# Pediatric Surgery Update: Clinical Advances — GCMD Library living collection

Updated: n/a · 4 episodes · 65 cited statements

## Episodes
### Annual Updates and Highlights
- [Update Course Rewind: 2024 Top Ten Key Takeaways](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591) — podcast · 18:01 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591.md)

### Congenital Conditions
- [Does the Presence of a Hernia Sac Improve Survival in Newborns with Congenital Diaphragmatic Hernia? A United Kingdom Single-Center Experience](https://library.globalcastmd.com/watch/does-the-presence-of-a-hernia-sac-improve-survival-in-newborns-with-congenital-d-2668) — article · [machine version](https://library.globalcastmd.com/watch/does-the-presence-of-a-hernia-sac-improve-survival-in-newborns-with-congenital-d-2668.md)

### Hernia Repair Techniques
- [Inguinal Hernia: Adult](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441) — podcast · 31:02 · [machine version](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441.md)
- [Laparoscopic modified percutaneous internal ring suturing - a mesh-free alternative for indirect inguinal hernia repair in adults. a pilot prospective cohort study](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternativ-11894) — video · 0:43 · [machine version](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternativ-11894.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=0) Introduction and Asymptomatic Hernia Management (Ep 3)
- [2:11](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=131) Evidence for Watchful Waiting: The Fitzgibbons Study (Ep 3)
- [5:00](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=300) High-Risk Patients and Non-Operative Management (Ep 3)
- [7:52](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=472) Selecting the Operative Approach: Open vs Laparoscopic (Ep 3)
- [10:17](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=617) TAPP vs TEP: Laparoscopic Technique Comparison (Ep 3)
- [11:41](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=701) Patient Counseling: Laparoscopic vs Open Benefits and Risks (Ep 3)
- [14:58](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=898) Contraindications to Laparoscopy (Ep 3)
- [16:56](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1016) Laparoscopic Technique: Dissection Principles (Ep 3)
- [20:26](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1226) Mesh Selection and Sizing (Ep 3)
- [23:43](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1423) Mesh Fixation Techniques (Ep 3)
- [24:26](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1466) Open Repair: Lichtenstein and Contaminated Fields (Ep 3)
- [25:45](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1545) Femoral Hernia Repair Technique (Ep 3)
- [28:04](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1684) Special Situations: Recurrent, Bilateral, and Incarcerated Hernias (Ep 3)
- [30:05](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1805) Summary and Conclusion (Ep 3)
- [0:00](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternativ-11894?t=0) Laparoscopic mesh-free hernia repair in adults: PIRS technique outcomes (Ep 4)
- [0:00](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=0) Introduction and Takeaway #10: Collaboration of Surgery and Interventional Radiology in the OR (Ep 1)
- [2:04](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=124) Takeaway #9: Top AI Tools of 2024 (Ep 1)
- [4:17](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=257) Takeaway #8: Cryoanalgesia in Pectus Surgery (Ep 1)
- [5:40](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=340) Takeaway #7: ECMO and Surgical Repair in Severe Congenital Diaphragmatic Hernia (Ep 1)
- [7:59](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=479) Takeaway #6: CO₂ Laser in Pediatric Surgery (Ep 1)
- [9:12](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=552) Takeaway #5: Autofluorescence and ICG in Thyroid Surgery (Ep 1)
- [11:09](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=669) Takeaway #4: Surgery-First Mindset in Pediatric Biliary Stone Disease (Ep 1)
- [12:48](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=768) Takeaway #3: MMP-7 as a Diagnostic Biomarker for Biliary Atresia (Ep 1)
- [14:45](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=885) Takeaway #2: REBOA in Pediatric Trauma (Ep 1)
- [16:07](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=967) Takeaway #1: Non-Surgical Management of Pilonidal Disease (Ep 1)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- In the Fitzgibbons VA study of minimally symptomatic to asymptomatic inguinal hernias in patients in their 70s-80s, the risk of presenting with an emergency problem (incarceration or strangulation) requiring operation was 0.3% over 2 years. — Michael Rosen (epidemiological) [Ep 3 · 3:30](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=210)
- In the Fitzgibbons study, almost one-third of patients in the observation group developed symptoms requiring operation by 2 years. — Michael Rosen (epidemiological) [Ep 3 · 4:11](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=251)
- In long-term follow-up of the Fitzgibbons study, almost three-fifths of patients in the observation group developed symptoms requiring operation by 5 years. — Michael Rosen (epidemiological) [Ep 3 · 4:21](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=261)
- For an 89-year-old patient with an asymptomatic hernia, watchful waiting is acceptable because the odds are they may not develop symptoms over their remaining lifespan. — Michael Rosen (opinion) [Ep 3 · 4:33](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=273)
- For younger patients with asymptomatic hernias, the odds are against them living the rest of their life without the hernia becoming symptomatic, so repair should be recommended when the time is right. — Michael Rosen (opinion) [Ep 3 · 4:36](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=276)
- Inguinal hernia repairs can be performed under local anesthesia in high-risk patients. — Michael Rosen (clinical) [Ep 3 · 6:06](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=366)
- For symptomatic hernias in high-risk patients, it is much worse for them to present with an emergency problem in the middle of the night, which could be life-threatening, so they should still be offered repair. — Michael Rosen (opinion) [Ep 3 · 6:06](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=366)
- For unilateral primary inguinal hernias, tissue repair, open mesh repair, or laparoscopic mesh repair are all acceptable approaches with ample literature support. — Michael Rosen (clinical) [Ep 3 · 7:56](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=476)
- The best approach for inguinal hernia repair is what the surgeon does best, and this is supported by literature. — Michael Rosen (opinion) [Ep 3 · 8:29](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=509)
- The learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200-250 cases required. — Michael Rosen (epidemiological) [Ep 3 · 9:04](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=544)
- In laparoscopic inguinal hernia repair, the mesh is placed away from the nerves, and the risk of chronic pain is lower than in open inguinal hernia repair when done correctly. — Michael Rosen (clinical) [Ep 3 · 9:18](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=558)
- Chronic pain after open inguinal hernia repair can occur due to technical problems or simply due to mesh laying on the nerves, and affected patients are absolutely miserable. — Michael Rosen (clinical) [Ep 3 · 9:51](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=591)
- For young, healthy patients with unilateral hernias who are not anesthetic risks, laparoscopic repair is preferred by Dr. Rosen if the surgeon is past the learning curve. — Michael Rosen (opinion) [Ep 3 · 9:04](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=544)
- TAPP (transabdominal preperitoneal) and TEP (total extraperitoneal) approaches have not been studied well enough to provide level-one evidence distinguishing their outcomes. — Michael Rosen (epidemiological) [Ep 3 · 10:45](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=645)
- TEP repair requires use of a balloon dissector, which is more expensive, and provides a smaller working space but perhaps easier angles to operate with. — Michael Rosen (clinical) [Ep 3 · 10:58](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=658)
- TAPP repair provides a better view and larger working space, and makes it easier for surgeons early in their learning curve to look intraperitoneally and confirm hernia reduction. — Michael Rosen (clinical) [Ep 3 · 11:09](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=669)
- TAPP and TEP ultimately work in the same anatomical space—one enters through the front door, one through the ceiling—and should result in the same operation. — Michael Rosen (clinical) [Ep 3 · 11:26](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=686)
- Laparoscopic inguinal hernia repair offers approximately 1 week to 10 days earlier recovery compared to open repair. — Michael Rosen (clinical) [Ep 3 · 12:23](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=743)
- Laparoscopic inguinal hernia repair carries a risk of intestinal injury and injury to major blood vessels because the operation is performed near these structures, but this risk should be incredibly low if the surgeon knows the planes and operates safely. — Michael Rosen (clinical) [Ep 3 · 12:45](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=765)
- In elderly patients with any anesthetic risk or anyone on anticoagulation who needs to restart quickly, Dr. Rosen prefers open repair because he does not want to dissect the retroperitoneal space in these patients. — Michael Rosen (opinion) [Ep 3 · 13:28](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=808)
- In a 78-year-old patient with a symptomatic hernia on one side and an asymptomatic hernia discovered laparoscopically on the other side, Dr. Rosen does not fix the asymptomatic side, citing concerns about doubling anesthetic time and increasing hematoma risk. — Michael Rosen (opinion) [Ep 3 · 14:10](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=850)
- Pneumoperitoneum is rarely a problem in patients with reduced cardiac capacity as long as insufflation is done slowly, pressures are kept low, and the patient is positioned in Trendelenburg to help cardiac return. — Michael Rosen (clinical) [Ep 3 · 15:17](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=917)
- The benefits of laparoscopy for inguinal hernia repair are small for the vast majority of patients, though still worthwhile. — Michael Rosen (opinion) [Ep 3 · 15:39](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=939)
- Surgeons must check their minimally invasive ego at the door and ensure they can also perform open inguinal hernias or refer to someone who can, rather than pushing laparoscopy in sick comorbid patients simply because it is their go-to approach. — Michael Rosen (opinion) [Ep 3 · 15:55](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=955)
- Previous lower abdominal surgery is a contraindication to laparoscopic inguinal hernia repair in Dr. Rosen's practice because it increases the risk of enterotomy and OR time. — Michael Rosen (opinion) [Ep 3 · 16:24](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=984)
- Previous prostate surgery makes laparoscopic inguinal hernia repair unpredictable—sometimes straightforward, sometimes brutal—and Dr. Rosen now performs these as open repairs. — Michael Rosen (opinion) [Ep 3 · 16:42](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1002)
- Basic tenets of laparoscopic inguinal hernia repair include achieving a wide dissection plane, with parietalization of the cord (stripping peritoneum off the cord inferiorly and posteriorly) being the most critical element. — Michael Rosen (clinical) [Ep 3 · 17:52](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1072)
- Parietalization of the cord is a basic principle promoted by René Stoppa during open preperitoneal repairs. — Michael Rosen (clinical) [Ep 3 · 18:15](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1095)
- The length of parietalization is critical because it prevents the peritoneum from coming under the mesh and going back out to the defect, which is the mechanism of recurrence. — Michael Rosen (clinical) [Ep 3 · 18:27](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1107)
- The inferior dissection is the Achilles heel of any laparoscopic inguinal hernia repair because it is awkward to view, surgeons fear making holes in the peritoneum, and it requires dissection very close to the vessels. — Michael Rosen (clinical) [Ep 3 · 18:53](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1133)
- When surgeons do not take the peritoneum far enough back inferiorly, they tend to use a smaller piece of mesh, which is problematic. — Michael Rosen (clinical) [Ep 3 · 19:03](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1143)
- All mesh contracts to some degree and can move. — Michael Rosen (clinical) [Ep 3 · 19:30](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1170)
- According to Stoppa's original descriptions, for a unilateral inguinal hernia, surgeons should never use less than a 15 by 15 centimeter (6 by 6 inch) piece of mesh, which is much bigger than the vast majority of laparoscopic pre-formed meshes being placed. — Michael Rosen (clinical) [Ep 3 · 19:40](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1180)
- For large direct inguinal hernias, mesh choice should change and surgeons should use a heavier weight material. — Michael Rosen (opinion) [Ep 3 · 20:26](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1226)
- Heavyweight mesh is approximately 90 grams per meter squared (e.g., Marlex or Prolene). — Michael Rosen (clinical) [Ep 3 · 21:37](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1297)
- Midweight mesh is between 40 to 50 grams per meter squared. — Michael Rosen (clinical) [Ep 3 · 21:57](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1317)
- Lightweight mesh (Ultrapro) is less than 30 grams per meter squared, starting heavier but degrading over time to about 28 grams per meter squared. — Michael Rosen (clinical) [Ep 3 · 21:57](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1317)
- Mesh weight categories (heavyweight, midweight, lightweight) were defined by marketing companies, not based on science. — Michael Rosen (clinical) [Ep 3 · 21:37](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1297)
- Advantages of lighter weight mesh include less foreign body, less palpability, and potentially less contraction because it ingrows more. — Michael Rosen (clinical) [Ep 3 · 22:16](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1336)
- Disadvantages of lightweight mesh include having half the material, and in direct hernias where the mesh bridges and muscles never come together, the mesh is at risk for fracturing, with reports now showing central mesh failures. — Michael Rosen (clinical) [Ep 3 · 22:23](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1343)
- Heavier weight mesh rarely breaks, but patients sometimes feel it in their groin if there are wrinkles or buckles, which can cause issues. — Michael Rosen (clinical) [Ep 3 · 22:42](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1362)
- Pre-formed meshes for inguinal hernia anatomy are technically easier to place but surgeons commonly downsize to a much smaller piece of mesh, which is problematic. — Michael Rosen (clinical) [Ep 3 · 22:51](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1371)
- For laparoscopic inguinal hernia repair, surgeons should never use smaller than a large pre-formed mesh because the entire myopectineal orifice needs to be covered. — Michael Rosen (opinion) [Ep 3 · 23:08](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1388)
- If the mesh is too big during laparoscopic inguinal hernia repair, the problem is not the mesh size but inadequate dissection of the space. — Michael Rosen (clinical) [Ep 3 · 23:24](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1404)
- Dr. Rosen believes mesh should be fixed in laparoscopic inguinal hernia repair and uses ProTack, though some surgeons use glue or no fixation. — Michael Rosen (opinion) [Ep 3 · 23:53](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1433)
- Even surgeons who advocate no fixation will selectively use fixation for large direct hernias. — Michael Rosen (clinical) [Ep 3 · 23:59](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1439)
- There is no evidence that absorbable fixation causes reduction in pain, provides better fixation, or improves long-term outcomes compared to non-absorbable fixation. — Michael Rosen (epidemiological) [Ep 3 · 24:10](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1450)
- If a tack is placed through a nerve, it is the neuroma that causes the problem, not the tack itself. — Michael Rosen (clinical) [Ep 3 · 24:22](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1462)
- Dr. Rosen performs Lichtenstein repair as his preferred open inguinal hernia technique. — Michael Rosen (opinion) [Ep 3 · 24:30](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1470)
- There is mounting evidence that medium weight polypropylene mesh can be placed in a contaminated field, with several series in ventral hernias supporting this. — Michael Rosen (epidemiological) [Ep 3 · 24:56](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1496)
- Depending on the level of contamination and indication, it is also appropriate to perform a Bassini or McVay repair without mesh in contaminated fields. — Michael Rosen (opinion) [Ep 3 · 25:01](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1501)
- For incarcerated femoral hernias with bowel compromise, Dr. Rosen makes a vertical incision (vascular exposure), dissects onto the hernia sac, and can resect compromised bowel infrainguinally without dividing the inguinal ligament. — Michael Rosen (opinion) [Ep 3 · 25:55](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1555)
- To gain space for reducing femoral hernia contents without dividing the inguinal ligament, surgeons can release the lacunar ligament medially (which gives off from the inguinal ligament and goes to the pectineal line) to gain an extra 1 centimeter. — Michael Rosen (clinical) [Ep 3 · 26:36](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1596)
- Dr. Rosen performs a 'reverse McVay' repair for femoral hernias from the infrainguinal approach, sewing the inferior border of the inguinal ligament down to Cooper's ligament starting medially to avoid impinging on the femoral vein. — Michael Rosen (opinion) [Ep 3 · 27:19](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1639)
- Dr. Rosen does not use mesh plugs in femoral hernia repair because femoral hernias tend to occur in thin women and he has had a DVT occur due to irritation of the femoral vein from the plug. — Michael Rosen (opinion) [Ep 3 · 27:44](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1664)
- For recurrent inguinal hernias, surgeons should approach from where nobody has been before, or if both spaces have been operated, go where they are most skilled. — Michael Rosen (opinion) [Ep 3 · 28:12](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1692)
- For known bilateral inguinal hernias in a skilled laparoscopic surgeon's hands, laparoscopy is the preferred approach. — Michael Rosen (opinion) [Ep 3 · 28:31](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1711)
- Surgeons learning laparoscopic inguinal hernia repair should avoid bilateral and recurrent hernias during their learning curve, even though these patients might benefit most from laparoscopy, because these cases are twice as hard. — Michael Rosen (opinion) [Ep 3 · 28:36](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1716)
- For large inguinoscrotal hernias, Dr. Rosen now performs all repairs open, whereas when he was younger he did them laparoscopically. — Michael Rosen (opinion) [Ep 3 · 29:10](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1750)
- For incarcerated hernias that are difficult to reduce, Dr. Rosen puts patients to sleep and reduces the hernia under general anesthesia, then can proceed with TAPP repair. — Michael Rosen (opinion) [Ep 3 · 29:23](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1763)
- For truly incarcerated hernias, TEP repair is not a good idea because surgeons want the hernia contents out of the sac; TAPP is preferred. — Michael Rosen (opinion) [Ep 3 · 29:30](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1770)
- Surgeons can laparoscopically cut the internal ring at the 2 o'clock position while watching the epigastric vessels to help reduce an incarcerated hernia. — Michael Rosen (clinical) [Ep 3 · 29:43](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1783)
- If an incarcerated hernia cannot be reduced laparoscopically, it should be done open, because making holes in the bowel increases the morbidity of the operation unacceptably high. — Michael Rosen (opinion) [Ep 3 · 29:53](https://library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1793)
- At lower volume institutions where neonatologists are very involved with care, switching to early repair when only putting one or two children on ECMO per year for CDH is a challenge and requires whole team buy-in. (opinion) [Ep 1 · 7:12](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=432)
- No matter how good you are at ERCP, you're going to get pancreatitis 10% of the time, and if the patient gets pancreatitis when you could have gone straight to surgery, that was a mistake. (clinical) [Ep 1 · 12:02](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=722)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- The study was published in the International Journal of Surgery. — Jill Knepprath summarizing a resource [Ep 4 · 0:08](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternativ-11894?t=8)
- The study used the modified percutaneous internal ring suturing technique to evaluate whether a laparoscopic non-mesh repair works on indirect inguinal hernias in adults. — Jill Knepprath summarizing a resource [Ep 4 · 0:12](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternativ-11894?t=12)
- There were 20 patients in the study. — Jill Knepprath summarizing a resource [Ep 4 · 0:23](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternativ-11894?t=23)
- The majority of patients were male. — Jill Knepprath summarizing a resource [Ep 4 · 0:25](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternativ-11894?t=25)
- No patients had hernia recurrence on follow-up, with a median follow-up of 79 months. — Jill Knepprath summarizing a resource [Ep 4 · 0:26](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternativ-11894?t=26)
- Patients reported a decrease in pain and an improved activity post-operatively. — Jill Knepprath summarizing a resource [Ep 4 · 0:31](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternativ-11894?t=31)
- This is a small single-center study. — Jill Knepprath summarizing a resource [Ep 4 · 0:35](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternativ-11894?t=35)
- The study shows success with the modified PIRS technique in adults. — Jill Knepprath summarizing a resource [Ep 4 · 0:35](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternativ-11894?t=35)
- Image-guided surgery uses real-time imaging like CT, MRI, ultrasound, or fluoroscopy to improve precision during procedures. — The host summarizing the discussion [Ep 1 · 0:28](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=28)
- At Cincinnati Children's, interventional radiologists teach pediatric surgery fellows how to use ultrasound guidance for vascular access. — The host summarizing the discussion [Ep 1 · 0:53](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=53)
- You don't have to have a hybrid OR to do surgery-interventional radiology collaboration; it can occur in a regular OR by bringing in an ultrasound machine. — The host summarizing the discussion [Ep 1 · 1:02](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=62)
- A hybrid operating room eliminates the need to transfer patients between imaging and surgical areas and combines advanced imaging technology with a traditional surgical setup. — The host summarizing the discussion [Ep 1 · 1:11](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=71)
- Cone beam CT is a CT scan performed on a C-arm fluoroscopy unit that rotates around the patient's point of interest, collecting multiple images which are stacked together to create a CT. — The host summarizing the discussion [Ep 1 · 1:21](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=81)
- Cone beam CT can be used for identifying and protecting critical structures during surgery and at the end of the case to confirm vessel patency. — The host summarizing the discussion [Ep 1 · 1:39](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=99)
- ChatGPT can be used in systematic review and meta-analysis to screen thousands of articles based on title and abstract, with prompts asking it to explain its screening decisions. — The host summarizing the discussion [Ep 1 · 2:17](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=137)
- Jenny AI is an academic model that helps with research paper writing by providing suggestions that the user can accept or modify, and includes a built-in chatbot that can research topics, provide relevant answers, cite supporting papers, and format citations. — The host summarizing the discussion [Ep 1 · 3:05](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=185)
- ChatGPT can be used to upload a guideline and create a training session with interactive questions for learning specific topics. — The host summarizing the discussion [Ep 1 · 3:41](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=221)
- Cryoanalgesia is a minimally invasive procedure to alleviate pain during chest wall surgery by temporarily freezing the nerve. — The host summarizing the discussion [Ep 1 · 4:24](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=264)
- For cryoanalgesia in pectus surgery, a double lumen endotracheal tube is used in all patients to deflate the lung on the side of the cryoablation, and the surgeon uses a thoracoscope to guide the cryoprobe through axillary incisions from T3 to T8. — The host summarizing the discussion [Ep 1 · 4:35](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=275)
- After cryoanalgesia, intercostal nerve blocks are performed with subpleural injection of 0.25% marcaine with epinephrine, which works immediately as opposed to the 8 to 10 hour delay with the cryo nerve block. — The host summarizing the discussion [Ep 1 · 4:48](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=288)
- The cryoanalgesia procedure takes about 15 seconds per interspace with a 2 minute freeze cycle starting at the third rib and working down. — The host summarizing the discussion [Ep 1 · 4:52](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=292)
- The double lumen endotracheal tube helps reduce the risk of pneumothorax during cryoanalgesia. — The host summarizing the discussion [Ep 1 · 5:09](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=309)
- Cryoanalgesia blocks sometimes don't work when surgeons use a single lumen tube and do the block too far anteriorly. — The host summarizing the discussion [Ep 1 · 5:13](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=313)
- Cryoanalgesia is an effective tool for pediatric pectus procedures, controlling pain and decreasing hospital length of stay with few short-term complications. — The host summarizing the discussion [Ep 1 · 5:24](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=324)
- The SEER protocol from Michigan used prenatal criteria to guide decisions on offering ECMO versus comfort care for severe unilateral CDH, and outcomes showed that survival was equivalent between groups, revealing clinicians are often wrong about who will benefit from ECMO. — The host summarizing the discussion [Ep 1 · 6:43](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=403)
- If there is good prenatal counseling with the parents, ECMO should be pursued for every unilateral isolated CDH. — The host summarizing the discussion [Ep 1 · 6:58](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=418)
- With bivalirudin anticoagulation, you don't have to wait for the ECMO circuit to equilibrate; it's very fast and you can operate after 8 hours of starting bivalirudin as long as levels are stable, which happens really soon, and it's a much easier surgical repair. — The host summarizing the discussion [Ep 1 · 7:26](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=446)
- In cases of very severe isolated unilateral CDH, the patient should be considered a survivor until proven otherwise. — The host summarizing the discussion [Ep 1 · 7:41](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=461)
- Early repair while on ECMO is safe and can offer physiological benefits with the optimal window between 8 to 24 hours. — The host summarizing the discussion [Ep 1 · 7:49](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=469)
- The CO₂ laser emits infrared light in the spectrum of 920 to 1400 nm which is really well absorbed by water and biological tissues. — The host summarizing the discussion [Ep 1 · 8:09](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=489)
- CO₂ laser is very effective for precise cutting and ablation, reduces blood loss, has reduced pain and edema, and shorter operative time. — The host summarizing the discussion [Ep 1 · 8:21](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=501)
- In 56 circumcision cases using CO₂ laser with the sleeve technique, dorsal slit, and cyanoacrylate adhesive, the complication rate was only 3%. — The host summarizing the discussion [Ep 1 · 8:30](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=510)
- CO₂ laser has been used for frenulectomy in 47 patients with low pain profile and no suture required. — The host summarizing the discussion [Ep 1 · 8:40](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=520)
- CO₂ laser has been used for perianal fistulas with fistulotomy, pilonidal cysts with laser ablation of sinus tracts, labial fusion, and condylomatosis ablation. — The host summarizing the discussion [Ep 1 · 8:45](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=525)
- Barriers to CO₂ laser adoption include high equipment costs, required training, and limited availability. — The host summarizing the discussion [Ep 1 · 9:08](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=548)
- In thyroid surgery, the goal is to preserve the parathyroids and decrease the risk of hypocalcemia and the need for calcium supplementation both initially and over a long period of time. — The host summarizing the discussion [Ep 1 · 9:28](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=568)
- A randomized controlled trial from France demonstrated that autofluorescence has shown to reduce rates of hypoparathyroidism and hypocalcemia following thyroidectomy. — The host summarizing the discussion [Ep 1 · 9:37](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=577)
- With autofluorescence, you don't inject anything; the parathyroids naturally autofluoresce at that wavelength, and in addition you can inject ICG to look at the perfusion of the actual parathyroid glands. — The host summarizing the discussion [Ep 1 · 9:53](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=593)
- Studies using the FluoBeam system and probe system noted hypocalcemia rates that were about 50% lower with using autofluorescence versus not using it. — The host summarizing the discussion [Ep 1 · 10:07](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=607)
- A surgery-first pathway for pediatric biliary stone disease reduces resource utilization, including MRCP. — The host summarizing the discussion [Ep 1 · 11:32](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=692)
- Before a gastroenterologist does an ERCP, often the patient has had an ultrasound and an MRCP, but predictive factors can be used to go straight to a procedure if needed, whether a combined procedure with laparoscopic cholecystectomy, an intraoperative cholangiogram, and potentially ERCP if needed. — The host summarizing the discussion [Ep 1 · 11:42](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=702)
- With a surgery-first mindset, the stone clearance rate reflected by negative intraoperative cholangiogram was 86%, and if you just did flushing or got the catheter a little more into the common bile duct or reamed the sphincter, that success rate was in the 90s. — The host summarizing the discussion [Ep 1 · 12:14](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=734)
- The key to treating biliary atresia is making an early diagnosis. — The host summarizing the discussion [Ep 1 · 13:02](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=782)
- MMP-7 was identified about 10 years ago by Georgia Bizarro as a diagnostic biomarker for biliary atresia. — The host summarizing the discussion [Ep 1 · 13:07](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=787)
- You have to get the Kasai procedure done as soon as possible; the sooner you get it done, the more likely you'll save the native liver. — The host summarizing the discussion [Ep 1 · 13:22](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=802)
- Data from a recent Midwest study shows that every 10 day delay in Kasai treatment worsens outcomes by 20%. — The host summarizing the discussion [Ep 1 · 13:41](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=821)
- MMP-7 is not a validated biomarker for biliary atresia; it's not perfect, the sensitivity is pretty good, but the cutoffs that different teams used vary because it's an assay that's still evolving. — The host summarizing the discussion [Ep 1 · 13:58](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=838)
- At Cincinnati Children's, the commitment to patients with suspected biliary atresia is that within 7 days of showing up, if they have it, they're in the OR for Kasai. — The host summarizing the discussion [Ep 1 · 14:21](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=861)
- REBOA (resuscitative endovascular balloon aortic occlusion) is a procedure to control bleeding in traumatic shock or cardiac arrest where a catheter is inserted through the femoral artery into the aorta and a balloon is inflated to stop blood flow, buying time for surgical intervention. — The host summarizing the discussion [Ep 1 · 15:20](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=920)
- REBOA would be appropriate for a patient in traumatic shock if you could not get them to the operating room to actually control the source of bleeding. — The host summarizing the discussion [Ep 1 · 15:33](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=933)
- REBOA is often compared to resuscitative thoracotomy, which opens the chest surgically to control the source of bleeding, since both techniques occlude the aorta. — The host summarizing the discussion [Ep 1 · 15:39](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=939)
- REBOA seems to take longer than opening the abdomen or the chest if you're just needing to cross clamp the aorta. — The host summarizing the discussion [Ep 1 · 15:48](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=948)
- REBOA can be performed in pediatric patients but is rarely done with no clear survival advantage over laparotomy. — The host summarizing the discussion [Ep 1 · 15:54](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=954)
- Most surgeons favor laparotomy over REBOA for quickly treating shock in a controlled environment. — The host summarizing the discussion [Ep 1 · 16:01](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=961)
- Patients presenting with wounds as their initial presentation for pilonidal disease tend to not always get to the finish line fully healed with a minimally invasive approach. — The host summarizing the discussion [Ep 1 · 16:23](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=983)
- John Armstrong, while serving in the US Army, ran a clinic with a captive patient population where they implemented a protocol of weekly shaving for pilonidal disease and observed a dramatic improvement, significantly reducing the need for surgical intervention. — The host summarizing the discussion [Ep 1 · 16:40](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=1000)
- If you're not pushing hair removal and meticulous hygiene for pilonidal disease, you're probably going to end up operating on some people that might not need an operation. — The host summarizing the discussion [Ep 1 · 16:55](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=1015)
- For pilonidal disease hair removal, options include shaving, depilatory hair removal agents like Nair, or laser hair removal. — The host summarizing the discussion [Ep 1 · 17:08](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=1028)
- Many pilonidal disease patients are teenagers or people going to college who sometimes don't have anybody to help them with hair removal. — The host summarizing the discussion [Ep 1 · 17:17](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=1037)
- If there's a parent or an active caregiver involved, clipping is probably the easiest and simplest approach for pilonidal disease hair removal, and having someone do it once a week is recommended. — The host summarizing the discussion [Ep 1 · 17:24](https://library.globalcastmd.com/watch/update-course-rewind-2024-top-ten-key-takeaways-13591?t=1044)

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