I think you also have to remember that, and I said this before, but, you know, the benefits of laparoscopy are small for the vast majority of patients. Still worthwhile. But you have to check your minimally invasive ego at the door and make sure that you also can do opening oral hernias or in a patient who's a candidate, send it to somebody who can do opening oral hernias.
I think you also have to remember that, and I said this before, but, you know, the benefits of laparoscopy are small for the vast majority of patients. Still worthwhile. But you have to check your minimally invasive ego at the door and make sure that you also can do opening oral hernias or in a patient who's a candidate, send it to somebody who can do opening oral hernias.
And so if you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon. It's that you didn't dissect out the space to put the mesh. And it's not because you have too big of a mesh. It's because you need to take out the mesh and dissect bigger.
And so if you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon. It's that you didn't dissect out the space to put the mesh. And it's not because you have too big of a mesh. It's because you need to take out the mesh and dissect bigger.
If you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon, it's that you didn't dissect out the space to put the mesh.
If you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon, it's that you didn't dissect out the space to put the mesh.
clinicalIn VA study of minimally symptomatic to asymptomatic hernias in patients in their 70s-80s, risk of emergency presentation requiring operation was less than 1%, specifically one-third of 1%↗
▶Ep 1 · 4:00
clinicalIn VA study over two years, almost one-third of observed patients developed symptoms and needed operation, with no worse outcomes than immediate surgery group↗
▶Ep 1 · 4:20
clinicalBy five years follow-up in VA study, almost three-quarters of patients with initially asymptomatic hernias developed symptoms↗
▶Ep 1 · 9:00
clinicalLearning curve for laparoscopic inguinal hernia repair is 200 to 250 cases in some studies↗
▶Ep 1 · 9:20
clinicalRisk of chronic pain in laparoscopic inguinal hernia repair, when done right, is lower than in open inguinal hernias because mesh is placed away from nerves↗
▶Ep 1 · 12:00
quoteI think that that surgical skill is critical. And you don't want to be getting an inguinal hernia in the surgeon's first couple laparoscopic inguinal hernia operators because there is a real learning curve.↗
▶Ep 1 · 12:10
clinicalLaparoscopic repair offers approximately one week to 10 days earlier recovery compared to open repair↗
▶Ep 1 · 16:00
quoteI think you should check your minimally invasive ego at the door and make sure that you also can do opening oral hernias or in a patient who's a candidate, send it to somebody who can do opening oral hernias.↗
▶Ep 1 · 18:20
clinicalMost important part of laparoscopic repair is parietalization of the cord - stripping peritoneum off the cord inferiorly and posteriorly↗
▶Ep 1 · 18:53
clinicalRisk of recurrence in laparoscopic repair is peritoneum coming under the mesh inferiorly and going back out to the defect↗
▶Ep 1 · 19:40
guidelineStoppa's original description for unilateral inguinal hernia specified never using less than 15 by 15 centimeter mesh or 6 by 6 inch mesh↗
▶Ep 1 · 21:02
clinicalHeavyweight mesh is approximately 90 grams per meter squared (Marlex or Prolene), midweight is 40-50 grams per meter squared, lightweight (Ultrapro) is less than 30 grams per meter squared↗
▶Ep 1 · 21:50
clinicalLighter weight mesh has advantage of less foreign body and less contraction, but disadvantage is half the material with risk of fracturing in direct hernias where it bridges and muscles never come together↗
▶Ep 1 · 23:20
quoteIf you're doing an inguinal hernia, I don't think you should ever use smaller than a large of those preformed meshes because you need to cover the whole myelope.↗
▶Ep 1 · 24:09
clinicalNo evidence that absorbable fixation causes reduction in pain, better fixation, or improved long-term outcomes compared to permanent fixation↗
▶Ep 1 · 24:20
clinicalIf absorbable fixation is put through a nerve, it is the neuroma that causes the problem, not the tack itself↗
▶Ep 1 · 24:56
clinicalMounting evidence supports placing medium-weight polypropylene mesh in contaminated fields↗
▶Ep 1 · 28:12
opinionFor recurrent hernia, should go where nobody has been before; if both spaces have been operated, go where surgeon is most skilled↗
▶Ep 1 · 28:30
opinionFor bilateral hernias in skilled laparoscopic surgeon, laparoscopy is the best approach↗
▶Ep 1 · 28:40
opinionSurgeons learning laparoscopic technique should avoid bilateral and recurrent hernias during learning curve, though these patients may benefit most↗
Inguinal Hernia With M. Rosen
▶Ep 2 · 3:22
host_summaryIn the Fitzgibbons VA study of minimally symptomatic to asymptomatic hernias in patients in their 70s-80s, the risk of presenting with an emergency problem (incarceration/strangulation) requiring operation was less than 1% (actually one-third of 1%) over the initial study period.↗
▶Ep 2 · 4:00
host_summaryIn the Fitzgibbons study, almost one-third of observed patients developed symptoms requiring operation within two years, and by five years almost three-quarters developed symptoms.↗
▶Ep 2 · 4:20
host_summaryPatients who developed symptoms during observation in the Fitzgibbons study did not do any worse with their eventual operation compared to immediate repair.↗
▶Ep 2 · 4:40
opinionFor an 89-year-old with asymptomatic hernia, observation is appropriate because odds are in a couple years they might not develop symptoms, but in younger patients the odds are against them living the rest of their life without symptoms.↗
▶Ep 2 · 6:32
clinicalInguinal hernias can be repaired under local anesthesia in high-risk patients with severe comorbidities (cardiac disease, ascites, coagulopathy).↗
▶Ep 2 · 8:20
quoteI think that the right answer to that question would be defined based on the patient that you have in front of you. And I think equally, if not more important, based on your skill set and where you're at with the learning curve of all of these operations.↗
▶Ep 2 · 8:40
quoteI think that ultimately, it's been shown in the literature that the best approach is what you do best.↗
▶Ep 2 · 9:00
host_summaryThe learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200-250 cases required.↗
▶Ep 2 · 9:20
clinicalThe primary advantage of laparoscopic repair is placing mesh away from nerves, resulting in lower risk of chronic pain compared to open repair when done correctly.↗
▶Ep 2 · 9:20
quoteWith the primary reason that there is one difference in skilled surgeons' hands that seems to be consistent, is that laparoscopy, you're putting the mesh away from the nerves, and the risk of chronic pain in laparoscopic inguinal hernia repair, when done right, is lower than the risk in open inguinal hernias.↗
▶Ep 2 · 9:50
epidemiologicalChronic pain incidence in open inguinal hernia repair varies depending on measurement method: very high if detailed surveys are used, lower if only counting patients who present with complaints.↗
▶Ep 2 · 12:10
clinicalLaparoscopic repair offers approximately one week to 10 days earlier recovery compared to open repair.↗
▶Ep 2 · 12:25
clinicalThe disadvantage of laparoscopic repair is operating near intestines with risk of intestinal injury and major blood vessel injury, though this risk should be incredibly low with proper technique.↗
▶Ep 2 · 13:20
opinionIn elderly patients or those on anticoagulation requiring quick restart, open repair is preferred to avoid dissecting the retroperitoneal space.↗
▶Ep 2 · 14:26
opinionIn a 78-year-old with symptomatic hernia on one side and asymptomatic hernia discovered laparoscopically on the other side, repairing the asymptomatic side doubles anesthetic time and increases hematoma risk without clear benefit.↗
▶Ep 2 · 15:50
quoteI think you also have to remember that, and I said this before, but, you know, the benefits of laparoscopy are small for the vast majority of patients. Still worthwhile. But you have to check your minimally invasive ego at the door and make sure that you also can do opening oral hernias or in a patient who's a candidate, send it to somebody who can do opening oral hernias.↗
▶Ep 2 · 16:26
opinionPrevious lower abdominal surgery increases risk of enterotomy and OR time for laparoscopic repair; if patient has not had previous open inguinal hernia, open approach is preferred.↗
▶Ep 2 · 16:55
opinionPrevious prostate surgery creates unpredictable difficulty for laparoscopic repair, ranging from straightforward to brutal; currently managed with open repair.↗
▶Ep 2 · 17:58
clinicalThe most important part of laparoscopic repair is parietalization of the cord (stripping peritoneum off cord inferiorly and posteriorly), a principle promoted by Rene Stoppa in open preperitoneal repairs.↗
▶Ep 2 · 18:10
quoteI think the most important part of any laparoscopic repair, and it's a basic principle that Rene Stoppa promoted during open preperitoneal repairs, which is parietalization of the cord, which essentially just means stripping the peritoneum off the cord inferiorly and posteriorly.↗
▶Ep 2 · 18:40
quoteAnd the inferior dissection is the Achilles heel of any laparoscopic repair because it's awkward to view it. It's a little bit scary that you're going to start to make holes in it, and you're taking it very close off the vessels.↗
▶Ep 2 · 18:40
clinicalThe inferior dissection is the Achilles heel of laparoscopic repair because it is awkward to view, risky for creating peritoneal holes, and close to vessels.↗
▶Ep 2 · 19:05
host_summaryInadequate inferior peritoneal dissection leads to use of smaller mesh, but Stoppa's original description for unilateral inguinal hernia specified never using less than 15×15 cm (6×6 inch) mesh, which is larger than most laparoscopic meshes being placed.↗
▶Ep 2 · 19:30
quoteIf you go back and read stopa's original descriptions, his description, if you were doing a unilateral inguinal hernia, was to never use less than a 15 by 15 centimeter piece of mesh or a 6 by 6 inch piece of mesh, which is much bigger than the vast majority of laparoscopic preform meshes or meshes that are being placed.↗
▶Ep 2 · 20:30
opinionFor large direct hernias, heavier weight mesh material should be used.↗
▶Ep 2 · 21:02
clinicalHeavyweight mesh is approximately 90 grams per meter squared (Marlex or Prolene), midweight is 40-50 grams per meter squared, and lightweight (Ultrapro) is less than 30 grams per meter squared.↗
▶Ep 2 · 21:50
clinicalLightweight mesh has less foreign body and may contract less due to better ingrowth, but has half the material and is at risk for fracturing, particularly in direct hernias where it bridges and muscles never come together.↗
▶Ep 2 · 22:30
clinicalHeavier weight mesh rarely breaks but can cause chronic pain if wrinkles or buckles are present in the groin.↗
▶Ep 2 · 23:00
opinionSurgeons commonly downsize preformed meshes; for inguinal hernia repair, never use smaller than a large preformed mesh to cover the entire myopectineal orifice.↗
▶Ep 2 · 23:24
clinicalIf struggling with mesh placement during laparoscopic repair, the problem is inadequate dissection of the space, not oversized mesh; the solution is to remove mesh and dissect more widely.↗
▶Ep 2 · 23:24
quoteAnd so if you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon. It's that you didn't dissect out the space to put the mesh. And it's not because you have too big of a mesh. It's because you need to take out the mesh and dissect bigger.↗
▶Ep 2 · 24:09
clinicalThere is no evidence that absorbable fixation causes reduction in pain, provides better fixation, or improves long-term outcomes compared to permanent fixation.↗
▶Ep 2 · 24:20
clinicalIf absorbable tack is placed through a nerve, it is the neuroma that causes the problem, not the tack itself.↗
▶Ep 2 · 24:56
host_summaryThere is mounting evidence that medium-weight polypropylene mesh can be placed in contaminated fields, with several series in ventral hernias supporting this.↗
▶Ep 2 · 25:10
opinionBassini or McVay tissue repairs remain appropriate operations for contaminated fields.↗
▶Ep 2 · 25:55
clinicalFor incarcerated femoral hernia with bowel compromise, an infrainguinal vertical incision allows direct access to the hernia sac, bowel resection if needed, and reduction without dividing the inguinal ligament.↗
▶Ep 2 · 26:35
clinicalTo facilitate reduction of incarcerated femoral hernia contents, the lacunar ligament (medial to femoral space) can be released with scissors or bovie to gain an extra centimeter, avoiding destruction of the inguinal ligament.↗
▶Ep 2 · 27:20
clinicalReverse McVay repair for femoral hernia involves taking the inferior border of the inguinal ligament and sewing it down to Cooper's ligament from below, starting immediately lateral to the femoral vein to avoid impingement.↗
▶Ep 2 · 27:46
clinicalMesh plugs in femoral hernia repair can cause DVT due to irritation of the femoral vein, particularly in thin women who typically present with femoral hernias.↗
▶Ep 2 · 28:12
opinionFor recurrent hernias, operate where no prior surgery has been performed; if both spaces have been operated, choose the approach where you have the most skill.↗
▶Ep 2 · 28:30
opinionFor bilateral hernias in a skilled laparoscopic surgeon, laparoscopy is the best approach, but surgeons learning laparoscopy should avoid bilateral and recurrent hernias as these are twice as hard despite potentially offering the most benefit.↗
▶Ep 2 · 29:09
opinionLarge inguinoscrotal hernias are managed with open operation; if truly incarcerated and cannot be reduced in office, open approach is used.↗
▶Ep 2 · 29:30
clinicalFor difficult-to-reduce but not truly incarcerated hernias, patient can be put to sleep for reduction under anesthesia, then TAPP repair performed; the internal ring can be cut laparoscopically at the two o'clock position (avoiding epigastric vessels) to facilitate reduction.↗
▶Ep 2 · 30:00
clinicalIf bowel holes are made during incarcerated hernia repair, the morbidity of the operation increases unacceptably high.↗
Inguinal Hernia With M. Rosen
▶Ep 3 · 2:10
quoteI think like anybody who sent you with an inguinal hernia, first you want to do an exam and you want to confirm whether they have an inguinal hernia. I have to say that can be one of the hardest things to do because there are small hernias that on physical exam are extremely difficult to feel.↗
▶Ep 3 · 3:22
host_summaryIn the Fitzgibbon VA study of minimally symptomatic to asymptomatic hernias in patients in their 70s-80s, the risk of presenting with an emergency problem requiring operation due to incarceration or strangulation was less than 1% (actually one-third of 1%).↗
▶Ep 3 · 4:00
host_summaryIn the Fitzgibbon study over two years, almost one-third of observed patients went on to develop symptoms and need an operation, and by five years almost three-quarters developed symptoms.↗
▶Ep 3 · 4:00
quoteSo it's safe to watch people. But the problem with this study is this study was over two years. Almost a third of the patients went on to develop symptoms and need an operation.↗
▶Ep 3 · 4:30
opinionFor an 89-year-old with asymptomatic hernia, observation is appropriate because in a couple years they might not have symptoms, but in younger patients the odds are against them living without it becoming symptomatic.↗
▶Ep 3 · 6:32
clinicalInguinal hernia repairs can be done under local anesthesia in patients with severe comorbidities, and it is worse for them to present with an emergency problem in the middle of the night.↗
▶Ep 3 · 8:20
quoteI think that the right answer to that question would be defined based on the patient that you have in front of you. And I think equally, if not more important, based on your skill set and where you're at with the learning curve of all of these operations.↗
▶Ep 3 · 9:00
host_summaryThere is a real learning curve to laparoscopic inguinal hernia repair, with some studies showing 200 to 250 cases required.↗
▶Ep 3 · 9:20
clinicalThe primary advantage of laparoscopy in skilled hands is that mesh is placed away from nerves, and the risk of chronic pain is lower than in open inguinal hernias.↗
▶Ep 3 · 9:40
quoteI think that how do you measure chronic pain in open inguinal hernias depends. If you do a very detailed survey, you'll have a very high incidence of chronic pain. If you just wait until patients come back and present with chronic pain, it will be lower. But those patients are absolutely miserable.↗
▶Ep 3 · 10:44
quoteI think the TEP pair, it's a little bit more expensive because you need to use the balloon. It's a little bit smaller of a space, but perhaps the angles are a little bit easier to operate with. I think a TAP, you get a little bit of a better view. You get a little bit more of a working space.↗
▶Ep 3 · 11:20
quoteThe way that I look at it is it's the same room. One comes through the front door. One comes through the ceiling. Ultimately, you work in the same space, and it should be the same operation regardless.↗
▶Ep 3 · 11:53
opinionFor young, healthy, active patients with unilateral hernia who are not anesthetic risks, laparoscopic repair is preferred in experienced hands, offering about a week to 10 days earlier recovery than open repair.↗
▶Ep 3 · 12:30
clinicalDisadvantages of laparoscopic repair include operating near intestines with risk of intestinal injury and risk of injury to major blood vessels, though these risks should be incredibly low if planes are known.↗
▶Ep 3 · 13:00
opinionIn elderly patients or anyone on anticoagulation who needs to restart quickly, open operation is preferred to avoid dissecting the retroperitoneal space.↗
▶Ep 3 · 14:09
opinionIn a 78-year-old patient with symptomatic hernia on one side and asymptomatic hernia discovered laparoscopically on the other side, the asymptomatic side should not be repaired due to doubled anesthetic time and increased hematoma risk.↗
▶Ep 3 · 14:58
opinionIn younger active patients, an asymptomatic contralateral hernia discovered laparoscopically should be repaired because the chance of it becoming symptomatic is much higher.↗
▶Ep 3 · 15:50
quoteI think that you also have to remember that, and I said this before, but, you know, the benefits of laparoscopy are small for the vast majority of patients. Still worthwhile. But you have to check your minimally invasive ego at the door.↗
▶Ep 3 · 16:26
opinionPrevious lower abdominal surgery increases risk of enterotomy and OR time for laparoscopic repair; if patient hasn't had open inguinal hernia, open approach is preferred.↗
▶Ep 3 · 16:55
opinionPrevious prostate surgery cases are unpredictable laparoscopically and can be brutal; in current practice these get open inguinal hernia repair.↗
▶Ep 3 · 17:58
clinicalThe most important part of any laparoscopic repair is parietalization of the cord (stripping peritoneum off the cord inferiorly and posteriorly), a principle promoted by Rene Stoppa during open preperitoneal repairs.↗
▶Ep 3 · 18:10
quoteI think the most important part of any laparoscopic repair, and it's a basic principle that Rene Stoppa promoted during open preperitoneal repairs, which is parietalization of the cord, which essentially just means stripping the peritoneum off the cord inferiorly and posteriorly.↗
▶Ep 3 · 18:40
quoteAnd the inferior dissection is the Achilles heel of any laparoscopic repair because it's awkward to view it. It's a little bit scary that you're going to start to make holes in it, and you're taking it very close off the vessels.↗
▶Ep 3 · 18:40
clinicalThe inferior dissection is the Achilles heel of any laparoscopic repair because it's awkward to view, scary to make holes, and taken very close off the vessels.↗
▶Ep 3 · 19:10
host_summaryAccording to Stoppa's original descriptions, for unilateral inguinal hernia repair, never use less than a 15 by 15 centimeter (6 by 6 inch) piece of mesh, which is much bigger than the vast majority of laparoscopic meshes being placed.↗
▶Ep 3 · 20:40
opinionFor large direct hernias, mesh choice should change to a heavier weight material.↗
▶Ep 3 · 21:02
clinicalHeavyweight mesh is around 90 grams per meter squared (Marlex or Prolene), midweight is 40-50 grams per meter squared, and lightweight (Ultrapro) is less than 30 grams per meter squared.↗
▶Ep 3 · 21:50
clinicalAdvantage of lighter weight mesh is less foreign body and less contraction; disadvantage is half the material with risk of fracturing, particularly in direct hernias where it's a bridge.↗
▶Ep 3 · 22:30
clinicalHeavier weight mesh rarely breaks but sometimes people feel it in their groin if there are wrinkles or buckles, which can cause issues.↗
▶Ep 3 · 23:00
opinionFor inguinal hernia repair, should never use smaller than a large preformed mesh because you need to cover the whole myopectineal orifice.↗
▶Ep 3 · 23:00
quoteSo if you're doing an inguinal hernia, I don't think you should ever use smaller than a large of those preformed meshes because you need to cover the whole myelope.↗
▶Ep 3 · 23:24
clinicalIf struggling with mesh placement during laparoscopic repair, it's not that you're not a good enough laparoscopic surgeon, it's that you didn't dissect out the space enough - you need to take out the mesh and dissect bigger.↗
▶Ep 3 · 23:24
quoteAnd so if you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon. It's that you didn't dissect out the space to put the mesh.↗
▶Ep 3 · 23:53
opinionMesh should be fixed in place; options include Protack tacks, glue, or no fixation, though for big direct hernias everybody uses fixation.↗
▶Ep 3 · 24:09
quoteNo evidence that absorbable fixation causes reduction in pain, better fixation, or improve long-term outcomes. So I use permanent fixation. And absorbable fixation, if you put it through the nerve, it's the neuroma that causes the problem, not the attack.↗
▶Ep 3 · 24:09
clinicalThere is no evidence that absorbable fixation causes reduction in pain, better fixation, or improved long-term outcomes; permanent fixation is used because if absorbable fixation goes through a nerve, it's the neuroma that causes the problem, not the tack.↗
▶Ep 3 · 24:56
host_summaryThere is mounting evidence that medium-weight polypropylene can be placed in a contaminated field, with several series in ventral hernias supporting this.↗
▶Ep 3 · 25:55
clinicalFor incarcerated femoral hernia with bowel compromise, make a vertical incision for vascular-type exposure, dissect onto hernia sac, bring out compromised intestine infrainguinally, resect and anastomose, then reduce.↗
▶Ep 3 · 26:32
clinicalTo reduce incarcerated femoral hernia without dividing inguinal ligament, release the lacunar ligament medially (which gives off from the inguinal ligament) to gain an extra centimeter of space.↗
▶Ep 3 · 27:10
clinicalA 'reverse McVay' repair can be performed from below for femoral hernias, taking the inferior border of the inguinal ligament and sewing it down to Cooper's ligament starting immediately lateral to the femoral vein.↗
▶Ep 3 · 27:46
clinicalMesh plugs are not preferred for femoral hernias because femoral hernias tend to occur in thin women and there have been DVTs due to irritation on the femoral vein.↗
▶Ep 3 · 28:12
opinionFor recurrent hernias, operate where nobody has been before; if both spaces have been operated, go where you're best.↗
▶Ep 3 · 28:30
opinionFor bilateral hernias in a skilled laparoscopic surgeon, laparoscopy is the best approach, but if learning, avoid bilateral and recurrent hernias laparoscopically because it makes it twice as hard despite these patients getting the most benefit.↗
▶Ep 3 · 29:09
opinionFor really big inguinal scrotal hernias that can't be reduced in office, open operation is preferred; when younger, these were done laparoscopically but now all done open.↗
▶Ep 3 · 29:40
clinicalFor incarcerated hernias, TAP approach is preferred over TEP because you want the contents out of the hernia; can laparoscopically cut the internal ring at the two o'clock position relative to epigastric vessels to help reduce.↗
clinicalThe risk of presenting with an emergency problem needing an operation due to hernia incarceration or strangulation in asymptomatic elderly patients is 0.3%↗
▶Ep 6 · 3:49
quoteThe risk of presenting with an emergency problem needing an operation due to your hernia, due to incarceration or strangulation or something in the middle of the night was less than 1%, it was actually 0.3 of 1%.↗
▶Ep 6 · 4:04
clinicalIn the Fitzgibbons VA study over 2 years, almost one-third of patients with asymptomatic hernias went on to develop symptoms and need an operation↗
▶Ep 6 · 4:21
clinicalBy 5 years follow-up, almost three-fifths of patients with initially asymptomatic hernias developed symptoms↗
▶Ep 6 · 6:06
clinicalInguinal hernia repairs can be done under local anesthesia↗
clinicalThe learning curve for laparoscopic inguinal hernia repair is 200 to 250 cases↗
▶Ep 6 · 9:31
quoteThe risk of chronic pain and laparoscopic inguinal hernia repair, when done right, is lower than the risk in opening oral hernias.↗
▶Ep 6 · 9:31
clinicalIn laparoscopic repair, mesh is placed away from the nerves, resulting in lower risk of chronic pain compared to open repair↗
▶Ep 6 · 11:26
quoteIt's the same room. One comes through the front door, one comes through the ceiling, ultimately you work in the same space and it should be the same operation regardless.↗
▶Ep 6 · 11:55
quoteIf it was my family member who called me and had an inguinal hernia, was seeing a surgeon, I would say make sure you pick somebody that you like who's done this operation a lot.↗
▶Ep 6 · 12:23
clinicalLaparoscopic repair offers approximately 1 week to 10 days earlier recovery compared to open repair↗
▶Ep 6 · 12:45
clinicalLaparoscopic repair has risk of intestinal injury and major blood vessel injury because of operating near these structures↗
▶Ep 6 · 15:50
quoteYou have to check your minimally invasive ego at the door and make sure that you also can do opening oral hernias.↗
▶Ep 6 · 18:15
clinicalParietalization of the cord (stripping peritoneum off the cord inferiorly and posteriorly) is the most important part of any laparoscopic repair↗
▶Ep 6 · 18:15
quoteParietalization of the cord, which essentially just means stripping the peritoneum off the cord inferiorly and posteriorly, and that length is what's critical.↗
▶Ep 6 · 18:53
quoteThe inferior dissection is the Achilles heel any laparoscopic repair because it's awkward to view it.↗
▶Ep 6 · 18:53
clinicalThe inferior dissection is the Achilles heel of any laparoscopic repair because it is awkward to view and surgeons risk making holes in the peritoneum↗
▶Ep 6 · 19:30
guidelineStoppa's original description for unilateral inguinal hernia was to never use less than a 15 by 15 centimeter piece of mesh↗
▶Ep 6 · 20:26
clinicalFor large direct hernias, a heavier weight mesh material should be used↗
▶Ep 6 · 21:47
clinicalHeavyweight mesh is approximately 90 grams per meter squared (Marlex or Prolene)↗
▶Ep 6 · 21:57
clinicalMidweight mesh is between 40 to 50 grams per meter squared↗
▶Ep 6 · 22:10
clinicalLightweight mesh (Ultrapro) is less than 30 grams per meter squared and contracts down to about 28 grams per meter squared over time↗
▶Ep 6 · 22:23
clinicalLightweight mesh is at risk for fracturing, particularly in direct hernias where it acts as a bridge↗
▶Ep 6 · 23:08
clinicalFor laparoscopic inguinal hernia repair, surgeons should never use smaller than a large pre-formed mesh to cover the whole myopectineal orifice↗
▶Ep 6 · 23:20
quoteIf you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon, it's that you didn't dissect out the space to put the mesh.↗
▶Ep 6 · 24:10
clinicalThere is no evidence that absorbable fixation causes reduction in pain, better fixation, or improved long-term outcomes compared to permanent fixation↗
▶Ep 6 · 24:22
quoteIf you put it through the nerve, it's the neuroma that causes the problem, not the attack.↗
▶Ep 6 · 24:22
clinicalIf a tack is put through a nerve, it is the neuroma that causes the problem, not the tack itself↗
▶Ep 6 · 24:56
clinicalThere is mounting evidence that medium weight polypropylene mesh can be placed in a contaminated field↗
▶Ep 6 · 26:58
clinicalThe lacunar ligament can be released to gain an extra 1 centimeter of space when reducing incarcerated femoral hernias without destroying the inguinal ligament↗
▶Ep 6 · 28:12
opinionFor recurrent hernias, surgeons should go where nobody has been before, or if both approaches have been used, go where they are best↗
▶Ep 6 · 28:36
opinionSurgeons learning laparoscopic hernia repair should avoid bilateral and recurrent hernias during their learning curve↗
▶Ep 6 · 29:31
clinicalFor truly incarcerated hernias, TEP approach is not a good idea because you want the contents out of the hernia sac; TAPP is preferred↗
Inguinal Hernia With M. Rosen
▶Ep 26 · 3:22
clinicalIn VA study of minimally symptomatic to asymptomatic hernias in patients in their 70s-80s, risk of emergency presentation requiring operation was less than 1%, specifically one-third of 1%↗
▶Ep 26 · 4:00
clinicalIn VA study over two years, almost one-third of observed patients developed symptoms and needed operation, with no worse outcomes than immediate surgery group↗
▶Ep 26 · 4:20
clinicalBy five years follow-up in VA study, almost three-quarters of patients with initially asymptomatic hernias developed symptoms↗
▶Ep 26 · 9:00
clinicalLearning curve for laparoscopic inguinal hernia repair is 200 to 250 cases in some studies↗
▶Ep 26 · 9:20
clinicalRisk of chronic pain in laparoscopic inguinal hernia repair, when done right, is lower than in open inguinal hernias because mesh is placed away from nerves↗
▶Ep 26 · 12:00
quoteI think that that surgical skill is critical. And you don't want to be getting an inguinal hernia in the surgeon's first couple laparoscopic inguinal hernia operators because there is a real learning curve.↗
▶Ep 26 · 12:10
clinicalLaparoscopic repair offers approximately one week to 10 days earlier recovery compared to open repair↗
▶Ep 26 · 16:00
quoteI think you should check your minimally invasive ego at the door and make sure that you also can do opening oral hernias or in a patient who's a candidate, send it to somebody who can do opening oral hernias.↗
▶Ep 26 · 18:20
clinicalMost important part of laparoscopic repair is parietalization of the cord - stripping peritoneum off the cord inferiorly and posteriorly↗
▶Ep 26 · 18:53
clinicalRisk of recurrence in laparoscopic repair is peritoneum coming under the mesh inferiorly and going back out to the defect↗
▶Ep 26 · 19:40
guidelineStoppa's original description for unilateral inguinal hernia specified never using less than 15 by 15 centimeter mesh or 6 by 6 inch mesh↗
▶Ep 26 · 21:02
clinicalHeavyweight mesh is approximately 90 grams per meter squared (Marlex or Prolene), midweight is 40-50 grams per meter squared, lightweight (Ultrapro) is less than 30 grams per meter squared↗
▶Ep 26 · 21:50
clinicalLighter weight mesh has advantage of less foreign body and less contraction, but disadvantage is half the material with risk of fracturing in direct hernias where it bridges and muscles never come together↗
▶Ep 26 · 23:20
quoteIf you're doing an inguinal hernia, I don't think you should ever use smaller than a large of those preformed meshes because you need to cover the whole myelope.↗
▶Ep 26 · 24:09
clinicalNo evidence that absorbable fixation causes reduction in pain, better fixation, or improved long-term outcomes compared to permanent fixation↗
▶Ep 26 · 24:20
clinicalIf absorbable fixation is put through a nerve, it is the neuroma that causes the problem, not the tack itself↗
▶Ep 26 · 24:56
clinicalMounting evidence supports placing medium-weight polypropylene mesh in contaminated fields↗
▶Ep 26 · 28:12
opinionFor recurrent hernia, should go where nobody has been before; if both spaces have been operated, go where surgeon is most skilled↗
▶Ep 26 · 28:30
opinionFor bilateral hernias in skilled laparoscopic surgeon, laparoscopy is the best approach↗
▶Ep 26 · 28:40
opinionSurgeons learning laparoscopic technique should avoid bilateral and recurrent hernias during learning curve, though these patients may benefit most↗
Inguinal Hernia With M. Rosen
▶Ep 27 · 3:22
host_summaryIn the Fitzgibbons VA study of minimally symptomatic to asymptomatic hernias in patients in their 70s-80s, the risk of presenting with an emergency problem (incarceration/strangulation) requiring operation was less than 1% (actually one-third of 1%) over the initial study period.↗
▶Ep 27 · 4:00
host_summaryIn the Fitzgibbons study, almost one-third of observed patients developed symptoms requiring operation within two years, and by five years almost three-quarters developed symptoms.↗
▶Ep 27 · 4:20
host_summaryPatients who developed symptoms during observation in the Fitzgibbons study did not do any worse with their eventual operation compared to immediate repair.↗
▶Ep 27 · 4:40
opinionFor an 89-year-old with asymptomatic hernia, observation is appropriate because odds are in a couple years they might not develop symptoms, but in younger patients the odds are against them living the rest of their life without symptoms.↗
▶Ep 27 · 6:32
clinicalInguinal hernias can be repaired under local anesthesia in high-risk patients with severe comorbidities (cardiac disease, ascites, coagulopathy).↗
▶Ep 27 · 8:20
quoteI think that the right answer to that question would be defined based on the patient that you have in front of you. And I think equally, if not more important, based on your skill set and where you're at with the learning curve of all of these operations.↗
▶Ep 27 · 8:40
quoteI think that ultimately, it's been shown in the literature that the best approach is what you do best.↗
▶Ep 27 · 9:00
host_summaryThe learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200-250 cases required.↗
▶Ep 27 · 9:20
clinicalThe primary advantage of laparoscopic repair is placing mesh away from nerves, resulting in lower risk of chronic pain compared to open repair when done correctly.↗
▶Ep 27 · 9:20
quoteWith the primary reason that there is one difference in skilled surgeons' hands that seems to be consistent, is that laparoscopy, you're putting the mesh away from the nerves, and the risk of chronic pain in laparoscopic inguinal hernia repair, when done right, is lower than the risk in open inguinal hernias.↗
▶Ep 27 · 9:50
epidemiologicalChronic pain incidence in open inguinal hernia repair varies depending on measurement method: very high if detailed surveys are used, lower if only counting patients who present with complaints.↗
▶Ep 27 · 12:10
clinicalLaparoscopic repair offers approximately one week to 10 days earlier recovery compared to open repair.↗
▶Ep 27 · 12:25
clinicalThe disadvantage of laparoscopic repair is operating near intestines with risk of intestinal injury and major blood vessel injury, though this risk should be incredibly low with proper technique.↗
▶Ep 27 · 13:20
opinionIn elderly patients or those on anticoagulation requiring quick restart, open repair is preferred to avoid dissecting the retroperitoneal space.↗
▶Ep 27 · 14:26
opinionIn a 78-year-old with symptomatic hernia on one side and asymptomatic hernia discovered laparoscopically on the other side, repairing the asymptomatic side doubles anesthetic time and increases hematoma risk without clear benefit.↗
▶Ep 27 · 15:50
quoteI think you also have to remember that, and I said this before, but, you know, the benefits of laparoscopy are small for the vast majority of patients. Still worthwhile. But you have to check your minimally invasive ego at the door and make sure that you also can do opening oral hernias or in a patient who's a candidate, send it to somebody who can do opening oral hernias.↗
▶Ep 27 · 16:26
opinionPrevious lower abdominal surgery increases risk of enterotomy and OR time for laparoscopic repair; if patient has not had previous open inguinal hernia, open approach is preferred.↗
▶Ep 27 · 16:55
opinionPrevious prostate surgery creates unpredictable difficulty for laparoscopic repair, ranging from straightforward to brutal; currently managed with open repair.↗
▶Ep 27 · 17:58
clinicalThe most important part of laparoscopic repair is parietalization of the cord (stripping peritoneum off cord inferiorly and posteriorly), a principle promoted by Rene Stoppa in open preperitoneal repairs.↗
▶Ep 27 · 18:10
quoteI think the most important part of any laparoscopic repair, and it's a basic principle that Rene Stoppa promoted during open preperitoneal repairs, which is parietalization of the cord, which essentially just means stripping the peritoneum off the cord inferiorly and posteriorly.↗
▶Ep 27 · 18:40
quoteAnd the inferior dissection is the Achilles heel of any laparoscopic repair because it's awkward to view it. It's a little bit scary that you're going to start to make holes in it, and you're taking it very close off the vessels.↗
▶Ep 27 · 18:40
clinicalThe inferior dissection is the Achilles heel of laparoscopic repair because it is awkward to view, risky for creating peritoneal holes, and close to vessels.↗
▶Ep 27 · 19:05
host_summaryInadequate inferior peritoneal dissection leads to use of smaller mesh, but Stoppa's original description for unilateral inguinal hernia specified never using less than 15×15 cm (6×6 inch) mesh, which is larger than most laparoscopic meshes being placed.↗
▶Ep 27 · 19:30
quoteIf you go back and read stopa's original descriptions, his description, if you were doing a unilateral inguinal hernia, was to never use less than a 15 by 15 centimeter piece of mesh or a 6 by 6 inch piece of mesh, which is much bigger than the vast majority of laparoscopic preform meshes or meshes that are being placed.↗
▶Ep 27 · 20:30
opinionFor large direct hernias, heavier weight mesh material should be used.↗
▶Ep 27 · 21:02
clinicalHeavyweight mesh is approximately 90 grams per meter squared (Marlex or Prolene), midweight is 40-50 grams per meter squared, and lightweight (Ultrapro) is less than 30 grams per meter squared.↗
▶Ep 27 · 21:50
clinicalLightweight mesh has less foreign body and may contract less due to better ingrowth, but has half the material and is at risk for fracturing, particularly in direct hernias where it bridges and muscles never come together.↗
▶Ep 27 · 22:30
clinicalHeavier weight mesh rarely breaks but can cause chronic pain if wrinkles or buckles are present in the groin.↗
▶Ep 27 · 23:00
opinionSurgeons commonly downsize preformed meshes; for inguinal hernia repair, never use smaller than a large preformed mesh to cover the entire myopectineal orifice.↗
▶Ep 27 · 23:24
clinicalIf struggling with mesh placement during laparoscopic repair, the problem is inadequate dissection of the space, not oversized mesh; the solution is to remove mesh and dissect more widely.↗
▶Ep 27 · 23:24
quoteAnd so if you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon. It's that you didn't dissect out the space to put the mesh. And it's not because you have too big of a mesh. It's because you need to take out the mesh and dissect bigger.↗
▶Ep 27 · 24:09
clinicalThere is no evidence that absorbable fixation causes reduction in pain, provides better fixation, or improves long-term outcomes compared to permanent fixation.↗
▶Ep 27 · 24:20
clinicalIf absorbable tack is placed through a nerve, it is the neuroma that causes the problem, not the tack itself.↗
▶Ep 27 · 24:56
host_summaryThere is mounting evidence that medium-weight polypropylene mesh can be placed in contaminated fields, with several series in ventral hernias supporting this.↗
▶Ep 27 · 25:10
opinionBassini or McVay tissue repairs remain appropriate operations for contaminated fields.↗
▶Ep 27 · 25:55
clinicalFor incarcerated femoral hernia with bowel compromise, an infrainguinal vertical incision allows direct access to the hernia sac, bowel resection if needed, and reduction without dividing the inguinal ligament.↗
▶Ep 27 · 26:35
clinicalTo facilitate reduction of incarcerated femoral hernia contents, the lacunar ligament (medial to femoral space) can be released with scissors or bovie to gain an extra centimeter, avoiding destruction of the inguinal ligament.↗
▶Ep 27 · 27:20
clinicalReverse McVay repair for femoral hernia involves taking the inferior border of the inguinal ligament and sewing it down to Cooper's ligament from below, starting immediately lateral to the femoral vein to avoid impingement.↗
▶Ep 27 · 27:46
clinicalMesh plugs in femoral hernia repair can cause DVT due to irritation of the femoral vein, particularly in thin women who typically present with femoral hernias.↗
▶Ep 27 · 28:12
opinionFor recurrent hernias, operate where no prior surgery has been performed; if both spaces have been operated, choose the approach where you have the most skill.↗
▶Ep 27 · 28:30
opinionFor bilateral hernias in a skilled laparoscopic surgeon, laparoscopy is the best approach, but surgeons learning laparoscopy should avoid bilateral and recurrent hernias as these are twice as hard despite potentially offering the most benefit.↗
▶Ep 27 · 29:09
opinionLarge inguinoscrotal hernias are managed with open operation; if truly incarcerated and cannot be reduced in office, open approach is used.↗
▶Ep 27 · 29:30
clinicalFor difficult-to-reduce but not truly incarcerated hernias, patient can be put to sleep for reduction under anesthesia, then TAPP repair performed; the internal ring can be cut laparoscopically at the two o'clock position (avoiding epigastric vessels) to facilitate reduction.↗
▶Ep 27 · 30:00
clinicalIf bowel holes are made during incarcerated hernia repair, the morbidity of the operation increases unacceptably high.↗
Inguinal Hernia With M. Rosen
▶Ep 28 · 2:10
quoteI think like anybody who sent you with an inguinal hernia, first you want to do an exam and you want to confirm whether they have an inguinal hernia. I have to say that can be one of the hardest things to do because there are small hernias that on physical exam are extremely difficult to feel.↗
▶Ep 28 · 3:22
host_summaryIn the Fitzgibbon VA study of minimally symptomatic to asymptomatic hernias in patients in their 70s-80s, the risk of presenting with an emergency problem requiring operation due to incarceration or strangulation was less than 1% (actually one-third of 1%).↗
▶Ep 28 · 4:00
quoteSo it's safe to watch people. But the problem with this study is this study was over two years. Almost a third of the patients went on to develop symptoms and need an operation.↗
▶Ep 28 · 4:00
host_summaryIn the Fitzgibbon study over two years, almost one-third of observed patients went on to develop symptoms and need an operation, and by five years almost three-quarters developed symptoms.↗
▶Ep 28 · 4:30
opinionFor an 89-year-old with asymptomatic hernia, observation is appropriate because in a couple years they might not have symptoms, but in younger patients the odds are against them living without it becoming symptomatic.↗
▶Ep 28 · 6:32
clinicalInguinal hernia repairs can be done under local anesthesia in patients with severe comorbidities, and it is worse for them to present with an emergency problem in the middle of the night.↗
▶Ep 28 · 8:20
quoteI think that the right answer to that question would be defined based on the patient that you have in front of you. And I think equally, if not more important, based on your skill set and where you're at with the learning curve of all of these operations.↗
▶Ep 28 · 9:00
host_summaryThere is a real learning curve to laparoscopic inguinal hernia repair, with some studies showing 200 to 250 cases required.↗
▶Ep 28 · 9:20
clinicalThe primary advantage of laparoscopy in skilled hands is that mesh is placed away from nerves, and the risk of chronic pain is lower than in open inguinal hernias.↗
▶Ep 28 · 9:40
quoteI think that how do you measure chronic pain in open inguinal hernias depends. If you do a very detailed survey, you'll have a very high incidence of chronic pain. If you just wait until patients come back and present with chronic pain, it will be lower. But those patients are absolutely miserable.↗
▶Ep 28 · 10:44
quoteI think the TEP pair, it's a little bit more expensive because you need to use the balloon. It's a little bit smaller of a space, but perhaps the angles are a little bit easier to operate with. I think a TAP, you get a little bit of a better view. You get a little bit more of a working space.↗
▶Ep 28 · 11:20
quoteThe way that I look at it is it's the same room. One comes through the front door. One comes through the ceiling. Ultimately, you work in the same space, and it should be the same operation regardless.↗
▶Ep 28 · 11:53
opinionFor young, healthy, active patients with unilateral hernia who are not anesthetic risks, laparoscopic repair is preferred in experienced hands, offering about a week to 10 days earlier recovery than open repair.↗
▶Ep 28 · 12:30
clinicalDisadvantages of laparoscopic repair include operating near intestines with risk of intestinal injury and risk of injury to major blood vessels, though these risks should be incredibly low if planes are known.↗
▶Ep 28 · 13:00
opinionIn elderly patients or anyone on anticoagulation who needs to restart quickly, open operation is preferred to avoid dissecting the retroperitoneal space.↗
▶Ep 28 · 14:09
opinionIn a 78-year-old patient with symptomatic hernia on one side and asymptomatic hernia discovered laparoscopically on the other side, the asymptomatic side should not be repaired due to doubled anesthetic time and increased hematoma risk.↗
▶Ep 28 · 14:58
opinionIn younger active patients, an asymptomatic contralateral hernia discovered laparoscopically should be repaired because the chance of it becoming symptomatic is much higher.↗
▶Ep 28 · 15:50
quoteI think that you also have to remember that, and I said this before, but, you know, the benefits of laparoscopy are small for the vast majority of patients. Still worthwhile. But you have to check your minimally invasive ego at the door.↗
▶Ep 28 · 16:26
opinionPrevious lower abdominal surgery increases risk of enterotomy and OR time for laparoscopic repair; if patient hasn't had open inguinal hernia, open approach is preferred.↗
▶Ep 28 · 16:55
opinionPrevious prostate surgery cases are unpredictable laparoscopically and can be brutal; in current practice these get open inguinal hernia repair.↗
▶Ep 28 · 17:58
clinicalThe most important part of any laparoscopic repair is parietalization of the cord (stripping peritoneum off the cord inferiorly and posteriorly), a principle promoted by Rene Stoppa during open preperitoneal repairs.↗
▶Ep 28 · 18:10
quoteI think the most important part of any laparoscopic repair, and it's a basic principle that Rene Stoppa promoted during open preperitoneal repairs, which is parietalization of the cord, which essentially just means stripping the peritoneum off the cord inferiorly and posteriorly.↗
▶Ep 28 · 18:40
clinicalThe inferior dissection is the Achilles heel of any laparoscopic repair because it's awkward to view, scary to make holes, and taken very close off the vessels.↗
▶Ep 28 · 18:40
quoteAnd the inferior dissection is the Achilles heel of any laparoscopic repair because it's awkward to view it. It's a little bit scary that you're going to start to make holes in it, and you're taking it very close off the vessels.↗
▶Ep 28 · 19:10
host_summaryAccording to Stoppa's original descriptions, for unilateral inguinal hernia repair, never use less than a 15 by 15 centimeter (6 by 6 inch) piece of mesh, which is much bigger than the vast majority of laparoscopic meshes being placed.↗
▶Ep 28 · 20:40
opinionFor large direct hernias, mesh choice should change to a heavier weight material.↗
▶Ep 28 · 21:02
clinicalHeavyweight mesh is around 90 grams per meter squared (Marlex or Prolene), midweight is 40-50 grams per meter squared, and lightweight (Ultrapro) is less than 30 grams per meter squared.↗
▶Ep 28 · 21:50
clinicalAdvantage of lighter weight mesh is less foreign body and less contraction; disadvantage is half the material with risk of fracturing, particularly in direct hernias where it's a bridge.↗
▶Ep 28 · 22:30
clinicalHeavier weight mesh rarely breaks but sometimes people feel it in their groin if there are wrinkles or buckles, which can cause issues.↗
▶Ep 28 · 23:00
opinionFor inguinal hernia repair, should never use smaller than a large preformed mesh because you need to cover the whole myopectineal orifice.↗
▶Ep 28 · 23:00
quoteSo if you're doing an inguinal hernia, I don't think you should ever use smaller than a large of those preformed meshes because you need to cover the whole myelope.↗
▶Ep 28 · 23:24
quoteAnd so if you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon. It's that you didn't dissect out the space to put the mesh.↗
▶Ep 28 · 23:24
clinicalIf struggling with mesh placement during laparoscopic repair, it's not that you're not a good enough laparoscopic surgeon, it's that you didn't dissect out the space enough - you need to take out the mesh and dissect bigger.↗
▶Ep 28 · 23:53
opinionMesh should be fixed in place; options include Protack tacks, glue, or no fixation, though for big direct hernias everybody uses fixation.↗
▶Ep 28 · 24:09
clinicalThere is no evidence that absorbable fixation causes reduction in pain, better fixation, or improved long-term outcomes; permanent fixation is used because if absorbable fixation goes through a nerve, it's the neuroma that causes the problem, not the tack.↗
▶Ep 28 · 24:09
quoteNo evidence that absorbable fixation causes reduction in pain, better fixation, or improve long-term outcomes. So I use permanent fixation. And absorbable fixation, if you put it through the nerve, it's the neuroma that causes the problem, not the attack.↗
▶Ep 28 · 24:56
host_summaryThere is mounting evidence that medium-weight polypropylene can be placed in a contaminated field, with several series in ventral hernias supporting this.↗
▶Ep 28 · 25:55
clinicalFor incarcerated femoral hernia with bowel compromise, make a vertical incision for vascular-type exposure, dissect onto hernia sac, bring out compromised intestine infrainguinally, resect and anastomose, then reduce.↗
▶Ep 28 · 26:32
clinicalTo reduce incarcerated femoral hernia without dividing inguinal ligament, release the lacunar ligament medially (which gives off from the inguinal ligament) to gain an extra centimeter of space.↗
▶Ep 28 · 27:10
clinicalA 'reverse McVay' repair can be performed from below for femoral hernias, taking the inferior border of the inguinal ligament and sewing it down to Cooper's ligament starting immediately lateral to the femoral vein.↗
▶Ep 28 · 27:46
clinicalMesh plugs are not preferred for femoral hernias because femoral hernias tend to occur in thin women and there have been DVTs due to irritation on the femoral vein.↗
▶Ep 28 · 28:12
opinionFor recurrent hernias, operate where nobody has been before; if both spaces have been operated, go where you're best.↗
▶Ep 28 · 28:30
opinionFor bilateral hernias in a skilled laparoscopic surgeon, laparoscopy is the best approach, but if learning, avoid bilateral and recurrent hernias laparoscopically because it makes it twice as hard despite these patients getting the most benefit.↗
▶Ep 28 · 29:09
opinionFor really big inguinal scrotal hernias that can't be reduced in office, open operation is preferred; when younger, these were done laparoscopically but now all done open.↗
▶Ep 28 · 29:40
clinicalFor incarcerated hernias, TAP approach is preferred over TEP because you want the contents out of the hernia; can laparoscopically cut the internal ring at the two o'clock position relative to epigastric vessels to help reduce.↗
quoteThe risk of presenting with an emergency problem needing an operation due to your hernia, due to incarceration or strangulation or something in the middle of the night was less than 1%, it was actually 0.3 of 1%.↗
▶Ep 1 · 3:49
clinicalThe risk of presenting with an emergency problem needing an operation due to hernia incarceration or strangulation in asymptomatic elderly patients is 0.3%↗
▶Ep 1 · 4:04
clinicalIn the Fitzgibbons VA study over 2 years, almost one-third of patients with asymptomatic hernias went on to develop symptoms and need an operation↗
▶Ep 1 · 4:21
clinicalBy 5 years follow-up, almost three-fifths of patients with initially asymptomatic hernias developed symptoms↗
▶Ep 1 · 6:06
clinicalInguinal hernia repairs can be done under local anesthesia↗
clinicalThe learning curve for laparoscopic inguinal hernia repair is 200 to 250 cases↗
▶Ep 1 · 9:31
clinicalIn laparoscopic repair, mesh is placed away from the nerves, resulting in lower risk of chronic pain compared to open repair↗
▶Ep 1 · 9:31
quoteThe risk of chronic pain and laparoscopic inguinal hernia repair, when done right, is lower than the risk in opening oral hernias.↗
▶Ep 1 · 11:26
quoteIt's the same room. One comes through the front door, one comes through the ceiling, ultimately you work in the same space and it should be the same operation regardless.↗
▶Ep 1 · 11:55
quoteIf it was my family member who called me and had an inguinal hernia, was seeing a surgeon, I would say make sure you pick somebody that you like who's done this operation a lot.↗
▶Ep 1 · 12:23
clinicalLaparoscopic repair offers approximately 1 week to 10 days earlier recovery compared to open repair↗
▶Ep 1 · 12:45
clinicalLaparoscopic repair has risk of intestinal injury and major blood vessel injury because of operating near these structures↗
▶Ep 1 · 15:50
quoteYou have to check your minimally invasive ego at the door and make sure that you also can do opening oral hernias.↗
▶Ep 1 · 18:15
quoteParietalization of the cord, which essentially just means stripping the peritoneum off the cord inferiorly and posteriorly, and that length is what's critical.↗
▶Ep 1 · 18:15
clinicalParietalization of the cord (stripping peritoneum off the cord inferiorly and posteriorly) is the most important part of any laparoscopic repair↗
▶Ep 1 · 18:53
clinicalThe inferior dissection is the Achilles heel of any laparoscopic repair because it is awkward to view and surgeons risk making holes in the peritoneum↗
▶Ep 1 · 18:53
quoteThe inferior dissection is the Achilles heel any laparoscopic repair because it's awkward to view it.↗
▶Ep 1 · 19:30
guidelineStoppa's original description for unilateral inguinal hernia was to never use less than a 15 by 15 centimeter piece of mesh↗
▶Ep 1 · 20:26
clinicalFor large direct hernias, a heavier weight mesh material should be used↗
▶Ep 1 · 21:47
clinicalHeavyweight mesh is approximately 90 grams per meter squared (Marlex or Prolene)↗
▶Ep 1 · 21:57
clinicalMidweight mesh is between 40 to 50 grams per meter squared↗
▶Ep 1 · 22:10
clinicalLightweight mesh (Ultrapro) is less than 30 grams per meter squared and contracts down to about 28 grams per meter squared over time↗
▶Ep 1 · 22:23
clinicalLightweight mesh is at risk for fracturing, particularly in direct hernias where it acts as a bridge↗
▶Ep 1 · 23:08
clinicalFor laparoscopic inguinal hernia repair, surgeons should never use smaller than a large pre-formed mesh to cover the whole myopectineal orifice↗
▶Ep 1 · 23:20
quoteIf you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon, it's that you didn't dissect out the space to put the mesh.↗
▶Ep 1 · 24:10
clinicalThere is no evidence that absorbable fixation causes reduction in pain, better fixation, or improved long-term outcomes compared to permanent fixation↗
▶Ep 1 · 24:22
quoteIf you put it through the nerve, it's the neuroma that causes the problem, not the attack.↗
▶Ep 1 · 24:22
clinicalIf a tack is put through a nerve, it is the neuroma that causes the problem, not the tack itself↗
▶Ep 1 · 24:56
clinicalThere is mounting evidence that medium weight polypropylene mesh can be placed in a contaminated field↗
▶Ep 1 · 26:58
clinicalThe lacunar ligament can be released to gain an extra 1 centimeter of space when reducing incarcerated femoral hernias without destroying the inguinal ligament↗
▶Ep 1 · 28:12
opinionFor recurrent hernias, surgeons should go where nobody has been before, or if both approaches have been used, go where they are best↗
▶Ep 1 · 28:36
opinionSurgeons learning laparoscopic hernia repair should avoid bilateral and recurrent hernias during their learning curve↗
▶Ep 1 · 29:31
clinicalFor truly incarcerated hernias, TEP approach is not a good idea because you want the contents out of the hernia sac; TAPP is preferred↗
clinicalThe risk of presenting with an emergency problem needing an operation due to hernia incarceration or strangulation in asymptomatic elderly patients is 0.3%↗
▶Ep 10 · 3:49
quoteThe risk of presenting with an emergency problem needing an operation due to your hernia, due to incarceration or strangulation or something in the middle of the night was less than 1%, it was actually 0.3 of 1%.↗
▶Ep 10 · 4:04
clinicalIn the Fitzgibbons VA study over 2 years, almost one-third of patients with asymptomatic hernias went on to develop symptoms and need an operation↗
▶Ep 10 · 4:21
clinicalBy 5 years follow-up, almost three-fifths of patients with initially asymptomatic hernias developed symptoms↗
▶Ep 10 · 6:06
clinicalInguinal hernia repairs can be done under local anesthesia↗
clinicalThe learning curve for laparoscopic inguinal hernia repair is 200 to 250 cases↗
▶Ep 10 · 9:31
clinicalIn laparoscopic repair, mesh is placed away from the nerves, resulting in lower risk of chronic pain compared to open repair↗
▶Ep 10 · 9:31
quoteThe risk of chronic pain and laparoscopic inguinal hernia repair, when done right, is lower than the risk in opening oral hernias.↗
▶Ep 10 · 11:26
quoteIt's the same room. One comes through the front door, one comes through the ceiling, ultimately you work in the same space and it should be the same operation regardless.↗
▶Ep 10 · 11:55
quoteIf it was my family member who called me and had an inguinal hernia, was seeing a surgeon, I would say make sure you pick somebody that you like who's done this operation a lot.↗
▶Ep 10 · 12:23
clinicalLaparoscopic repair offers approximately 1 week to 10 days earlier recovery compared to open repair↗
▶Ep 10 · 12:45
clinicalLaparoscopic repair has risk of intestinal injury and major blood vessel injury because of operating near these structures↗
▶Ep 10 · 15:50
quoteYou have to check your minimally invasive ego at the door and make sure that you also can do opening oral hernias.↗
▶Ep 10 · 18:15
quoteParietalization of the cord, which essentially just means stripping the peritoneum off the cord inferiorly and posteriorly, and that length is what's critical.↗
▶Ep 10 · 18:15
clinicalParietalization of the cord (stripping peritoneum off the cord inferiorly and posteriorly) is the most important part of any laparoscopic repair↗
▶Ep 10 · 18:53
quoteThe inferior dissection is the Achilles heel any laparoscopic repair because it's awkward to view it.↗
▶Ep 10 · 18:53
clinicalThe inferior dissection is the Achilles heel of any laparoscopic repair because it is awkward to view and surgeons risk making holes in the peritoneum↗
▶Ep 10 · 19:30
guidelineStoppa's original description for unilateral inguinal hernia was to never use less than a 15 by 15 centimeter piece of mesh↗
▶Ep 10 · 20:26
clinicalFor large direct hernias, a heavier weight mesh material should be used↗
▶Ep 10 · 21:47
clinicalHeavyweight mesh is approximately 90 grams per meter squared (Marlex or Prolene)↗
▶Ep 10 · 21:57
clinicalMidweight mesh is between 40 to 50 grams per meter squared↗
▶Ep 10 · 22:10
clinicalLightweight mesh (Ultrapro) is less than 30 grams per meter squared and contracts down to about 28 grams per meter squared over time↗
▶Ep 10 · 22:23
clinicalLightweight mesh is at risk for fracturing, particularly in direct hernias where it acts as a bridge↗
▶Ep 10 · 23:08
clinicalFor laparoscopic inguinal hernia repair, surgeons should never use smaller than a large pre-formed mesh to cover the whole myopectineal orifice↗
▶Ep 10 · 23:20
quoteIf you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon, it's that you didn't dissect out the space to put the mesh.↗
▶Ep 10 · 24:10
clinicalThere is no evidence that absorbable fixation causes reduction in pain, better fixation, or improved long-term outcomes compared to permanent fixation↗
▶Ep 10 · 24:22
quoteIf you put it through the nerve, it's the neuroma that causes the problem, not the attack.↗
▶Ep 10 · 24:22
clinicalIf a tack is put through a nerve, it is the neuroma that causes the problem, not the tack itself↗
▶Ep 10 · 24:56
clinicalThere is mounting evidence that medium weight polypropylene mesh can be placed in a contaminated field↗
▶Ep 10 · 26:58
clinicalThe lacunar ligament can be released to gain an extra 1 centimeter of space when reducing incarcerated femoral hernias without destroying the inguinal ligament↗
▶Ep 10 · 28:12
opinionFor recurrent hernias, surgeons should go where nobody has been before, or if both approaches have been used, go where they are best↗
▶Ep 10 · 28:36
opinionSurgeons learning laparoscopic hernia repair should avoid bilateral and recurrent hernias during their learning curve↗
▶Ep 10 · 29:31
clinicalFor truly incarcerated hernias, TEP approach is not a good idea because you want the contents out of the hernia sac; TAPP is preferred↗
