There is a reflux called the recto anal inhibitory reflex. That when you blow a balloon up in the rectum and stretch the rectum, the sphincter should relax. That is a normal recto anal inhibitory reflex. But if the patient has Hirschsprung disease, that reflex, it's gone.
There is a reflux called the recto anal inhibitory reflex. That when you blow a balloon up in the rectum and stretch the rectum, the sphincter should relax. That is a normal recto anal inhibitory reflex. But if the patient has Hirschsprung disease, that reflex, it's gone.
There is a reflux called the recto anal inhibitory reflex. That when you blow a balloon up in the rectum and stretch the rectum, the sphincter should relax. That is a normal recto anal inhibitory reflex. But if the patient has Hirschsprung disease, that reflex, it's gone.
There is a reflux called the recto anal inhibitory reflex. That when you blow a balloon up in the rectum and stretch the rectum, the sphincter should relax. That is a normal recto anal inhibitory reflex. But if the patient has Hirschsprung disease, that reflex, it's gone.
2025 Pediatric Surgery Update Course - Updates in Colorectal: Debunking Dogma
▶Ep 60 · 0:57
quotethere isn't a ton of earth shattering stuff that's occurred in the literature in the past couple of years that is really game changing↗
▶Ep 60 · 4:17
clinicalGoal of fistula dilation is to maintain patency just large enough for soft, mustardy stool to pass through↗
▶Ep 60 · 4:17
quoteif you're gonna just try to keep it open, you just have to keep it open enough for like little soft, mustardy poop to be able to make it through there↗
▶Ep 60 · 8:41
clinicalFistula dilations represent controlled tears when starting from pinhole size, not true stretching↗
▶Ep 60 · 11:04
quotethis is basically like the same thing one would do in a bulbbar fistula but applied to a vestibular fistula↗
▶Ep 60 · 11:04
clinicalPerineal body-preserving PSARP is essentially the same technique used for bulbar fistula applied to vestibular fistula↗
▶Ep 60 · 11:32
clinicalKey technical principle for perineal body-preserving PSARP is to mobilize lateral planes and back wall thoroughly before coming around the anterior common plane↗
▶Ep 60 · 14:29
quoteIt's like become one of my favorite operations to do↗
▶Ep 60 · 20:25
clinicalPCPLC retrospective study of Hirschsprung disease found no difference in preoperative enterocolitis, postoperative enterocolitis, or fecal incontinence between neonatal pull-through (median 11 days) and delayed primary pull-through (median 98 days)↗
▶Ep 60 · 23:40
epidemiologicalMulti-center retrospective study found 24% of Hirschsprung patients received at least one Botox injection↗
▶Ep 60 · 23:58
clinicalCincinnati Children's prospective study (2020-2024, unpublished) found decreased risk of enterocolitis within 31 days after pull-through in patients receiving Botox (30% vs 50%)↗
▶Ep 60 · 24:23
clinicalPatients receiving Botox at time of pull-through had higher risk of diaper rash (60%)↗
▶Ep 60 · 24:58
clinicalEarly work from Boston used per-kilogram Botox dosing up to maximum of 100 units↗
▶Ep 60 · 29:29
quoteevery little flick of the bovie, like that's a blood vessel, that's a nerve, and that's another week in the bowel management clinic↗
clinicalHirschsprung disease is a congenital condition affecting the lower most aspect of the intestine (rectum or sigmoid), characterized by missing ganglion cells in the submucosal and myenteric plexus that allow the intestine to relax.↗
▶Ep 106 · 1:05
quoteHirschsprung's disease is a congenital issue. It is a condition that children are born with. It usually affects the lower most aspect of the intestine. A.K.A. the rectum or the sigmoid.↗
▶Ep 106 · 1:05
clinicalHirschsprung disease is a congenital condition affecting the lower most aspect of the intestine (rectum or sigmoid), characterized by missing ganglion cells in the submucosal and myenteric plexus that allow the intestine to relax.↗
▶Ep 106 · 1:05
quoteHirschsprung's disease is a congenital issue. It is a condition that children are born with. It usually affects the lower most aspect of the intestine. A.K.A. the rectum or the sigmoid.↗
▶Ep 106 · 1:25
quotethe GI system is like a big tube, right? It's like a big tube that goes from your mouth to your anus. But it's not just a pipe. It's also a pump.↗
▶Ep 106 · 1:25
quotethe GI system is like a big tube, right? It's like a big tube that goes from your mouth to your anus. But it's not just a pipe. It's also a pump.↗
▶Ep 106 · 1:50
quotein Hirschsprung's disease, we are missing the system of nerves that allows that to relax.↗
▶Ep 106 · 1:50
quotein Hirschsprung's disease, we are missing the system of nerves that allows that to relax.↗
▶Ep 106 · 2:00
clinicalIn Hirschsprung disease, the rectum and lowest part of the colon are always affected, with the aganglionosis always ending right above the anus.↗
▶Ep 106 · 2:00
clinicalIn Hirschsprung disease, the rectum and lowest part of the colon are always affected, with the aganglionosis always ending right above the anus.↗
▶Ep 106 · 2:15
quotewith Hirschsprung's, we know that it always ends right above the anus. But where does it begin? That's where the variability is.↗
▶Ep 106 · 2:15
quotewith Hirschsprung's, we know that it always ends right above the anus. But where does it begin? That's where the variability is.↗
▶Ep 106 · 2:25
epidemiologicalAbout 85% of Hirschsprung cases begin in the very end part of the sigmoid colon or the beginning of the rectum.↗
▶Ep 106 · 2:25
epidemiologicalAbout 85% of Hirschsprung cases begin in the very end part of the sigmoid colon or the beginning of the rectum.↗
▶Ep 106 · 2:35
epidemiologicalIn about 10% of Hirschsprung cases, the entire colon is affected.↗
▶Ep 106 · 2:35
epidemiologicalIn about 10% of Hirschsprung cases, the entire colon is affected.↗
▶Ep 106 · 3:30
clinicalIn newborns with suspected Hirschsprung disease, the initial workup includes a water-soluble contrast enema looking for a narrower distal segment (rectum) with dilation above.↗
▶Ep 106 · 3:30
clinicalIn newborns with suspected Hirschsprung disease, the initial workup includes a water-soluble contrast enema looking for a narrower distal segment (rectum) with dilation above.↗
▶Ep 106 · 3:40
quotewe're going to start off with a water-soluble contrast enema. What is the radiologist looking for? Is the lowest segment of the intestine, the rectum, is that narrower? And then it dilates up above that. That's a sign that we have concern for Hirschsprung's disease.↗
▶Ep 106 · 3:40
quotewe're going to start off with a water-soluble contrast enema. What is the radiologist looking for? Is the lowest segment of the intestine, the rectum, is that narrower? And then it dilates up above that. That's a sign that we have concern for Hirschsprung's disease.↗
▶Ep 106 · 4:05
clinicalIf contrast enema raises concern for Hirschsprung disease, a suction rectal biopsy is performed to examine tissue for the presence of ganglion cells.↗
▶Ep 106 · 4:05
clinicalIf contrast enema raises concern for Hirschsprung disease, a suction rectal biopsy is performed to examine tissue for the presence of ganglion cells.↗
▶Ep 106 · 4:46
quoteIn older children, Hirschsprungs can be missed. Those situations usually establish themselves. Children with Hirschsprungs very rarely thrive and develop normally. Because they're often small for their age group.↗
▶Ep 106 · 4:46
clinicalIn older children, Hirschsprung disease can be missed and typically presents with failure to thrive (small for age) and significant constipation.↗
▶Ep 106 · 4:46
clinicalIn older children, Hirschsprung disease can be missed and typically presents with failure to thrive (small for age) and significant constipation.↗
▶Ep 106 · 4:46
quoteIn older children, Hirschsprungs can be missed. Those situations usually establish themselves. Children with Hirschsprungs very rarely thrive and develop normally. Because they're often small for their age group.↗
▶Ep 106 · 5:00
clinicalChildren with Hirschsprung disease very rarely thrive and develop normally.↗
▶Ep 106 · 5:00
clinicalChildren with Hirschsprung disease very rarely thrive and develop normally.↗
▶Ep 106 · 5:20
clinicalIn older children with suspected Hirschsprung disease, the diagnostic pathway includes plain films to assess degree of constipation, followed by contrast rectal enema, and then biopsy depending on findings.↗
▶Ep 106 · 5:20
clinicalIn older children with suspected Hirschsprung disease, the diagnostic pathway includes plain films to assess degree of constipation, followed by contrast rectal enema, and then biopsy depending on findings.↗
▶Ep 106 · 5:45
clinicalIn older children with low-risk presentations (normal early years, then worsening constipation), biopsy should usually be done only after routine constipation management measures are tried and fail.↗
▶Ep 106 · 5:45
clinicalIn older children with low-risk presentations (normal early years, then worsening constipation), biopsy should usually be done only after routine constipation management measures are tried and fail.↗
▶Ep 106 · 6:25
clinicalAnorectal manometry uses a balloon catheter to measure pressures in the anus and rectum, specifically looking for the rectoanal inhibitory reflex.↗
▶Ep 106 · 6:25
clinicalAnorectal manometry uses a balloon catheter to measure pressures in the anus and rectum, specifically looking for the rectoanal inhibitory reflex.↗
▶Ep 106 · 7:05
clinicalThe normal rectoanal inhibitory reflex causes the anal sphincter to relax when a balloon is inflated in the rectum, but this reflex is absent in Hirschsprung disease.↗
▶Ep 106 · 7:05
quoteThere is a reflux called the recto anal inhibitory reflex. That when you blow a balloon up in the rectum and stretch the rectum, the sphincter should relax. That is a normal recto anal inhibitory reflex. But if the patient has Hirschsprung disease, that reflex, it's gone.↗
▶Ep 106 · 7:05
quoteThere is a reflux called the recto anal inhibitory reflex. That when you blow a balloon up in the rectum and stretch the rectum, the sphincter should relax. That is a normal recto anal inhibitory reflex. But if the patient has Hirschsprung disease, that reflex, it's gone.↗
▶Ep 106 · 7:05
clinicalThe normal rectoanal inhibitory reflex causes the anal sphincter to relax when a balloon is inflated in the rectum, but this reflex is absent in Hirschsprung disease.↗
▶Ep 106 · 7:33
quoteIt's not very sensitive. In other words, if you have a normal manometry, it doesn't completely rule out Hirschsprungs disease.↗
▶Ep 106 · 7:33
clinicalAnorectal manometry is not sufficiently sensitive to rule out Hirschsprung disease; a normal manometry does not completely exclude the diagnosis.↗
▶Ep 106 · 7:33
quoteIt's not very sensitive. In other words, if you have a normal manometry, it doesn't completely rule out Hirschsprungs disease.↗
▶Ep 106 · 7:33
clinicalAnorectal manometry is not sufficiently sensitive to rule out Hirschsprung disease; a normal manometry does not completely exclude the diagnosis.↗
2025 Pediatric Surgery Update Course - Updates in Colorectal: Debunking Dogma
▶Ep 180 · 0:57
quotethere isn't a ton of earth shattering stuff that's occurred in the literature in the past couple of years that is really game changing↗
▶Ep 180 · 4:17
clinicalGoal of fistula dilation is to maintain patency just large enough for soft, mustardy stool to pass through↗
▶Ep 180 · 4:17
quoteif you're gonna just try to keep it open, you just have to keep it open enough for like little soft, mustardy poop to be able to make it through there↗
▶Ep 180 · 8:41
clinicalFistula dilations represent controlled tears when starting from pinhole size, not true stretching↗
▶Ep 180 · 11:04
clinicalPerineal body-preserving PSARP is essentially the same technique used for bulbar fistula applied to vestibular fistula↗
▶Ep 180 · 11:04
quotethis is basically like the same thing one would do in a bulbbar fistula but applied to a vestibular fistula↗
▶Ep 180 · 11:32
clinicalKey technical principle for perineal body-preserving PSARP is to mobilize lateral planes and back wall thoroughly before coming around the anterior common plane↗
▶Ep 180 · 14:29
quoteIt's like become one of my favorite operations to do↗
▶Ep 180 · 20:25
clinicalPCPLC retrospective study of Hirschsprung disease found no difference in preoperative enterocolitis, postoperative enterocolitis, or fecal incontinence between neonatal pull-through (median 11 days) and delayed primary pull-through (median 98 days)↗
▶Ep 180 · 23:40
epidemiologicalMulti-center retrospective study found 24% of Hirschsprung patients received at least one Botox injection↗
▶Ep 180 · 23:58
clinicalCincinnati Children's prospective study (2020-2024, unpublished) found decreased risk of enterocolitis within 31 days after pull-through in patients receiving Botox (30% vs 50%)↗
▶Ep 180 · 24:23
clinicalPatients receiving Botox at time of pull-through had higher risk of diaper rash (60%)↗
▶Ep 180 · 24:58
clinicalEarly work from Boston used per-kilogram Botox dosing up to maximum of 100 units↗
▶Ep 180 · 29:29
quoteevery little flick of the bovie, like that's a blood vessel, that's a nerve, and that's another week in the bowel management clinic↗
quoteHirschsprung's disease is a congenital issue. It is a condition that children are born with. It usually affects the lower most aspect of the intestine. A.K.A. the rectum or the sigmoid.↗
▶Ep 43 · 1:05
clinicalHirschsprung disease is a congenital condition affecting the lower most aspect of the intestine (rectum or sigmoid), characterized by missing ganglion cells in the submucosal and myenteric plexus that allow the intestine to relax.↗
▶Ep 43 · 1:05
quoteHirschsprung's disease is a congenital issue. It is a condition that children are born with. It usually affects the lower most aspect of the intestine. A.K.A. the rectum or the sigmoid.↗
▶Ep 43 · 1:05
clinicalHirschsprung disease is a congenital condition affecting the lower most aspect of the intestine (rectum or sigmoid), characterized by missing ganglion cells in the submucosal and myenteric plexus that allow the intestine to relax.↗
▶Ep 43 · 1:25
quotethe GI system is like a big tube, right? It's like a big tube that goes from your mouth to your anus. But it's not just a pipe. It's also a pump.↗
▶Ep 43 · 1:25
quotethe GI system is like a big tube, right? It's like a big tube that goes from your mouth to your anus. But it's not just a pipe. It's also a pump.↗
▶Ep 43 · 1:50
quotein Hirschsprung's disease, we are missing the system of nerves that allows that to relax.↗
▶Ep 43 · 1:50
quotein Hirschsprung's disease, we are missing the system of nerves that allows that to relax.↗
▶Ep 43 · 2:00
clinicalIn Hirschsprung disease, the rectum and lowest part of the colon are always affected, with the aganglionosis always ending right above the anus.↗
▶Ep 43 · 2:00
clinicalIn Hirschsprung disease, the rectum and lowest part of the colon are always affected, with the aganglionosis always ending right above the anus.↗
▶Ep 43 · 2:15
quotewith Hirschsprung's, we know that it always ends right above the anus. But where does it begin? That's where the variability is.↗
▶Ep 43 · 2:15
quotewith Hirschsprung's, we know that it always ends right above the anus. But where does it begin? That's where the variability is.↗
▶Ep 43 · 2:25
epidemiologicalAbout 85% of Hirschsprung cases begin in the very end part of the sigmoid colon or the beginning of the rectum.↗
▶Ep 43 · 2:25
epidemiologicalAbout 85% of Hirschsprung cases begin in the very end part of the sigmoid colon or the beginning of the rectum.↗
▶Ep 43 · 2:35
epidemiologicalIn about 10% of Hirschsprung cases, the entire colon is affected.↗
▶Ep 43 · 2:35
epidemiologicalIn about 10% of Hirschsprung cases, the entire colon is affected.↗
▶Ep 43 · 3:30
clinicalIn newborns with suspected Hirschsprung disease, the initial workup includes a water-soluble contrast enema looking for a narrower distal segment (rectum) with dilation above.↗
▶Ep 43 · 3:30
clinicalIn newborns with suspected Hirschsprung disease, the initial workup includes a water-soluble contrast enema looking for a narrower distal segment (rectum) with dilation above.↗
▶Ep 43 · 3:40
quotewe're going to start off with a water-soluble contrast enema. What is the radiologist looking for? Is the lowest segment of the intestine, the rectum, is that narrower? And then it dilates up above that. That's a sign that we have concern for Hirschsprung's disease.↗
▶Ep 43 · 3:40
quotewe're going to start off with a water-soluble contrast enema. What is the radiologist looking for? Is the lowest segment of the intestine, the rectum, is that narrower? And then it dilates up above that. That's a sign that we have concern for Hirschsprung's disease.↗
▶Ep 43 · 4:05
clinicalIf contrast enema raises concern for Hirschsprung disease, a suction rectal biopsy is performed to examine tissue for the presence of ganglion cells.↗
▶Ep 43 · 4:05
clinicalIf contrast enema raises concern for Hirschsprung disease, a suction rectal biopsy is performed to examine tissue for the presence of ganglion cells.↗
▶Ep 43 · 4:46
quoteIn older children, Hirschsprungs can be missed. Those situations usually establish themselves. Children with Hirschsprungs very rarely thrive and develop normally. Because they're often small for their age group.↗
▶Ep 43 · 4:46
quoteIn older children, Hirschsprungs can be missed. Those situations usually establish themselves. Children with Hirschsprungs very rarely thrive and develop normally. Because they're often small for their age group.↗
▶Ep 43 · 4:46
clinicalIn older children, Hirschsprung disease can be missed and typically presents with failure to thrive (small for age) and significant constipation.↗
▶Ep 43 · 4:46
clinicalIn older children, Hirschsprung disease can be missed and typically presents with failure to thrive (small for age) and significant constipation.↗
▶Ep 43 · 5:00
clinicalChildren with Hirschsprung disease very rarely thrive and develop normally.↗
▶Ep 43 · 5:00
clinicalChildren with Hirschsprung disease very rarely thrive and develop normally.↗
▶Ep 43 · 5:20
clinicalIn older children with suspected Hirschsprung disease, the diagnostic pathway includes plain films to assess degree of constipation, followed by contrast rectal enema, and then biopsy depending on findings.↗
▶Ep 43 · 5:20
clinicalIn older children with suspected Hirschsprung disease, the diagnostic pathway includes plain films to assess degree of constipation, followed by contrast rectal enema, and then biopsy depending on findings.↗
▶Ep 43 · 5:45
clinicalIn older children with low-risk presentations (normal early years, then worsening constipation), biopsy should usually be done only after routine constipation management measures are tried and fail.↗
▶Ep 43 · 5:45
clinicalIn older children with low-risk presentations (normal early years, then worsening constipation), biopsy should usually be done only after routine constipation management measures are tried and fail.↗
▶Ep 43 · 6:25
clinicalAnorectal manometry uses a balloon catheter to measure pressures in the anus and rectum, specifically looking for the rectoanal inhibitory reflex.↗
▶Ep 43 · 6:25
clinicalAnorectal manometry uses a balloon catheter to measure pressures in the anus and rectum, specifically looking for the rectoanal inhibitory reflex.↗
▶Ep 43 · 7:05
clinicalThe normal rectoanal inhibitory reflex causes the anal sphincter to relax when a balloon is inflated in the rectum, but this reflex is absent in Hirschsprung disease.↗
▶Ep 43 · 7:05
quoteThere is a reflux called the recto anal inhibitory reflex. That when you blow a balloon up in the rectum and stretch the rectum, the sphincter should relax. That is a normal recto anal inhibitory reflex. But if the patient has Hirschsprung disease, that reflex, it's gone.↗
▶Ep 43 · 7:05
clinicalThe normal rectoanal inhibitory reflex causes the anal sphincter to relax when a balloon is inflated in the rectum, but this reflex is absent in Hirschsprung disease.↗
▶Ep 43 · 7:05
quoteThere is a reflux called the recto anal inhibitory reflex. That when you blow a balloon up in the rectum and stretch the rectum, the sphincter should relax. That is a normal recto anal inhibitory reflex. But if the patient has Hirschsprung disease, that reflex, it's gone.↗
▶Ep 43 · 7:33
clinicalAnorectal manometry is not sufficiently sensitive to rule out Hirschsprung disease; a normal manometry does not completely exclude the diagnosis.↗
▶Ep 43 · 7:33
quoteIt's not very sensitive. In other words, if you have a normal manometry, it doesn't completely rule out Hirschsprungs disease.↗
▶Ep 43 · 7:33
clinicalAnorectal manometry is not sufficiently sensitive to rule out Hirschsprung disease; a normal manometry does not completely exclude the diagnosis.↗
▶Ep 43 · 7:33
quoteIt's not very sensitive. In other words, if you have a normal manometry, it doesn't completely rule out Hirschsprungs disease.↗
2025 Pediatric Surgery Update Course - Updates in Colorectal: Debunking Dogma
▶Ep 78 · 0:57
quotethere isn't a ton of earth shattering stuff that's occurred in the literature in the past couple of years that is really game changing↗
▶Ep 78 · 4:17
clinicalGoal of fistula dilation is to maintain patency just large enough for soft, mustardy stool to pass through↗
▶Ep 78 · 4:17
quoteif you're gonna just try to keep it open, you just have to keep it open enough for like little soft, mustardy poop to be able to make it through there↗
▶Ep 78 · 8:41
clinicalFistula dilations represent controlled tears when starting from pinhole size, not true stretching↗
▶Ep 78 · 11:04
quotethis is basically like the same thing one would do in a bulbbar fistula but applied to a vestibular fistula↗
▶Ep 78 · 11:04
clinicalPerineal body-preserving PSARP is essentially the same technique used for bulbar fistula applied to vestibular fistula↗
▶Ep 78 · 11:32
clinicalKey technical principle for perineal body-preserving PSARP is to mobilize lateral planes and back wall thoroughly before coming around the anterior common plane↗
▶Ep 78 · 14:29
quoteIt's like become one of my favorite operations to do↗
▶Ep 78 · 20:25
clinicalPCPLC retrospective study of Hirschsprung disease found no difference in preoperative enterocolitis, postoperative enterocolitis, or fecal incontinence between neonatal pull-through (median 11 days) and delayed primary pull-through (median 98 days)↗
▶Ep 78 · 23:40
epidemiologicalMulti-center retrospective study found 24% of Hirschsprung patients received at least one Botox injection↗
▶Ep 78 · 23:58
clinicalCincinnati Children's prospective study (2020-2024, unpublished) found decreased risk of enterocolitis within 31 days after pull-through in patients receiving Botox (30% vs 50%)↗
▶Ep 78 · 24:23
clinicalPatients receiving Botox at time of pull-through had higher risk of diaper rash (60%)↗
▶Ep 78 · 24:58
clinicalEarly work from Boston used per-kilogram Botox dosing up to maximum of 100 units↗
▶Ep 78 · 29:29
quoteevery little flick of the bovie, like that's a blood vessel, that's a nerve, and that's another week in the bowel management clinic↗
2025 Pediatric Surgery Update Course - Updates in Colorectal: Debunking Dogma
▶Ep 3 · 0:57
quotethere isn't a ton of earth shattering stuff that's occurred in the literature in the past couple of years that is really game changing↗
▶Ep 3 · 4:17
clinicalGoal of fistula dilation is to maintain patency just large enough for soft, mustardy stool to pass through↗
▶Ep 3 · 4:17
quoteif you're gonna just try to keep it open, you just have to keep it open enough for like little soft, mustardy poop to be able to make it through there↗
▶Ep 3 · 8:41
clinicalFistula dilations represent controlled tears when starting from pinhole size, not true stretching↗
▶Ep 3 · 11:04
clinicalPerineal body-preserving PSARP is essentially the same technique used for bulbar fistula applied to vestibular fistula↗
▶Ep 3 · 11:04
quotethis is basically like the same thing one would do in a bulbbar fistula but applied to a vestibular fistula↗
▶Ep 3 · 11:32
clinicalKey technical principle for perineal body-preserving PSARP is to mobilize lateral planes and back wall thoroughly before coming around the anterior common plane↗
▶Ep 3 · 14:29
quoteIt's like become one of my favorite operations to do↗
▶Ep 3 · 20:25
clinicalPCPLC retrospective study of Hirschsprung disease found no difference in preoperative enterocolitis, postoperative enterocolitis, or fecal incontinence between neonatal pull-through (median 11 days) and delayed primary pull-through (median 98 days)↗
▶Ep 3 · 23:40
epidemiologicalMulti-center retrospective study found 24% of Hirschsprung patients received at least one Botox injection↗
▶Ep 3 · 23:58
clinicalCincinnati Children's prospective study (2020-2024, unpublished) found decreased risk of enterocolitis within 31 days after pull-through in patients receiving Botox (30% vs 50%)↗
▶Ep 3 · 24:23
clinicalPatients receiving Botox at time of pull-through had higher risk of diaper rash (60%)↗
▶Ep 3 · 24:58
clinicalEarly work from Boston used per-kilogram Botox dosing up to maximum of 100 units↗
▶Ep 3 · 29:29
quoteevery little flick of the bovie, like that's a blood vessel, that's a nerve, and that's another week in the bowel management clinic↗
