Speaker 1 (00:00:00):
Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live, our weekly Q&A every Tuesday. My name is Dr. Shirin Towfigh. I am your host and hernia and laparoscopic surgery specialist. Many of you are joining me via Zoom and others via my Facebook page as a Facebook live at Dr. Towfigh. And thank you to those of you that follow me on Twitter and Instagram at hernia doc. As always, by the end of this session, I will make sure you have access to the full hour of this and all previous Hernia Talk Live episodes on my YouTube channel. So thanks for everyone who me on that. So I’m very excited because today’s guest is Dr. Caroline Reinke. She is currently at Charlotte, North Carolina. She’s an emergency surgery specialist. She’s actually more than that. We’ll discuss that as we get to know her better. She works out of Atrium Health, which used to be the Carolinas Institute. You can follow at Twitter at CE Reinke and please say hi to Dr. Reinke. Hi, how are you?
Speaker 2 (00:01:09):
Good evening everybody. I’m doing great. How
Speaker 1 (00:01:11):
Are you? So nice to see you. Thanks for your time because it’s what it should be what seven 30 right now? PM your time. Yes. So you probably had a long day, so I do appreciate your time. So for those of you that may not know, first of all, we’ve interviewed several surgeons from your institution already. We are a hernia talk group, so Dr. Vedra Augenstein and Dr. Todd Heniford, both from the Carolinas are very well-known hernia specialist and friends of mine and they had great sessions with me. So I’m very grateful. Your role in the hospital is a little bit different. If you can just explain how you’re similar but a little bit different than your colleagues there.
Speaker 2 (00:02:02):
Yeah, absolutely. So we have a somewhat unique situation, although the more I talk to people, it’s less uncommon than I thought. But we have a group of seven surgeons that are general surgeons. We all did a minimally invasive fellowship, so expertise in laparoscopic skills and we cover unassigned call so patients that come into the emergency room as well as an elective practice. We’re a group practice. So we do really share our patients in a pretty unique way. But our goal is I sometimes say we do emergency general surgery with an MIS flare, but a little bit of everything and that’s really what makes what I do so fun.
Speaker 1 (00:02:50):
Yeah. So I was sharing with you that when I was around your age, I was doing a similar job. It was my first job out of residency and it was my funnest job I would say because I call them my box of chocolates. You just show up to work. You have no idea what you’re going to inherit. It could be the sickest patients or it could be the most interesting patient. It’s whatever comes to the emergency room you inherit. And by offering that extra minimally invasive specialty care, then you end up, I feel doing a better job than the typical general surgeon that just takes call. Although I must say I do not miss taking call. That is one part of my job I did not miss operating between the peak hours of 10:00 PM and 4:00 AM I dunno about you.
Speaker 2 (00:03:44):
I was going to say, so then you wouldn’t count my 4:00 AM case from this morning.
Speaker 1 (00:03:47):
Yeah, I mean it gets too much. It’s like it’s a lot.
Speaker 2 (00:03:55):
Yes, it gets harder as the years go along. Yes. But
Speaker 1 (00:04:00):
Yeah, I did six years of it no fun. And my next job I’m like, I don’t want to take call. They’re like, that’s okay, we don’t need you to take call. We have plenty of people. I’m like, oh my god. It’s like the best job ever. No call. Yeah. But as a general surgeon it’s very hard not to take call. That’s kind of like saving lives is part of what we do. So that comes with taking call and it is what it is. So
Speaker 2 (00:04:29):
I mean I think one of the really fun things about that where I am is as you mentioned, some of my colleagues who are here, we have great relationships with them because some of what we do is take the call and help care for their patients. And so really great collaboration when there’s difficult cases or challenging situations. So it’s an added,
Speaker 1 (00:04:52):
Yeah. So I train at UCLA but my job was at USC and as you know there’s a USC UCLA like football rivalry, but there’s also a cross down rivalry with everything that happens in the two campuses. So it was, they were like, what do we do with this girl that just came from UCLA because the U UCLA was considered the more elite institution, but also we weren’t taking care of ganglion violence and we had transplant patients. We didn’t have people that were shot 10 million times. So going to USC was a whole different patient population. They assumed I wouldn’t be able to handle it. Of course I was able to handle it. So within a month of opening up tests on the ward and saving lives and doing trauma call as backup, I earned my stripes there. But there was a little bit of can she handle it because USC is a totally different animal than u c when it comes to their emergency medical care.
Speaker 2 (00:05:59):
Speaker 1 (00:06:01):
USC is very famous, very
Speaker 2 (00:06:02):
Speaker 1 (00:06:03):
In fact, USC at the time was the training ground, believe it or not, for surgeons before they went off to or doctors before they went off to Iraq during the war. So I mean that just tells you a lot about the kind of yes crazy stuff we saw. But I was saying that this is the first time that we’ve really have the opportunity to talk about hernias in the emergency setting because everything we talk about is either elective surgery or it’s like some offshoot of chronic pelvic pain and chronic abdominal pain. Whereas dealing with your part of the world, it’s all acute. So it’s not the doctor, I’ve had 20 years of pain in my right corn, what can it be? It’s like I’m now vomiting or I’ve dead intestine or I’m very sick or I can’t walk anymore cause this thing is bulging and then they come to you.
Speaker 1 (00:07:05):
So maybe you can give us a little bit of an idea of what, since you also do elective surgery, how it’s different the type of patients you see. Because when we talk, I’ve had a lot of other colleagues on board and we talk about optimization. If you’re smoker, you should smoke for months before sur- you should stop smoking for months before surgery. Or if you’re obese you should lose weight before you have surgery. But you don’t have a luxury of necessarily optimizing your patients for that perfect hernia repair. So maybe give me a little flavor of the kind of patients you tend to see.
Speaker 2 (00:07:46):
Yeah, it’s a great question and one of the things that we all struggle with a little bit. So there’s some patients that come in with an emergency hernia that you can temporize, so you could reduce the hernia or soft acute problem. And then you get into this conversation that’s really interesting and it’s when I have often in clinic or in the emergency room where I say we’ve solved your emergency, that brought you to the emergency room very appropriately. And if you told me that this happens, it used to happen every month and now it happens every week and now it’s happening every day, then that would push me towards let’s just do something now. Yeah, if you told me I’ve been thinking about quitting smoking and losing weight and this is going to make me do it and if you just gave me three to four weeks doctor, I could do amazing things.
Speaker 2 (00:08:42):
And I’d be like, okay, well let’s wait three to four weeks and see if that prophecy comes true. So there’s a whole balancing act that happens there when you can open that opportunity. But certainly there’s times that I patient, I just say, be honest with me. They’ll be like, I’ve been trying to lose weight for 30 years and this ain’t going to change it. And I’m like, all right. And then if you’re coming into the emergency room using resources, it’s incredibly inconvenient for the patients. Then a lot of times we just say, well we’ll give it a shot and we just know that the outcomes won’t be what they could be, but we’ll give it our best.
Speaker 1 (00:09:26):
Yeah, that’s definitely a side of the world that I don’t see too much because I don’t take call anymore and it’s all elective and there are patients, so part of your patients are sick, ill, you have to emergently operate on them. Time is of the essence. There’s no discussion. But you’re right, there’s a fraction of patients that are there because they’re struggling with their hernia and they’ve probably been to me or someone else and I told them, lose weight or stop smoking or fix your constipation or whatever. And in the meantime they’re in pain and it’s like they can’t work or whatever. And the reality is people don’t sit in the emergency room for hours and hours because they’re nothing better to do that there’s something that is causing them to be there and need to get that care even if it means waiting and so on. So that’s where you kind of take that into account. Well let’s start easy. Let’s share some stories of the patients that are acutely ill. Why they come to you? What’s the situation and how do you usually approach those patients?
Speaker 2 (00:10:46):
So a recent things always come in three. So a recent threesome we had was a patients who come in with an incarcerated ventral hernia. That means that your bowels are through the hernia and they are stuck out and there’s nothing I can do to get them back in all the sedation, all the pushing, all the work in the world won’t get it back in. And in those situations what we’re worried about is the blood supply. And often on a CAT scan you can see signs of either early or late ischemia and that is a surgical emergency. And when you
Speaker 1 (00:11:27):
Emergency, how many hours do you have?
Speaker 2 (00:11:32):
Yeah, so I sort of think about it the way that we think about limb ischemia. So if we think about vascular disease and your foot, we sort of say get six to 12 hours before it dies completely. And so I sort of use a similar framework, but once I see a patient with that problem, we try to get them in the operating room immediately. So we had, case I did this morning, they were in the operating room within an asleep within an hour and a half of getting the call. And that may sound like a long time to the rest of the world. That’s pretty good. But the way things work, if you have to meet the anesthesiologist and do all the things to prep a patient for surgery, that’s pretty quickly.
Speaker 1 (00:12:15):
Yeah, that’s pretty good. So this is what scares most people is I don’t want to fall into that category. a lot of times we offer surgery because we want to prevent this exact situation. But then so now you have someone who has been sick and what are their symptoms? If you explain what people should be careful of to watch out for that are signs of a more acute life threatening problem that’s due to a hernia.
Speaker 2 (00:12:47):
So for most patients you can talk about whether or not they can push the hernia back in. So you can say if you can lay down and relax and push it back in and then all of a sudden you can no longer do that, that’s a reason to come to the emergency room because it’s stuck out. And that’s when we start to worry about blood supply. There’s a small subset of patients who probably have a chronically incarcerated or stuck out hernia. And so then it’s less about can it go in or out? And it’s more about how does it feel. So if patients describe acute pain, it starts all of a sudden it’s more severe than chronic discomfort they have with the hernia. And then almost always if there’s bowel involved, they’re going to have symptoms of nausea and vomiting and the patients will describe having nausea and vomiting and even after they stop, there’s nothing left to vomit up. They’re still having dry heaves because the intestines are just feeling that things are blocked and they they’re trying to get it out
Speaker 1 (00:13:51):
And the area of their hernia tends to be more tender, more red maybe or warm to the touch. Right.
Speaker 2 (00:14:00):
Yeah, it can depend a lot on the patient and their abdominal wall thickness. So for patients who have a thin abdominal wall, we saw one today, you know can start to see those underlying skin changes where it turns red purple and you can tell that something’s going on underneath. There are some patients who have a fairly thick abdominal wall and you won’t see those changes even though that’s happening underneath, there’s just enough layers over top of it that that’s not obvious on exam.
Speaker 1 (00:14:30):
Yeah, we actually published a paper that looked at bariatric patients, so they underwent laparoscopic bariatric surgery and within the first 21 days, within the first three weeks, if they come in with severe abdominal pain, you have to rule out a incarcerated, maybe strangulated trocar site hernia. So from where they did the laparoscopic surgery, but their abdominal wall is so thick because they weigh three, four or 500 pounds that the physical exam won’t show it. But if someone comes in within three weeks of surgery with severe abdominal pain, then you have to rule out that problem. Now they can get hernias later on in life, but when it occurs within the first 21 days it’s always surgical because it’s almost strangulated. Whereas when they get it after 21 days, usually it’s months to a week, years later, then it’s just like a hernia and you just fix it whenever. But it’s not an acute problem. But the patients that are morbidly obese, very difficult to examine. And so what kind of imaging do you tend to get on these patients, if any?
Speaker 2 (00:15:40):
Yeah, almost always a CAT scan is going to be incredibly helpful both because you can see the changes in the bowel if it’s really compromised blood supply, but also it helps with operative planning. So you get an idea of where the defect is relative. Not sure how much you guys have talked about this, but it’s going to describe it as a mushroom. You have a defect and then you have the things that come out of it and sometimes it’s hard to tell from that where the defect is, particularly if you can’t reduce it. And so a lot of times that’ll help with deciding where to make our incision or how to approach the hernia.
Speaker 1 (00:16:18):
And how often in these really sick patients we’ll get to the last sick patients later. But these really sick patients, how often do you think laparoscopy is an approach that you would take?
Speaker 2 (00:16:33):
So there are still patients that go as an emergency with an incarcerated hernia that I will approach laparoscopically and have success very commonly successful in inguinal hernias for this recently has success with the Spigelian hernia with that? Right. Then I think it depends. Once you get people start to have sort of a loss of domain type situation, then that’s just going to be a lot less successful because you have less room in there. And you sort of mentioned this, but it depends a little bit on how sick the patient is. So yeah, if they’re really sick then they won’t tolerate the laparoscopy and they don’t really have it. It does usually take a little bit of extra time laparoscopically compared to open to get the bowels completely freed. And so are they going to tolerate the insufflation and do you have that little bit of extra time?
Speaker 1 (00:17:32):
And then how often do you think these emergency cases, the really sick ones are from abdominal wall hernias versus groin hernias?
Speaker 2 (00:17:44):
The sicker ones tend to be the abdominal wall. Yeah, because I think that hides stutter and patients may attribute some symptoms. Either they didn’t know they have a hernia or they get symptoms and they just think, oh I’ve just got a GI bug and they wait a little bit longer. Yeah, I think the groin hernias are more visible and patients, patients aren’t like, oh I have a GI dog. They’re like, oh I have a bulge of microwave that’s hard and won’t go away. And so I think they tend to come in a little bit sooner and be less sick.
Speaker 1 (00:18:19):
And what about aged? Do they tend to be younger or older when they come in really sick, middle aged, not really make a difference. It
Speaker 2 (00:18:30):
Can vary. I think age is one of the factors. So if all the other things were the same, there probably are some older patients who either are less independent and so have to call someone to bring them in. Or when you get older you get a little bit more tolerant of pain, which can make for very lovely surgical patients. But maybe wait things out and hoping it’ll get better because it has for the last 89 years. So surely it will today as well.
Speaker 1 (00:18:57):
Yeah, there’s always the classic patient that they do in the oral boards or the questions they ask the residents on exams, which is elderly patient, maybe senile and under a nursing home, chronically constipated, very thin, comes in with a bowel obstruction, never had surgery before and usually answer is an obturator hernia or sometimes a femoral hernia. But obturator hernia, that gets missed because you can’t really see on examination and then hopefully you get that on image. So imaging helps. But yeah, hernias can be very dangerous. Fortunately not common to have a hernia end up in the emergency room, but they can happen. So tell me about the not so sick patients. So people that come in, a lot of pain, it’s hernia related. How often do you offer urgent surgery? Is it really based on their social status and ability to be able to get care outside the emergency room? Or if they’ve struggled with it for years trying to improve their quality of life, how do you approach those patients?
Speaker 2 (00:20:14):
I think all of those factors play a role. So one of the recent, I had a spigelian hernia, the ED couldn’t reduce, they told him he would need surgery and the time that I got out of the operating room and got there, he and his wife had made all the plans to have surgery that day and I reduced it and then I said, I could do surgery today, I could schedule you for two weeks from now, whatever works best for your schedule, you’ll get the same surgery. And they were like, actually we just spent the last 30 minutes rearranging life to have it today. Could we do that? And I was like, sure, sounds great.
Speaker 1 (00:20:50):
Speaker 2 (00:20:51):
Lovely. But that person was very healthy, they didn’t smoke, they didn’t have diabetes. So that was again, I could very confidently say to them that they were going to have the same surgery that day that they would two to four weeks later. But we do factor all of those things into the equation. If we have someone who says, I can’t tell when it’s incarcerated and I don’t know until I start vomiting every time, then you are like, ah, maybe we do it sooner rather than later. Or again, if they have what I almost call, we talked about crescendo, angina and heart attacks. This is like we talk about crescendo hernia symptoms.
Speaker 1 (00:21:33):
That’s a good one. I love that too.
Speaker 2 (00:21:36):
They’re getting a little more severe every time. A little bit harder to push in and like we could try to do this as an outpatient, but my prediction that you’ll come back in even if we waited two weeks. So let’s talk about,
Speaker 1 (00:21:50):
That’s a great term. So there’s crescendo d crescendo, it’s a music term. So yeah, you’re right. Crescendo angina is one. You’re like, it’s getting worse and worse. And we’re like the pain escalates. We see that with people with hernias and that’s one reason for us to expedite their care, whereas the same type of hernia. But in someone that’s not as symptomatic, maybe you can delay surgery. But I like that crescendo. That’s a good adjective. So the thing that we struggle with most and that I get called in a lot for when my colleagues are operating and there’s a hernia either in the way or needs to be addressed as part of the surgery. So often it’s like a liver surgery or a transplant or something where they kind of didn’t think about the hernia and then now they’re done with the surgery. They’re like, okay, now we have to close. Well shoot, how do we close? Cause there’s a hernia here, so you must get that where you have to operate on someone, let’s say a bowel obstruction, right? Let’s say someone had colon surgery and they have a hernia from the colon surgery, but it was never bothering them, they didn’t do anything. Now they’re here with a bowel obstruction and they need surgery.
Speaker 1 (00:23:14):
How do you handle those hernias when it’s, it’s not the primary problem. It’s like you also have to deal with it.
Speaker 2 (00:23:24):
Yeah, those are tricky situations. a lot of times it’s a phone call to a friend just for a second opinion even with us. But we do try to fix it in that time if we think it’s safe, mean we can always, I mean let’s just be honest, we can always fix a hernia doing a primary repair, right? I mean yes, whether or not that’s a real fix or a temporary fix, yes, gets into what we know about hernias, but if the patient is again otherwise pretty optimized and sometimes we’ll try a repair that’s somewhat similar to what we would do in elective situation. And we also had those conversations. Interestingly, when we have someone who we’ve, we have said no to surgery, elective surgery for, and then they come in and they have to have it. If their primary risk was not things like diabetes, smoking and obesity, but their primary risks were cardiopulmonary and we’ve sort of had to fight that bullet, then we’ll say, well let’s go ahead and do a really formal repair because the only anesthesia they’re getting, right?
Speaker 1 (00:24:40):
Speaker 2 (00:24:42):
And so it’s it even for patients who we’ve said no to an elective hernia repair, what we do in the emergency setting will depend on whether the no was because of their cardiopulmonary issues in general anesthesia or whether the no was because of the risk factors around the hernia repair in terms of the surgical site infection or other problem
Speaker 1 (00:25:06):
That’s with the
Speaker 2 (00:25:07):
Speaker 1 (00:25:08):
Yeah, that’s a really good point because you don’t want to offer them surgery that can kill them or potentially kill them because I always say life before hernia, but if they’re already in the operating room, then that risk has already been taken for another purpose. That’s a really good point. I like that. I always say life before hernia because sometimes I’m meant talking with the residents. They run a case by me or something and they’re always, they have a dilemma too like, oh, we got this hernia, but then they didn’t know if they should do a component separation ta, all these things I teach are right tar and use this Mesh and that Mesh. And I was like, whoa, whoa, whoa, listen. Like life before hernia. So you have to bring them down a notch and say, okay, they had dead bowel, they just got shot, they have a bowel, whatever the situation is that’s life threatening.
Speaker 1 (00:26:07):
You’re there for the life-threatening problem. The hernia in these situations we’re talking about was not the life-threatening. It’s a happenstance. They happen to also have that. So save the life deal with the dead bowel, whatever, and then the hernia can always fix later. And I get that a lot in these people. The surgeons often call me to the operating room and okay, what do we do with the hernia? I was like, nothing. Just nothing. And they’re looking at me, you’re a hernia surgeon, we be doing something fancy with this hernia. I’m like, Nope. Because I don’t want them to burn the bridges because whatever they do, it’s going to fail, it’s going to fall apart, it’s going to be too tight. There may be a higher risk of infection from their surgery alone, so it’s going to screw up whatever her repair potentially the patient really needs. So leave that virgin territory for me later to fix it and just save a life. So how often do you kind of face that too?
Speaker 2 (00:27:14):
Yeah, we face that a lot. Again, sort of in patients who have, I mean even if it’s not a life threatening thing, you could talk about acute cholecystitis in someone with sort of a massive abdominal wall hernia and taking out the gallbladder or any other appendicitis, diverticulitis. There’s a whole list of itises that happen in the abdomen in patients who may just have hernias that exist out in the world. And I think again, it really gets to that I we a hundred percent practice that when there’s an acute infection, you are don’t want to burn bridges, you’re making it a higher risk repair. We just let it be and we tell patients that we’re not doing it because it’s not the best thing for them. Maybe they think that in three days they’ll wish we’d repaired it, but I tell them in one year, five years you wish I didn’t.
Speaker 2 (00:28:06):
Yes. Because then we can do something even better and have a better longer term outcome. And for us, again, the interesting situations are the ones where there’s incarcerated bowel and a known hernia, but we get there before the bowel really becomes significantly ischemic. And then we’re sort of like, well, the hernia was the problem and now what do we do? We fix it. Do we not fix it? How much do we fix it? Yeah. So again, if it’s not the cause of the problem, I think almost always the answer we give is say that for another day. Yeah,
Speaker 1 (00:28:47):
Speaker 2 (00:28:48):
Agree. So when we can really get into the weeds,
Speaker 1 (00:28:52):
I think the issue is always the really sick patient, the dead bowel or whatever. And in some of those, I’m even closing the abdominal wall is not a lifesaving operation, just get rid of the dead bowel and get out. It’s almost, what do they call that?
Speaker 2 (00:29:11):
Damage control? Is
Speaker 1 (00:29:13):
That, yes, thank you. Damage control surgery, what
Speaker 2 (00:29:15):
You’re looking for,
Speaker 1 (00:29:16):
Emergency surgery as opposed to trauma surgery. But yeah, it’s like for groin sometimes they’re so sick, it’s not common, but when they are really sick, I’m just plug that hole, deal with a bowel, plug the hole with some surgicel or something just to temp temporarily, prevent another bowel obstruction while the patient’s recovering and bring it back two or three days. And when they’re healthy and fix the hernia, you can still do that. It’s okay to stage some of these patients. There’s so many options. Everyone thinks, how do I fix a hernia now? I’m like, just let it go. Okay, come back. You want a live patient, you don’t want a sick patient because I’ve seen people then struggle for the two hours to fix a hernia in the groin, let’s say. And I’m like, you forgot the purpose that you’re there is not for the hernia repair, it’s for the bowel, the dead bowel. Right. So yeah,
Speaker 2 (00:30:15):
I think the hernia ones, I mean the groin ones are the most challenging in that situation because like I said, sort of the abdominal wall ones, you can just put fit in it or just leave it open, but somehow it feels harder to do that in the groin.
Speaker 1 (00:30:33):
Totally agree. Okay, let’s go through some questions that were submitted. Okay, here’s one question and that is emergency hernia surgery better handled by a surgeon, specialize in hernia treatment or by a surgeon specialize in emergency surgery? That’s a great question
Speaker 2 (00:30:54):
Answers. And also that’s probably, you could create an eight hour debate on that one. Yes, I’m sure. Yeah. So I think that’s what we love about what we do is that we have a little bit of expertise in both of those and feel like we can really bring that together for those patients. I think it’s also one of the great things that many of our surgical societies have worked to promote sharing knowledge between those who consider themselves hernia specialists and those that consider themselves emergency surgeon specialists. And I think both at surgical national surgical meetings and then within your local environment, having those relationships when you get into a tough case where we can call you or we have someone that we feel comfortable having the patient follow up with if we don’t feel comfortable fixing it at the moment. But it’s a tough question and I don’t think that we know the answer to it. And there’s so many, the range of who’s a hernia specialist and the range of who’s an emergency surgeon specialist, it’s such a wide range that there’s not one option or the other, which is hard to put those directly against each other.
Speaker 1 (00:32:22):
So I would say the most half of the hernia surgeons that I know also take call. And then the people that do general surgery call, it’s highly variable. I mean there are people that still do hernia surgery the way they were trained in residency like 40 years ago. Or they’re people that are really enjoy hernia surgery and can do laparoscopic robotic open tissue, non Mesh, whatever repair they need to do and really approach it with the importance that we all think hernia, hernia should get so highly variable. And most importantly, when you are in an emergency setting, you usually do not have the choice of who’s going to be your surgeon on call. Yeah, I mean I tell my patients, just call me and I’ll come in because I don’t take call anyway. So I’m happy to come in for the infrequent time when a patient on my own ends up in the emergency room. But that’s not common. I mean it’s just really the person that’s on call.
Speaker 2 (00:33:36):
And I think to that point, again, when you have an emergency, the goal is to get through that emergency and how then are you going to define better is better your outcome in five days, 30 days, 10 years? True. And hopefully if you have an emergency surgeon specialist who solves immediate problem and refers you to an amazing hernias surgeon, or if you have a hernias surgeon who’s taking call that ultimately in eight years, five years, the outcome would be the same. So hopefully we all live in a world where you get through that emergency case and then whether something’s done at that moment or in the interval down the road, the outcome is good for the patient either way.
Speaker 1 (00:34:33):
Yeah, that’s a question to what you’re saying, which is are the outcomes different when you have emergency hernia surgery then if you have an elective surgery or a semi elective or urgent surgery?
Speaker 2 (00:34:52):
I think over and over again when we look at large data that the outcomes are worse in the emergency hernia situation, one of the things that’s always hard to sort out in that is did patients have an emergency hernia because they were too sick for an elective one? And how much does that factor into that finding? Good? And so a lot of times I talk, if I have a crystal ball and I know that your hernia is going to cause you a problem in the next two years and you’re going to live for two years, then let’s do it electively. But if my crystal ball said in two years it wasn’t going to cause you a problem and something else was going to be your major life issue and let’s avoid that risk.
Speaker 1 (00:35:44):
Speaker 2 (00:35:45):
Aren’t always perfect.
Speaker 1 (00:35:46):
That goes into that little bit of the watchful waiting trial. So we had Bob Fitzgibbons Fitzgibbons as one of our guests who’s the author of the American Watchful Waiting Trial, and his counterpart in the UK did a similar trial, but only in males 55 and older. And he had the same results, which is nothing bad happened. People did not end up in the emergency room in hoards because they didn’t get their hernia operated on. But the way they interpret the data in the UK was they specifically said an X percentage of patients had strokes and heart attacks, and as they got older, and therefore were we’re poor candidates for elective hernia surgery. Whereas if they had their surgery five to 10 years prior, they would’ve done this fine. So they basically said, and therefore you shouldn’t sit on these people that are older that have hernias. But that’s kind of a weird way of analyzing the data because the patients did well from a hernia standpoint, they just became sticker because they’re older still doesn’t mean they needed the hernia repaired. But that’s kind of what you’re alluding to though a little bit, which is now they’re in your emergency room saying about this hernia.
Speaker 2 (00:37:20):
Right. Yeah. I mean counsel patients, when I see patients where I recommend not doing a hernia surgery, not infrequently, and there are a percentage of those that show up and every time, that’s not what mature hope you were hoping for, but the truth is that that is rarely the way that someone presents and needs a hernia surgery.
Speaker 1 (00:37:50):
Yeah, fortunately. The other question proposed is do you generally use Mesh for emergency repairs? And if so, what types of Mesh are used?
Speaker 2 (00:37:59):
Yeah, so this is another fan favorite question that you could get a group of hernia surgeons together to talk about for hours. And sometimes I explain things to patients. I would say if you had 10 patients, 10 surgeons and they were all seeing you, I’ll say three of ’em would do this, three of ’em would do this, and four of them would do this. I mean, I’m sort of making up the numbers, but it’s a general good thought about how much we know about what the right answer is versus how much we’re doing the best with the numbers that we have. And so that those typically fall those situations where, again, depending on that combination of what the patient’s problem is, what their hernia related risk factors are, what their anesthesia related risk factors are, and where we are in their overall trajectory of life, we make those decisions.
Speaker 2 (00:38:52):
So there are a lot of research trials both going forward and backwards trying to answer that question. And lots of papers published on it every year. I think we always try to give patients the best repair that we can that’s safe and that ultimately is the final answer. And so if it’s a pretty healthy patient with a pretty clean situation in the abdomen, then sometimes we do use permanent Mesh like we would in an elective case. But if things are really infected or I’m worried that there’s a high risk of an infection, I’ll probably avoid that.
Speaker 1 (00:39:43):
What’s confusing is this data that’s come out that’s being reevaluated and every student has their own kind of long-term data on it, which is usually synthetic Mesh is not considered appropriate in non clean situations. So what we call contaminated or dirty. But there’s data that shows even prospectively that if you pick and choose the right patient, they do just fine. And so what’s your thought on using Mesh in contaminated situations?
Speaker 2 (00:40:24):
Yeah, because then you can really get into nitty gritty about the size of the pores in the Mesh. Yes. Because part of the question is even if you’ve got some bacteria living in that world, that may be more of a problem because you’ve got something synthetic for them to live on. The thought is that if you have more spread out Mesh instead of really dense Mesh, that even if there was some bacteria there, you would be able to treat it in a way that would avoid a major problem. So if it’s really contaminated, I’m probably not going to take that risk. It’s just not worth it. Yes, we can do it with that Mesh at a later time and not have to worry about that. But certainly when we start to get to those gray areas, some of that literature might push me to consider it a large four Mesh in a pre peritoneal position, a situation where there is some contamination, but not too much. But the general answer would be it’s just not worth the risk.
Speaker 1 (00:41:42):
I think dealing with Mesh infection is so difficult and poses so many risks to the patient, they need at least two or three more operations just to deal with it. And so I’m very conservative about it, but there’s data out there, it’s hard to just be strict about it when there’s data by perfectly talented surgeons that say otherwise. Wow. There’s a question about leach therapy. Have you ever used leach therapy?
Speaker 2 (00:42:13):
I have not. I was trying to think if at some point during residency, I think I might have been in a location where that was an option available. I believe that’s true. It’s been a few years, but I have not personally used it.
Speaker 1 (00:42:29):
They’re asking about leash therapy for the last pain and inflammation and wound healing. I mean, I know they use it for hematomas and severe edema and flops and stuff for plastic surgery, but okay, so the question is, if you’re talking about contaminated fields and Mesh use, where is this contamination coming from? Is it from prior surgery? Or maybe you could explain what we mean by contaminated or dirty wound classifications and why they would be contaminated.
Speaker 2 (00:43:06):
Yeah, that’s a great question. And again, a fun semantics and taxonomy to get into. Yes. But a lot of the times we go into the abdomen in an emergency situation, it’s because there’s either infection or inflammation of some organ. So if you have gallbladder inflammation, then everything there is probably got a little bit of bacteria, and that is otherwise wouldn’t have appendicitis anything that’s the bowel cause it’s the bowel and it’s not clean. And then part of the question becomes, is it some infection or inflammation that’s been ongoing for 2, 4, 10 days? And then that case you kind of think everything’s dirty everywhere. So a great example of that is diverticulitis because it can start small and then grow to be a bigger problem. You can also think about when bowel gets stuck in a hernia and it gets injured. We think that when there’s a lot of pressure and maybe less blood flow that some of the bacteria starts to go across the bowel wall. So there’s a lot of different ways to get contamination, but the general concept is that either you have a hole in something where bacteria got out or you have a compromise in an organ, the bacteria may be able to cross membranes and planes that it wasn’t doing in a normal situation.
Speaker 1 (00:44:40):
Another question has to do with patients underlying diseases. Have you had to perform emergency surgery of a patient with severe pots? POTS is postural orthostatic tachycardia syndrome? I mean, yeah, I don’t see why.
Speaker 2 (00:44:54):
Yeah. Yeah. I mean you might have to give some extra support in the recovery time, talk to anesthesia about some different techniques to use, but yeah. Yeah, I mean if they need surgery, then they need surgery.
Speaker 1 (00:45:07):
Yeah, absolutely. And they seem more hydration, maybe some magnesium. In fact, in a couple months we’re going to have a POTS specialist talk about pots because I see a lot of patients with pots and all these other weird diseases that are associated with hernias and hernia Mesh problems. So I have a special interest to learn more about it myself and we’ll get a specialist in a couple months. So excited about that one too. That’s awesome. I know. Okay. Let’s go back to watchful waiting. The question is, if on watchful waiting for confirmed hernia, what are the symptoms you look out for to avoid emergency surgery? Great question.
Speaker 2 (00:45:52):
Yeah, and I think sometimes the answer to that question is not what are the symptoms that can avoid an emergency surgery, but what are the symptoms that when you need an emergency surgery, you get to it sooner rather than later. So again, if you get that hernia that’s stuck out and it’s usually soft, but it’s firm, it usually goes in, but now it won’t. You have nausea and vomiting associated with it where the skin changes. Those are all things that I would tell patients if you know have a hernia and we’ve decided either not to fix it or to try to optimize you before fixing it in the interval, you have any of those symptoms come in soon or rather than later. And part of that is because if you have a hernia again and you can push it back in, you buy a lot of time and options. But the longer it’s stuck out, the more it gets inflamed. And I usually, and create an analogy to twisting your ankle or getting your goose egg on your forehead. The longer that after that injury, the more the swelling happens. And you can imagine that it’s just hard to put things back where they used to be if there’s all that swelling there.
Speaker 1 (00:47:03):
Speaker 2 (00:47:04):
Speaker 1 (00:47:05):
Yeah, if you break your ankle or twist your ankle or tear or something on your face, get treatment early, otherwise you lose a lot of options and the scar looks really ugly if it’s so swollen. Talking about scars is a question about what are surgeons using to minimize adhesions or scar tissue from forming during or after surgery, especially emergency surgeries known to have a higher rate of adhesion formation, right.
Speaker 2 (00:47:34):
Yeah. So we believe that the best thing to do to avoid hernia scarf formation is to use laparoscopy when available. Yes, the minimally invasive incision. And then there was a foray into some options that might reduce scar tissue several years ago. None of which I think have been wildly successful. And we’ll tell patients that if I could figure out something that would prevent scars on the inside, then of course I could retire and not be a surgeon anymore because that would be popular for everyone everywhere. And then again, if we’re talking about scars on the outside, just in terms of the incision and how it looks, it gets back into this weighing the risk and the benefits so we can close those incisions in an emergency situation with lots of very pretty options that are cosmetically appealing. But again, if there’s a risk of infection, then that makes it harder to manage the infection. So trying to figure out what is the best thing we can do with the lowest risk and balance those things.
Speaker 1 (00:48:54):
Trauma surgery is number one in terms of risk of postoperative adhesions and bowel obstructions. I think partially because you’re either bleeding, so blood is very caustic and can cause scar tissue and adhesions or there’s bowel that’s, let’s say there’s a hole in it. And so you got stool in your belly, which is also highly inflammatory and causes a lot of scar tissue. And probably third is they don’t really do laparoscopy with trauma surgery, whereas you all have the extra tool of applying laparoscopic surgery or minimally invasive surgery to urgent or emergent situations, which I think is fantastic and great. Do you use the robot for acute care problems? Just curious.
Speaker 2 (00:49:46):
The royal weed does. So I used to use the robot when I started and then just fell out of practice with it. But I’ve got a couple of new colleagues who are really committed to it and we’ve sort of just changed our access to the robot. So I suspect it will be coming back. But to me it’s a tool just like any of the other tools that we have available in the operating room and there’s no reason not to use it if it makes the surgery easier and it’s available and the surgeon knows how to use it.
Speaker 1 (00:50:22):
I just think emergency surgery is the best part of general surgery. I wanted to surgery because I wanted to save lives. I initially wanted to go into E N T, but we weren’t saving lives as much as we were in general surgery. And then there’s just so much you can do and there’s so much opportunities to help patients and I just found it fun. Like I said, box of chocolates can kind of show up and whatever. I like that rush of whatever came the door, you can go in there and help treat. I do what I currently do, which is a lot more thinking. I sit down and figure out these mystery illnesses and problems and pain and so on. I really enjoy that. And I definitely don’t want to go back to the sleeplessness that I had as an general surgeon that was doing emergencies, but I did enjoy the actual emergency surgery part of it.
Speaker 2 (00:51:20):
And it’s fun when you have, because it does have the thinking, trying to put together all those factors. Yes. And it’s fun when you have a variety of tools to attack it with, right? Yes. So you have options and you get to pick which options the best one. And we’re glad that you enjoy what you do now because you bring so much wonderful knowledge to all of us.
Speaker 1 (00:51:40):
I mean, hernias are fun, right?
Speaker 2 (00:51:42):
Speaker 1 (00:51:46):
And funny, fun and funny.
Speaker 2 (00:51:49):
Yes, they can be all of the above.
Speaker 1 (00:51:51):
I have a guy, he’s so great. I met him, he was a patient of mine, but he’s a really famous branding and marketing guy and he’s like the word hernia, I don’t know. You got to think of a better way of branding yourself. I’m like, but that’s what I do. He is like hernia. I don’t know. There must be a better word. And now I’ve known him for eight, nine years now. He’s like, yeah, it’s it. There’s no other word. It has to be hernia.
Speaker 2 (00:52:24):
Was he the one who came up with the core health and the abdominal wall specialist?
Speaker 1 (00:52:30):
Or he should have.
Speaker 2 (00:52:31):
There’s lots of different names now.
Speaker 1 (00:52:33):
It’s too long. I know. Now there’s abdominal core health. Here’s a good question. Isn’t the downside of doing laparoscopic surgery the potential of risking more hernias from the trocar sites? And how bad does scar tissue tissue have to to go back and clean it up? And does that put you in another risk for new scar tissue, therefore this kind of never ending loop?
Speaker 2 (00:52:58):
So I see a lot of patients with bowel obstruction, scar tissue, and oftentimes the question is, why don’t you just go in and fix the scar tissue? And the answer is because then you’ll create new scar tissue. And I don’t know if it will create in a way that’s more problematic or less problematic than the scar tissue that you have. Again, if someone could solve that problem, they would be very famous. We’ve studied a lot about hernias at port sites, and I think I feel fairly confident in saying that the risk of a hernia at one of our smaller port sites or a half we have five millimeter or half centimeter port is pretty dang low. And there’s a lot of things you can do with those small ports. Oftentimes if I’m doing a hernia repair laparoscopically, I do have to put in a 12 millimeter port. And so those are ones that I close because they’re big enough that you can get a hernia there and then you can be strategic about where you put that 12 millimeter port. So there are different parts of the abdominal wall that are more susceptible to hernias. And if you put it in the place that’s got some extra protection, then that risk can be pretty low.
Speaker 1 (00:54:15):
Yeah, very, very true. And that’s where your specialty as a laparoscopic specialist understands that. Whereas I feel that people that just dabble and aren’t necessarily like a true specialist, they don’t appreciate that little fine tuning, putting it through the rectus versus through a diastasis has a different risk of hernia formation. And I think that’s what I like about laparoscopy, which I don’t like about robotics, is you have much more leeway as to where you can put your trocars and you can start your trocars or whatever you need to do to reduce the risk of hernias. And then cosmetically, you can hide it in areas that are better than you can with the robot. So that’s what my one peeve with the robot is positioning of the trocar.
Speaker 2 (00:55:14):
Yeah, I mean there’s certainly some cases, I would say a lagunal where it’s pretty much the same either way, but there’s a lot of other things where the flexibility of putting ports, it can be greater with laparoscopy than with the robot.
Speaker 1 (00:55:30):
Yeah. Yeah, I agree. And my practice is so different than when I was at the county hospital, so we now do three millimeter pediatric trocars for my models and my porn starts. That’s
Speaker 2 (00:55:48):
Speaker 1 (00:55:49):
Because they can’t have these cars visible.
Speaker 2 (00:55:53):
No, no. Yeah, I’ve seen those and we’ve talked about it, but for the general population, we haven’t got the hospital to have those. For us.
Speaker 1 (00:56:05):
It took me a while. We haven’t, for the pediatric surgery, we have two trays. Okay. So we use it, I steal it, basically I’m like, go to the pediatric. I’m like, is anyone using this? Okay, I’m going to use it. And then on the surgery center side, we actually just bought one even though we don’t do pediatric surgery, because there’s enough of us that have these thin people who have jobs that need to expose their abdominal wall, and you want to be able to provide them with elective surgery that doesn’t give them ugly scars. Yeah. So there is that. Yeah. And doesn’t everyone wear crop tops now? I mean that’s the thing right?
Speaker 2 (00:56:53):
Back in fashion.
Speaker 1 (00:56:55):
Oh, here’s a question about that. With smaller trocar is in the force increase at the point of contact.
Speaker 2 (00:57:03):
I mean, I would say generally I think not there is some, again, science to how you put the trocar through the abdominal wall so that you’re not putting a lot of torque on it depending on where you’re going to be working. And also a little bit of science if you’ve got a great trajectory to put it in at a angle so that the holes don’t exactly overlap.
Speaker 1 (00:57:28):
Yes, exactly. I love it.
Speaker 2 (00:57:31):
But I’m not familiar with an increased force either on the abdominal wall or in the area where you’re working with the smaller trocars. I could imagine a situation where if there was more friction when you were moving in and out of the trocar that you could end up in a situation like that. But with modern technology, I don’t have issues with that.
Speaker 1 (00:57:55):
I know. What’s your favorite operation when you’re on call?
Speaker 2 (00:58:05):
Hate to say it. So it used to be the morbidly obese gallbladder because it scares a lot of other people and I feel very confident with it. And so it’s just a place where I felt like I could really help patients that other people might be uncomfortable with. I have to say, recently I’ve had a couple of fun cases where I got to do a laparoscopic preperitoneal repair and that I wasn’t planning to do that day. So it was super fun.
Speaker 1 (00:58:40):
But you don’t have to say hernia, it can be anything.
Speaker 2 (00:58:45):
Well, we won’t get too far into the weeds of Mesh, but there is a particular Mesh that I like and we somewhat recently got that available in our healthcare system.
Speaker 1 (00:58:59):
Yeah, that’s a great Mesh. And
Speaker 2 (00:59:01):
So I’ve enjoyed the opportunity to use that.
Speaker 1 (00:59:05):
That’s a great Mesh. Okay, well last question. It’ll be a fun one. So when I was at USC, like I said, we had a two service. We had the trauma service, which it was very famous for, and then we had everything else, which we called the non-trauma service, which was what the service I was on. And as you can imagine, the one area where we overlapped because no one wanted to take care of it, were ingested or were foreign body retrievals. So the way that we worked it out was if it was an ingested form, body non-trauma would take care of it. But if it was stuck up there, then trauma would take care of it.
Speaker 2 (00:59:51):
Speaker 1 (00:59:52):
That problem. Yeah. Did you guys have the vision of labor?
Speaker 2 (00:59:59):
We would. No. No, we don’t. So yeah, we would take care of, actually, one of the fun things is that we have, because we have nine hospitals in our system, different people cover different hospitals, and so we all get to experience all of the foreign objects. Oh, nice. It’s just depending on where the patients are and what day they come in. So there’s a division of labor, but not that way.
Speaker 1 (01:00:27):
We had a resident who was so lovely, he’s now a vascular surgeon and we played a prank on him. So it was like three o’clock in the morning and we fake, called an emergency surgery consult to him. He was on non-trauma, which means he would only be responsible for ingested foreign bodies. And we called him and said, you need to come down here. There’s a rectal foreign body. And he’s like, rectal foreign bodies. That’s trauma. You got to call trauma for that. Well, we did call trauma. The patient claims he ingested it. It’s now the rectum. And he was such a cool little kid. He actually went down to see this patient. It was like three o’clock in the morning. It’s completely unnecessary. Like joker on him. But he was like, what? Trauma doesn’t want to take it because they came and saw the patient. They could have taken care of it like Yep. But the history was, it was ingested. So it’s your service.
Speaker 2 (01:01:28):
That’s awesome. Yeah, that’s important to have fun.
Speaker 1 (01:01:32):
The 3:00 AM fun that we have. All right. Well that’s enough fun for today. Thank you so much, Caroline. That was fun.
Speaker 2 (01:01:43):
Thank you so
Speaker 1 (01:01:43):
Much. Thank you so much, and thanks everyone for joining me. I love these hours every week on Tuesday’s. Hernia Talk Live Q&A. We’ve been doing this for over two years and I’m still having fun with it. Thanks for everyone for joining me. See you all on Facebook, Instagram, Twitter at hernia doc. Go to my YouTube channel every single one of these episodes. We are over a hundred right now. You can watch live, especially today’s, which was a great one. Thanks to Dr. Reinke. Thank you so much. Hope to see you soon. Thanks.
Speaker 2 (01:02:16):
Still the great questions everybody.
Speaker 1 (01:02:17):
Take care. Bye
Speaker 2 (01:02:19):