:44:45):

Okay, here’s another question, doctors, thank you so much for this high level discussion. I had tissue repair over 40 years ago. Sounds like I assume inguinal. I have developed persistent bulging of my AL floor seen on exam and ultrasound, but no defect. Defect is also missing on MRI. I’ll bet you wasn’t red correctly. That seems to be giving me symptoms. Perhaps impending hernia, Gilmore groin, I don’t know. My surgeon recommends a laparoscopic Mesh placement, but recommends using absorbable tax to fixate Mesh to deal with the bulging weakness and attenuation to tighten inguinal floor. What are your thoughts?

Speaker 2 (00:45:24):

So my personal approach, so for inguinal now, I tend to use no tax, and I think that’s just me. I always just worry that tax can potentially hit whatever’s on the other side of the muscles in the transversesalis without you being able to see it. So I personally,

Speaker 1 (00:45:47):

I had a patient like that yesterday. He had a dimple in the skin from a tack.

Speaker 2 (00:45:53):

If you’re doing a TEPP probably and you use either a self fixating Mesh or a non fixating Mesh, you can generally put it in that space as long as it’s laying flat and you watch it sort of as you desufflate watch it lay flat in the right plane in space, you’re probably fine. If you do TEPPs rather than TAPs, I tend to suture close the peritoneum just to try and avoid the use of any tack fixation because you can’t hit a nerve if you don’t fire attack. So that’s my personal, but again, there are a ton of surgeons who I know and who I’ve watched videos of who use tack probably all the time and have really, really good outcomes. So I don’t think it’s, I don’t What

Speaker 1 (00:46:38):

About a really wide direct defect? You don’t tack those.

Speaker 2 (00:46:43):

So for big directs, it’s the one time that I usually will because I do worry about stuff kind of billowing out into it, but that’s the only one.

Speaker 1 (00:46:52):

You said billowing. I use billowing

Speaker 2 (00:46:54):

Billows.

Speaker 1 (00:46:56):

I know. I thought I was the only nerd that used the word billow in her op reports.

Speaker 2 (00:47:00):

Good.

Speaker 1 (00:47:01):

I love it. I knew there was something special about you, Jake. Well, I agree with you, and it’s possible. So it says it was seen on exam and ultrasound, but no defect. It could just be a weakness, like a direct

Speaker 2 (00:47:15):

Mean, it’s probably defect,

Speaker 1 (00:47:16):

Probably a direct it’s.

Speaker 2 (00:47:18):

And so for that, I think a an MIS repair makes total sense.

Speaker 1 (00:47:22):

Yeah, it totally does. And absorbable tacks is correctly placed within standard. Oh, look at someone else wrote a nice comment, love this discussion. Do you think you’ll have time to answer the above question about occult hernia strangulation? Oh, sorry. There was a question that said what are the risks of an occult inguinal hernia?

Speaker 2 (00:47:45):

So I don’t actually know of any data on that. So one, I think my gut instinct would be that it’s probably very small. So cult hernias being small enough that we usually can’t feel them on exam. They’re probably small enough that there’s not going to be a loop of intestine that can get into them and cause a problem. So my gut instinct would be it’s very, very low. In fact, when you look kind of at all hernias, the best study in this was probably the watchful waiting trial that really looked

Speaker 1 (00:48:18):

With gibbons. He was on as a guest last year, which

Speaker 2 (00:48:21):

Looked at incarceration and strangulation. So they had 700 men. Unfortunately there were no women in the study, so it doesn’t necessarily translate over to women, which is unfortunate. It’s probably the same, but we don’t know for sure.

Speaker 1 (00:48:35):

You know what I say, I see a lot of women, I said, even if it’s 10 x, which I probably isn’t, then 0.18% per year is 1.8% per year, which is still low. Exactly

Speaker 2 (00:48:48):

Right. It’s still really low. It was like a 0.2% risk of strangulation. You’re exactly right. It is really small on a yearly basis. And that was for palpable hernias that were asymptomatic. And so I think for a cult, it’s very, very low.

Speaker 1 (00:49:02):

The one exception is a femoral hernia, A which most femoral hernias are cul. So those are of all hernias or highest risk for strangulation. But yeah, if it’s so small you can’t even feel it, then definitely no bowel is going to get second in percent. Yeah, there’s not much in there.

Speaker 2 (00:49:18):

So I always say this to patients and it takes the right generation to understand the joke. When I’m patients about inguinal hernia, I always tell them that not only am I the president of the hair club for men, I’m also a client. I’ve had bilateral inguinal hernia repaired myself.

Speaker 1 (00:49:33):

That’s generational. Yeah,

Speaker 2 (00:49:34):

Yeah, exactly. So the people that are younger than me totally don’t just blank sticks. So I could have totally been a patient in that trial. I diagnosed myself when I was a third year resident. I clearly had a really, yeah, but it wasn’t bugging me and I didn’t want to take a week off of residency to recover from a hernia.

Speaker 1 (00:49:58):

So did you have hernia repair?

Speaker 2 (00:50:00):

Yeah, bilateral

Speaker 1 (00:50:01):

Laparoscopic with me.

Speaker 2 (00:50:04):

My fellowship director fixed me as he was teaching.

Speaker 1 (00:50:06):

Really?

Speaker 2 (00:50:07):

Yeah. He did a really good job.

Speaker 1 (00:50:10):

Did he use tax?

Speaker 2 (00:50:12):

No, he sutured. Sutured close. Just bilateral 3D max and sutures.

Speaker 1 (00:50:18):

Yeah. And you’re doing great.

Speaker 2 (00:50:20):

Oh, totally fine. That was no

Speaker 1 (00:50:21):

Mention plan. Illness was

Speaker 2 (00:50:23):

2000, I think it was January of 2011. So

Speaker 1 (00:50:27):

Here’s a follow-up question to that. Doctors, where do you place the attacks? Because I think I am the billowing patient that you described Cooper’s ligament into the transversesalis fascia conjoint tendon. Where do you place your tacks or fixation of any sort? I guess

Speaker 2 (00:50:41):

So one, so I now use, I am assuming we can just say product. Yeah. So I use progrip now,

Speaker 1 (00:50:50):

Which is a great Mesh. It’s

Speaker 2 (00:50:51):

A great mesh. I really, really like it. I do feel like it fixates really well for the big directs where I do think you need additional, I’ll put in into Cooper’s one high up into the rectus medially and then high lateral above the Iliopubic tract. So you make sure you can feel the attacker in your hand. And those are really kind of the only places.

Speaker 1 (00:51:12):

So the way I teach my Rives is you got to triangulate because the whole purpose of tacking, especially these large directs, is to prevent the mesh from falling into this weakened base. So if you triangulate it, then that should kind of reduce that risk. So yeah, I do one at Coopers just below femoral space, one at the rectus right before inserts into the pubic tubercle, and then one just medial to the epigastrics that the practice muscle. Okay.

Speaker 2 (00:51:45):

And I think the key to those is you need a big piece of mesh for those big directs too.

Speaker 1 (00:51:52):

Yeah, you need water. Listen, I had a patient come in from a European country that should know better. The guy is German and he’s like six foot four huge guy with a good size hernia and they put the smallest piece of mesh in him. I mean, the size matters for direct, especially matters. Anyway, here’s another question. Let’s see. On the basis of your experience, do you think that there is enough evidence to support recognizing hernia surgery as a separate surgery specialty?

Speaker 2 (00:52:35):

I think that’s a great question.

Speaker 1 (00:52:38):

I have great audience.

Speaker 2 (00:52:39):

That’s a great question. So I am a little conflicted about that. Tell

Speaker 1 (00:52:46):

Me. I am too, but tell me.

Speaker 2 (00:52:48):

Well, so I mean I think that hernia surgery is, I mean, when you look at the numbers, inguinal hernia repair is what it’s either the most common or second most common operation,

Speaker 1 (00:52:57):

Most common outpatient procedure.

Speaker 2 (00:53:00):

And so it’s the bread and butter of most practicing surgeons that endoscopy, cholecystectomy, appendectomy. Those are the common things. And so I don’t feel like it’s right for us to say you have to be a hernia surgeon to fix inguinal hernias. I don’t believe that to be true. I do think people can do great hernia repairs right out of residency when they’ve had appropriate training. I do think that for the super complex stuff like the multiply recurrent ventral, the EC fistulas in the setting of a complex Hernia and prior mesh, those types of things, I

Speaker 1 (00:53:41):

Think complex stuff

Speaker 2 (00:53:42):

That should be in the hands of a few and a few high volume centers that do a lot of that work because they understand what goes into it, how to take care of those patients. They have infrastructure around it. They usually have research programs around it. And to me, I think that is the specialized portion of it for

Speaker 1 (00:54:01):

Sure.

Speaker 2 (00:54:01):

But I think for the bread and butter stuff, I don’t think so. I think we still train people to do that and the people that go on into practice and generally do that, well really do it well. And so I don’t think that part is necessarily its own specialty.

Speaker 1 (00:54:16):

And what do you think the institution’s appetite appetites are? There’s plenty of institutions that have dedicated hernia centers, but there are also a lot that don’t care to have one. It’s not profitable to ’em or they don’t want to put their resources into that. What has your experience been?

Speaker 2 (00:54:35):

My experience has been, so having gone to a couple of different places where there wasn’t a focus on it and making a clinical focus on it. One, once you do, the other surgeons that have been doing a lot of it and don’t necessarily love it all of a sudden love you because they focus on the things that they want to do instead of, so we had a lot of our hernia, a lot of our surgeons that were fixing hernias at Duke we’re sort of the general surgeons. They would be partnering with plastics to do the cases. And so they’d be like an HPV specialist and they would go in and lyse adhesion so that the plastic surgeon can fix the hernia. And patients got great care and that went really well. But also then you have an HPV surgeon that instead of doing another HPV case to fix a cancer or something is doing. And so I think when you come and you sort of build those programs, the other surgeons are impacted by it in meaningful and good ways. And I think it elevates the level of care that those patients get because it becomes sort of a clinical focus and a program where you try and build some infrastructure and research around it. And usually I think that’s better for patients.

Speaker 1 (00:55:36):

Yeah, I totally agree.

Speaker 2 (00:55:38):

It’s good. But I think you have to have everyone aligned and willing and interested to do it. To

Speaker 1 (00:55:44):

Do it. And from a business standpoint, are the institutions interested in that?

Speaker 2 (00:55:47):

They do. Okay. It’s not as good as, I mean it’s, it’s not cardiac surgery and it’s not spine surgery and it’s not a lot of the other stuff, but it is, I think it’s one, it’s, again, it’s a high volume service. There’s just a lot of hernias out there to fix. It means that you’re giving service back to the community in which you live and work, which is good. And for the complex stuff, it’s higher RVU, it generally bills, well, it depends a little bit on your insurance contracts with everyone in terms of how it reimburses. But in general it does. Okay.

Speaker 1 (00:56:23):

Do you get pushback from community surgeons or general surgeons in the program that now I’m not going to get my referrals from gynecology, from the umbilical hernias or something like that?

Speaker 2 (00:56:35):

No, because again, one, I think we’ve tried to build it as a team effort. Everyone that wants to be interested and wants to be involved, all you have to do to be involved in the Hernia center is one, submit that your case go into a registry so that we can follow every,

Speaker 1 (00:56:51):

Yes, that’s very important.

Speaker 2 (00:56:52):

And then two, come to hernia conference, present your patients and see what other people think should be done about ’em. And as long as we engage in those two things and then do, I’m not going to tell people they shouldn’t do any case or can’t do any case, but if maybe we can do it robotically when they would have to do it open, they might say, oh, why don’t

Speaker 1 (00:57:12):

You a hundred percent agree with that? Yeah. Plus the intricacies of, I’m in Beverly Hills, so there’s a lot of plastic surgeons around. And today I had a patient with clearly an incisional hernia to my eyes, but imaging said diastasis. So he’s been to all these plastic surgeons are offering a tummy tuck to a male that’s retired. It’s just makes no sense to me. And the way they fix it is going to be different than a hernia surgeon would fix it. But what I think is the best is getting Hernia surgery specialists in every kind institution so that when the surgical oncologist takes out a big tumor off the abdominal wall, you’re available. When the transplant surgeon has a hernia, you’re available. Then the spine surgeon gets a denervations injury you can help that. And the gynecologist doesn’t know what to do with a pregnant lady with an umbilical, there’s so many specialties that can be serviced through the hernia surgeon kind of hat that they may not even be aware that they needed your help until you’re there. It’s superior service.

Speaker 2 (00:58:31):

I think it’s so I’m a huge believer in everyone should do what they do best. Right. So when I see patients with parastomal hernias, like if their stoma can come down, I get our colorectal surgeons involved because me, can I take down a stoma? Yeah, I probably can, but I’m not going to do it nearly as well as they do. Right, exactly. And they fix the hernia. Yeah, they can, but they might not do that part as well as I can.

Speaker 1 (00:58:55):

So

Speaker 2 (00:58:56):

Approach it as a team. The patients then get the best of that, of both of the surgeons experience doing the things that they do best and they get, I think by far better outcomes than if one of us tried to do everything all alone. A hundred

Speaker 1 (00:59:09):

Percent agree.

Speaker 2 (00:59:10):

Completely love that sort of team aspect to patient care. At the bigger institutions where we have all these specialists that can do everything, it’s great. It’s such a privilege to practice in a place like that. I

Speaker 1 (00:59:20):

Think. I agree. And I think it makes hernia surgery even more fun because it’s so cross specialty. It truly is a multi-specialty kind of application.

Speaker 2 (00:59:32):

Totally agree.

Speaker 1 (00:59:34):

Okay, one final question. It says you guys are great, but I have one more question. 12 by 15 mesh and do you use absorbable T? So when you mentioned for these direct hernias or large ones, do you use tax and what kind of tack do you use?

Speaker 2 (00:59:50):

So if I’m going to tack, I do use absorbable. I don’t know that that makes a difference. I mean, I think to me, most of the injuries that we see, the problems that we see with T are probably if you attack a nerve and if you attack a nerve with an absorbable or a permanent tack, you’ve still tack the nerve and you’ve probably been, I still like absorbable attacks just because I don’t really like much permanent anything with the exception of the Mesh. 12 by 15 is good

Speaker 1 (01:00:14):

Size and the size Mesh. Yeah.

Speaker 2 (01:00:16):

12 by 15 is good. I mean, so most of the programs are 15 by 10 or 16 by 12. D max is either I think 15 by 10 or 16. All of them,

Speaker 1 (01:00:26):

They’re standard sizes.

Speaker 2 (01:00:27):

15 by 10 is the minimum, right? It’s that or bigger

Speaker 1 (01:00:30):

Except in my six foot four German patient.

Speaker 2 (01:00:32):

Yeah. A

Speaker 1 (01:00:33):

Medium 3D max in a direct one.

Speaker 2 (01:00:35):

Yeah. Large or extra? Large only. But I also think the key is it’s got to be a well dissected space and it’s got to be nice and flat for sure. Yes.

Speaker 1 (01:00:48):

That’s so important. It’s so important. Well my friend, that was it. Thank you so much for your time. Can you believe, thank you. The hour goes by quickly.

Speaker 2 (01:00:58):

It does. Thank you for the invitation. It is always great to spend time with you.

Speaker 1 (01:01:02):

And thank you everyone for joining us on a Hernia, Talk Live. Don’t forget this will be up on the YouTube channel, hopefully by tomorrow or catch up with all the past episodes on our podcast. And oh, I forgot to tell you, I’m launching a hernia score. Jake, did I tell you about a hernia score? No. Okay. I’ll let you know the next way I see you. It’s a machine learning algorithm where if you’re not sure if your patient has groin pain or pelvic pain due to a hernia, you go to the scoring system, put in all this numbers and it gives you a percentage chance that inguinal hernia will treat their groin, testicular, pelvic pain, whatever.

Speaker 2 (01:01:44):

Well, I love that idea. Isn’t

Speaker 1 (01:01:45):

That great? Yeah. Okay. It’s launching soon. I have one more week to clean it up before we’re ready to launch. I’ll let you all know. Until then, I’ll see y’all next week. We have more guests coming. And thank you again, Jake. I appreciate you. You’re on the East coast so it’s much later for you than it is for me. So have a good time with your family. Thank you very much.

Speaker 2 (01:02:03):

Thank you.

Speaker 1 (01:02:04):

Bye.