Laparoscopic Pediatric Hernia Repair: Online Course 2017

All right. I hope you all can hear me OK. This is Todd Ponsky, and we're here at Akron Children's Hospital in Akron, Ohio. And uh this is our, I think our Ian was just asking me, I think it's our 4th or 5th uh hernia course. Um, and we want to thank everyone for joining us. I know we have people from all over the world, so that's good to know that a lot of people are trying to get into lap hernias. This is going to be a very casual interactive discussion. So what we really want to do is encourage everyone to tell us their thoughts, questions, comments, and we'll try to address it. We have about about an hour and a half to talk here and then those of us here in the room who are here in Akron, we're going to go down to the operating room and do a day of live cases, but we're not going to be broadcasting those, so. Hopefully you'll come here physically next year and then you can come and join us in the operating room. So, uh, I want to, um, uh, thank everyone for, uh, for coming here. Um, we have, uh, Ian is from uh San Antonio, Ian Mitchell, and Jeff, uh, Gander is uh coming from uh UVA and we have, uh, Sophia Dulhai who is a general surgery resident at East Carolina. And she's doing 2 years of research here at Akron Children's. Abdulru Flamoshi is a pediatric surgeon from Libya who's been here for quite some time, and he's doing research here as well. And Luis Zia Saya. Sea, who's coming from Ecuador. And so, uh, we, uh, I want to thank all of you for coming to beautiful, wonderful Akron, Ohio for this, uh, for the course. So, um, We're gonna start off. I'm gonna go ahead and share my screen here. See it OK? Awesome. All right. So, The hernia, this is pretty much defines us as pediatric surgeons, and I don't know if there's any urologists watching, but it's also a substantial portion of the urology practice as well. This is our bread and butter. It's what we do. It's what sort of defines us, and we all are pretty confident about our hernia repairs. This is the one thing that, you know, we feel. confident about the way we do our appendectomies and our hernias. And so to challenge that in any way is always tough because we really, this is one of those things that, and I'll just say this right off the bat, although I'm going to talk about the lap hernia. I think any type of hernia repair is probably fine. There's just different. I'm not going to state that one is substantially better than the other. It's that this is a new option. It's a nice option. It's an option that I prefer, and we'll talk about the pros and cons. So I want to first start off with some questions to get some idea of what we don't have today unfortunately is polling, but maybe Mark can look at the chat and see what people say. We can talk about people. I can't. Oh, you can. Oh, OK. So the first question is, so let me ask, let me ask Ian first since he's to my right. How do you manage an 8 year old boy who's got a good history? Of a groin bulge. It comes and goes, and the, the, the pediatrician says they felt it and reduced it, and, and mom says the same thing, but when they come to your office, you don't feel anything. What, what's your, do you do a groin exploration, a laparoscopy? Do you wait for a photograph or only operate with physical findings? I give mom the option of really the B or C. Usually I go with C, but if they're really insistent, I can always tell them. We can put a camera in and take a look. OK, Jeff, I would agree with that. I would probably say C. Um, you know, with B, obviously it would be a general anesthetic and maybe they don't have a hernia, so I'll wait for a photograph. Wait for a photograph, Luis. Well, I, I'm confident of my touching. OK, so that's interesting. So you feel for like the silk glove sign or fullness or thickness and, and that's, I would love to have Sophia and Raf do a study on that because I wonder the accuracy of that. You found it in your career, that's pretty accurate, that if you feel that silk glove sign or fullness, it's usually a hernia. Yes. OK. And if the mom has seen it, that's pretty good. OK. So I actually agree and disagree with that. I mean, not in my own practice. I, sometimes you can definitely see an asymmetry. It's more full on one side or the other, but I am not as comfortable that my assessment of that silk glove sign is as good as others have said. So, for me, I would be curious to see what my accuracy would be with that, but With a good history on top of someone who's had, who's had great experience with that, I bet you it's pretty accurate. It sounds like you probably have a good accuracy. So, uh, no, no correct answer here. Um, I, uh, if it's a good story, I will go to, and I, and I feel fullness or asymmetry, I will go to laparoscopy. Um, I don't always ask for a photograph. Um, the problem with a photograph is what I found is the, the most common, OK, so let me ask you, what do you guys think is the most common And I don't know the answer to this. I'm just guessing. What's the most common thing that they mistake for a hernia when they say they see a groin bulge. What do you, I mean, what do you guess is what they're mistaking it with? Could be, yeah. Could be. Well then if it's a hydrocele that's coming and going and, yeah, it could be. I think it's often the testicle in a boy that's riding up into their groin and they see a bulge, but they don't at the same time evaluate if the testicle is there. So I tell them, next time you see that bulge, make sure the testicle is still in the scrotum. Um, and the problem with the photograph is you won't be able to tell. You'll see a bulge there and you won't be able to tell if the testicle is in the scrotum or not. So it's tough. Um, what about if you're putting in a G tube, or let's say a nappy, and you see that? Um, Who would fix that open, who would fix it lap? Who would scrub out and go talk to the family, or who would close and tell the family that he may have an increased risk for a hernia, but you're not going to do anything at this time. So, Jeff, I'll start with you this time. Yeah, I wouldn't say I'm that consistent with it. Um, the, I think when I first started practicing, I probably would scrub out and talk to the family and go fix it, probably as an open repair. Uh, some of my more senior partners say, well, it's sort of dirty knowledge that you have there that maybe it was never going to become symptomatic. So I've sort of gone away from doing anything about it. I'd say probably made more so deep at this point. All right, Luis. Well, I don't do, uh, lab aspirations to, uh, diagnose a hernia when I program a a child it's because I'm gonna do a hernia, OK, yeah, and, uh, uh. I try to do most by laparoscopy. Yes, but, uh, it depends on the parents if they want it or not. But if you were doing it a lot, do you do if I find a hernia when I'm doing an appendectomy, I won't do the hernia because it can get infected, maybe, and I'll tell the parents and show the, the pictures that the, it, it should be operated on later. OK. And you, what do you do? I scrub out, tell them, and come back and do it, OK. I am just like you, Jeff. I started off fixing them. If I would do it, if it's an app, I agree. I don't do it because it's infected. But if you're there to do a non-dirty case and you incidentally find it, uh, in my first year, I was at a conference where I raised my hand and I was the only one who said they fixed them. And so I slowly put my hand back down because I was embarrassed. And now I don't. The greatest line that I always quote of my partner says, why eat tomorrow's lunch today? So, uh, you know, it does not mean they'll ever have a hernia, and I don't, but again, I'm putting this out there, not because there's a correct answer. It's always fun to see how everyone manages these controversies different. My point here is to show that hernias are not easy, that we think that everything is so straightforward. Uh, do you look on the other side, so fixing a unilateral, you're going on one side, you put a lap. Yes, that's how I do it with like a 70 degree scope at UVA we have the 4 millimeter 70 degree scope. So I usually put a little 4 millimeter reusable storage port through the sack and then look at the other side of the 70 degree scope. OK. All right. Um, Luis. Yes, I do. OK. So the other side that if there is one. OK. No, I couldn't, didn't trust it. OK, OK. Again, that's the why tomorrow's lunch today theory, so I don't do it either, but I also have seen people been fooled. So you'll only fix the one side and not explore. What I was doing what I'm doing them open, I only fix the other one. So I want to say one really cool thing though that Sophia had experience with a few days ago, last week or whatever it was. This challenges this challenges everything that I've thought about hernias. Um, first of all, people will sometimes do a contralateral look and then the patient will come back years later with a hernia. So what does that mean? Does it mean you missed it? Does that mean that they developed a hernia? Um, so, it's, it's very interesting. So, the question is, um, you know, is it accurate, but at the same time, uh, the opposite may be true that Sofia operated on a patient, I think, you know, a few days ago where the patient presented. Years ago with an incidentally identified patent processes just like the last case I showed. And they didn't do anything. They waited and then um uh years later, the patient had some lower abdominal pain, groin pain. So they put the laparoscope in to go do the lap hernia repair and it was gone. So they may close, even though we think they don't close, they may close. So, um, oh, there's like that green line there, Mark. You see that bottom bottom left corner. Um. So, so, uh, Witt Holcomb published a paper in '94 that contralateral patent process presents up to 30 to 40%. Um, the physical exam alone is not reliable, and there's a 4 times greater risk if they have a patent prosthesis that they'll actually get a hernia. Um, and there's a 3 to 11% risk of a metronous hernia. Uh, let's see if I can move myself out of the way here. Um. And Some would say it avoids cost and anxiety, a risk of a second anesthesia. Those who argue against it is that it doesn't necessarily mean it will ever be a hernia. 50% will be unnecessary repairs, uh, and there's a risk of a a vase injury, um, with repairs, so it's not a it's not a freebie. Um. There's some chats, blah blah blah. Yeah, what are they saying? Well, most people, uh, let's see, we have who says if you make a lab approach, you may do a bilateral evaluation. And then Answering. OK. So we'll look, we'll look as we ask the questions. I apologize for that. So, what about a baby in the NICU that has a hernia? Do you do it? Now, Before they go home, or do you have them go home and come back when they're older? What do you do, Jeff? So my training, um, we fix them before they left. Um, and when I first came to the UVA it was the same thing before, before they leave the hospital. And so we're actually involved in the hernia trial. I don't know if you guys are involved in it. Um, yeah, Oxford? No, the hernia premature trial, the hip trial, um, out of Vanderbilt. Um, so they're being randomized to immediate repair or, or repair. You're talking about premature. We're doing, yeah, we're doing a similar trial here. Aaron Garrison is doing it with our NICU where we're randomizing them to repair, not to repair. So maybe it is the same thing. Well, so what it's randomized is repair before discharge, repair 55 weeks corrected gestational age. Yeah, that's that's what I mean. Yeah, we're doing the same thing. OK. But anyway, so we're trying to randomize the children. The children who don't. Uh, enroll in this study. I've actually been now recommended the laser repair and, and kind of along the lines you were saying, I've seen a couple girls more so than boys, not become symptomatic anymore, uh, after following them for a couple of months, and you can't find any evidence that they're hurting them. So that's my bias. We'll see what the your trial shows. We'll see what the national trial shows, but we'll see. All right, I'm curious if the audience says if Luis or Ian have a comment about that or about when you do your repairs. Well, we send them home and do it when they're bigger. OK, OK. We fix them before they leave. We have a significant risk of losing the patients as well. That's an interesting, it depends on your demographics and yeah, I, I fix them before they go home and before we're on this trial, um, but now that they're on the trial, we're the same thing. We're randomizing them. Um So, uh, all right. Now we're getting into what we're here to talk about. So a six year old with a reducible left inguinal hernia. Let's look at what the audience says here. Who would do an open repair of that hernia? Who would look with a camera through the umbilicus and then do an open repair. Who would do an open repair and lap look? Who would do an intracorporeal laparoscopic repair, so basically a purse string or some sort of Three port technique or who would do some sort of percutaneous lap repair. So, uh, Mark, are there people, when you're, when you have a minute, we'll look and see what people are saying. Yeah, we've got all over the board, we've got, we've got A, E, D, C, A, all over the board, all over the board, yeah. And what about here? What do you guys think? Uh, so you asked me yesterday, I would say C. That that's the way I've been doing it. Um, maybe tomorrow I might change. And you do lap or what do you do? I do lap. OK. Oh, someone's, it's someone else drawing, I think, Mark. Yeah, I think it's one of the audience members. So, um, So, all right, and um Luis, you said you do laparoscopic, right? Yeah, OK. All right. Um, all right, so that's what we're gonna talk about now. So this is a tra traditional open repair, um, and I guess it was good to see that the audience is a good mix of who's doing lap and open. Um, and the question is, what about laparoscopy? So here's what Someone who is pretty adamant, we just had a great debate in London at BP's iPad debating open versus lap, and the open argument would be that this is the method we know works and that there is a very low recurrence rate. It works very, very well. And that there's a low complication rate. The scars are hidden. They're they're under the underwear line, so the lap repair is not going to offer a cosmetic benefit because those incisions are actually above the underwear line. So maybe the open repair is even better cosmetically. In the lap repair, the sac is left. Uh, not always. We're going to talk about some surgeons who, who like to do the, who excise the sac, Mario Reelme, um, and that's another option. So, but for the most part, most people leave the hernia sac. It may be that the laparoscopic repair relies on a stitch forever to hold things closed, and that doesn't sit well with a lot of people. Um, and the lap repair takes an extraperitoneal operation and makes it intraperitoneal. So those are the arguments for the open approach. For the laparoscopic approach, the big thing is not touching the cord, probably. You don't grab and pull on the cord. We know that in a rabbit, if you just grab the vase once with the pickups, it obliterates it. So we don't know what happens in these tiny little preemies that were pulling up on their cord to separate it from the sack, what effect that has on that tiny tiny uh little structure. Um, So Um, Cosmesis, again, I don't think it's a real argument. The incisions are quite small. We'll see how my little remote works here, but uh those are the incisions, so they're they're pretty small. This is a big thing. I mean, if you look at where there's a high density of nerves in the body, it's right here. And so we're avoiding making an incision and where there's a very high densely populated nerves. You're not making an incision there. So this is controversial. I don't know the answer to this, the whole infertility thing. There was a study by Zendejas in the Journal of American College of Surgeons that did a 50 year follow-up in patients that had had hernia repairs, and they found that 5% were infertile. Well, that matches the general population, so really it doesn't suggest that there's an infertility problem by doing hernia repairs. However, there was a study in Andrologia Andrologia. Uh, where they looked at 8500 patients in a fertility clinic, and they saw that the semen quality of those patients was markedly reduced in comparison to fertile men. So they saw a morphology problem. Whether or not that relates to fertility is a different story. But this is the argument, um, Mark, how do I clear those marks again? Yes, so go to more, yeah, and then annotate. Oh, annotate. I think you're doing that accidentally, by the way, because you're the only one that can draw it, OK. Uh, undo, yeah, we're clear, um. So OK, got it. All right, um, So Um, this is the the main argument that that I would make about why we do why I do lap hernias, and it's the ocean argument. If you're on a boat and you are sailing across the ocean on a beautiful, gorgeous, sunny day, and the water is flat, If you look under the ocean, Um, OK, how do I get back to, OK. There's another, now there's an arrow across the bottom. It's it's going crazy. So, um, the, the under the water, it's flat. It's nice and calm. Um, if you go on the ocean on a horrible day with terrible weather and the waves are crashing, and it's the outside of the, the, the surface of the water is dangerous, if you look under the ocean, it's still flat and calm. And that is the argument for the for the hernia, is that if it is, this is what I would say is like an easy hernia repair, that the ocean would be calm, flat, and nice on the outside. And it's going to be easy on the inside, but on a hernia like this where it's incarcerated or it's a preemie and it's just a bad ugly hernia that is not going to be easy to fix, I would call that the tempest. That's the typhoon, the storm on the ocean. But no matter how bad it is on the outside, it will still always be very easy on the inside. So there is no really hard hernia repair on the inside. For the most part, whereas that's not true if you go open. So, the other argument is incarceration. Um, this is a baby. You can see all the red they've been pushing on him and up in his groin, um, and so this is a kid that has an incarcerated hernia. So I, I just wanna ask everyone here. Let's say, um, Louise, let's say this patient came to the emergency room and you were able to reduce it. It was incarcerated for 6 hours, you waited a push, push, push, and it popped back in. What would you do with that patient after you pushed it in? Would you take them straight to the operating room? Well, usually when we did not do lab, yeah, we waited for 48 hours to operate, right? But uh I think now. It would be better to do direct laparoscopically in case of the there is some damage to the to the intestine that could be saved earlier before any, any symptoms of peritonitis or or other worse things are coming. Interesting. OK. Most people in the audience are waiting, um, either 24 reducing and then waiting for 48 hours and you too. Yeah, next. So, I used to do that as well, and one of the ad and I agree with Luis that now with laparoscopy, the game might be changed a little bit. Uh, the reason that I always waited 24 to 48 hours was to let the inflammation settle down so it would make it an easier repair. Well, that doesn't really matter laparoscopically. So, that whole thing of having to wait a day or 2 may not be necessary if you're doing it laparoscopically. So, in fact, if it's At a reasonable hour and the patient comes in with an incarcerated hernia, I tell the residents not even to try to reduce it. There's no reason to. We just go straight to the operating room. Don't push, put the baby through the torture of trying to reduce it. Just go to the operating room, put the laparoscope in, reduce it. Like Louis said, look at the bowel and then do the repair because it's not harder. Uh, like it is after it's when it's open. So, um, Same thing if you can't reduce it, that takes me to the operating room for a laparoscopy as well. So this is uh an example of what um a case where we had an incarcerated hernia. Here, I'm pushing firmly on the outside, trying to reduce it. And it's not going in, so we then gently pull. Now, this is dangerous because when you're pulling on that bow that's stuck, it could tear. So I pull, I excuse me, I pulled just a little bit of traction, uh, pulling it back inside the abdomen while I'm pushing. You'll see the The domino walls collapsing a little bit as we're operating because I'm pushing. So pushing and pulling gentle, barely pulling at all, just enough to give some inward traction, and once you see it start moving, you know you're gonna be OK. Uh, and you just keep going and, and eventually it pops in, and then you can get a good look at the ball. But you can see the anatomy is Pretty easy to do your laparoscopy, so Like I said, the incarceration is more of a problem out on the outside, not on the inside. Um, I think this is the main argument for the lap repair. Um. This is a patient that was I saw at our county hospital that had had an open hernia repair. And he presented with a recurrence, and when I put the laparoscope in, the indirect inguinal hernia was still nicely repaired, but the patient developed a direct hernia. And why does that happen? I don't know. Uh, I can tell you that it's the most common cause of a recurrence though. So patients of our patients that get indirect inguinal hernia repairs, if they come back with another hernia, it's usually a direct. So, 3 choices here. It's either that They just happened to develop a direct hernia, and that's just a coincidence. that they were misdiagnosed and done. Uh, open where you go in, you can always find sac if you try hard enough and pull up a little bit of peritoneum. So, we just misdiagnosed and did an indirect ininal hernia repair when in fact they had a direct, or, which I think it is, is that we caused it. And that when you have a patient who is a preemie, their floor is almost see-through. It is so thin, and that when we're delivering up the cord, I wonder if some people are taking some fibers of the floor with them and causing a direct hernia. I'd say definitely that's the adult general surgeon argument. I mean, in my general surgery training, same with yours, I'm sure, do a Liechtenstein repair, a mesh repair, although the majority of them are indirect hernias. General surgeons who taught me said just pulling up the cord disrupts that floor. And so they, and even though it's an indirect hernia, we'll always cover it with a mesh or a fasia repair or something like that because maybe it's, we're, like you said, we're causing. So that is, that is fascinating. That's the first I've heard of that in the adult, but I love that they're making that same argument because that supports, so. So if that's the case and like I said and then the big one was the Zendejas 50 year follow up that other occurrences they were direct. If, if that's the most common cause of recurrence, we will be eliminating those with laparoscopy. If it's, if it's either one of the two that we either misdiagnosed it or that we caused it. Now, if it's all happening just because it's a coincidence and they happened and then later in life got a direct hernia, that number will stay the same. But I think that the laparoscopic approach may eliminate what is the most common cause of recurrence. Well, what is our recurrence? You know, I will tell you that a lot of people, when they hear about lap hernias, they are afraid to do it because they've heard about a high recurrence rate. And that is true. Years ago, when the very first studies were, I will say that Felix Shear, uh, all credit should go to Dr. Felix Shear as the first to really promote the laparoscopic hernia repair. And as he was just getting started, they used a sort of a Z stitch. They would go in and go back out again, and they had a 6% or higher recurrence rate. Since then there have been numerous modifications, and I will tell you that having been fortunate enough to review a lot of the large studies from different countries, China mostly, We are pretty much finding almost all the studies that we're reviewing are the same recurrence rate, which is less than 1%. So if one of them gave a number lower than the rest, I would say maybe it's not true, but when you have every study pretty much showing about the same recurrence rate, which is about 1% or less, I think it's pretty, it makes me pretty comfortable to say this is probably a durable enough repair. Now, what we don't know is what happens in adulthood. How long are repairs lasting, we don't know that. So this is one technique we're going to talk about repairs. This is CK Young. CK Young, in my opinion, is one of the really great surgeons who's in Hong Kong, and he created this little device. It's similar to an awl. It's basically a curved, blunted needle. And he threads the needle with a prole and then passes it in a retroperitoneal fashion, and here are the vessels, and he's about to pass over the vessels and look how easily he slides right over the vessels with this needle. It's a big needle. It's holding the whole thing. You'll see it in a minute from the outside. And then here's the vase and look, look how he's able to just slide right over the vase. So it's really uh a nice slick technique. Um, I found it a little tricky um in the uh tiny babies, but I know a lot of people have switched to this technique and have borrowed the needle from uh CK. I'm gonna let you watch the rest of the video. Here he re-threads, he goes with the needle the other direction, re-threads it. Now that he makes it look easy. I will tell you that's that's the annoying part of the case. It's not so easy. And then you just pull it up through. Now CK likes to make the point that you have to do this right at the internal ring. You know, I realized I don't have a picture of his needle. I'll get it for next year's course. And then he ligates it. So this is, I heard a few of you guys mentioning you've done this. This is called Lils. This was published by Garrett Zalan and when he was in Buffalo. This is a video from my partner Scott Bollinger, and this is a girl. This is a girl and where the ball was incarcerated. They did this, this video, I think is about 12 years old. And they reduce it, and then what they do is they grab The The patent processes, the sac. They pull it in and they twist it, and then they ligate it. Now, let me put a very big disclaimer warning out there. Do not Do this in a buoy, first of all, you'll get the vase. The second thing is, don't just do just that. You have to cut off the tip of the sack. And the reason is, is that this loop will fall off. It will fall off, and when it does, the hernia will just recur, but if you cut the edge, the tip of the sack, uh, it will scar so that if the loop falls off, it will all be scarred anyways. So that's the Lil's approach. I don't ever use this, uh, but a lot of people do. This is probably one of the more common. This is called the seal technique, and this was developed by Mike Harrison and Craig Albanese and Carolynn Novahara in Stanford, and this is basically taking a big needle from the outside. So they're taking a big CT needle from the outside or through the skin, you pop through, you go down, and they skip over the vase and vessels. Some people actually Don't skip over. They just go into the peritoneum and then you bring the needle all the way out through the skin again, so you're getting a lot of tissue here. And then once the needle has made it to the outside of the skin, they back the needle through. Now, Mark, I'm gonna draw on the board here to try to demonstrate this. This is kind of hard to understand. All right, you ready for my drawings? Am I? OK. So this is the patent processes vaginalis, OK. Uh, this is the skin. And this is sort of sub sub Q fat here, OK? What you do is you take this big huge needle that you like close a fascia in a midline incision, like a big needle. And you pass the needle. Like this And it comes out like this. So you take one big whoosh, and you get I'm leading the audience with my sound effects to make you realize that I don't like this, so it's a big whoosh and you get all of this tissue and the needle. is here and I'll, I'll draw, so the needle's coming out like this. There's your, your tip of your needle with the suture behind it. You don't pull the needle all the way out. You actually then take once you pull it 99% of the way out, you take the back of the needle. And you push it, so it comes out through the same initial incision that you made to go through, so that your sutures come out through here. It goes in here and it comes out here. Now I will say, This technique that these guys developed is brilliant, and I do use it. I just don't use it for inguinal hernias that often. I have, I have still done it and I'll tell you an example when I do it. But this is nice. I use this when I do a diaphragmatic hernia repair and I do my whole thoracoscopic repair and to get that last corner stitch that's sometimes hard to get laterally, I'll do this technique on, on the diaphragm. So it's a nice technique when you have a hard time getting a stitch. I'll tell you when I do this technique. Do this technique. If it's a baby that you want to get done fast because let's say they're not tolerating the anesthesia or this is super fast. This, this operation will take you under a minute. I mean, it's one big stitch and that's it. So, and it works. And so if you need to do it fast and then you're having trouble with any other technique, it does work. It is very, very easy. And why did I not use it anymore? I don't use it. Let me just give credit where credit is due. I do lap hernias now because of one person that taught me this is Craig Albanese when he was at Stanford. He allowed me to come spend a day with him. I watched him do the lap hernias, and he did a full day of these techniques, and I used this for a while, and maybe I didn't do it as well as they did, but I was not finding that my patients enjoyed it. I think they had a lot of pain afterwards. And, and not everyone shares my feelings on this, but I found that they would be really crying in the recovery room and I feel like I got way too much tissue. And I probably got, who knows if I got nerves in there. I mean, you, you just get so much tissue. So, it's easy, it's fast, but I feel like it's not as delicate of a repair. You're getting a whole lot more than just a peritoneum. And I, I, I prefer to use other techniques. Yes. OK. OK, OK, OK. All right. This is what I use. This name of this technique has about 100 different names because so many people claim to be the originator of this technique. And over the years, I kept saying who I thought created it, but I think I've been corrected by Yama by Yama in Tokyo, who told me that it's actually Professor Takahara. Professor Takahara in Japan is the one who developed this percutaneous technique. Now, Professor Endo is another surgeon that uses this technique, and this was modified by Darius Patkowski, and that's where I learned it from. He published a great article in JLs, the Journal of Laparoscopic Advanced Surgical Techniques. He published an article showing this technique, and that's where I learned it, but I think it does date back to Professor Takahara. Now here is my completely pathetic attempt at animation to try to show in basic how this operation goes. So that yellow is supposed to be the patent prosthesis vaginalis, and that's a skin incision. So you take an 18 gauge spinal needle. And you pass it through the skin. Now this is threaded with a prole. It has a looped prole in it. And you push the pulling through. And pull the needle out. Now, that pulling would be coming out through the skin incision. I just didn't know how to draw that. And then you do the other one coming medialy through the first loop, and then you pull up on the first loop and it acts like a snare, and it pulls the second loop around. That's the Takahara or the Patkowski or the endo technique. And then here's an example of it. This was a video. I was doing this case in Argentina and they were videotaping the monitor, so it's uh it's not the best video, but first I hydro dissect. I use Local anesthetic and lift the peritoneum off of the cord structures. And then I take that 18 gauge spinal needle that's threaded with a proling. You can see the proling coming out of the end of it under my hand. And Here I am now. You'll see I don't see the chord structures. That's OK. Not seeing them is OK as long as you've lifted the perineum up. If you're passing under the cord, you won't see your needle like that. They're thick enough to cover the needle. So if you see some cord thing running over your needle, then that means you've gone under the cord. If you see just peritoneum, it's safe. And then once I pop through, I pass the prolene. And then I go medially. And you try to come out somewhere near the other hole, but you don't have to come out through the exact same hole. You gotta be careful you don't hit bow here, you just pop through, and then you put the needle through the other, the first loop. Now, yeah, not the appendix. Now I'm using another video because their video ended there, so I took another case to show you how it ends. So you pass the needle through the loop, then you pull the first loop up and it snares the first one and pulls it up through. So that's how that operation works. That's the Takahara. So the question is, how does it work? Does the repair lie on the stitch forever, or does some sort of scar form, or does it work like a Seton? Does it eventually erode through and in turn do a slow cutting ligation of the sac? No one really knows. And then I met these guys. So all the way to The left here is Doctor Jorge Godoy. This is Patricio Varela and Miguel Gilfan. They're down in Santiago, Chile at Clinical las Condes. And I was down there doing hernias, and Godoy says, come here, let me show you something. And he, he, he showed me this video. And he said, look, this is a girl. And all we do is grab their. Peyton processes vaginalis, grab the sack, invert the sack. And then buzz. And you just keep buzzing and you have to make sure you've got the true end of the sack. And then it's obliterated. So at that time, we decided we named this Bernia because it was a great, yeah, Bernia. So, so this was fascinating to me and they say that they had almost no recurrences, if any. So, uh, there was I think Nathan Navotny um just recently published a paper with them on their two-center experience with with no recurrences. So, Along the same lines, uh, Mario Romee also, um, does a resect the resection of the sack without um a repair. Just to removes the sack but no stitch. Um, and that got me thinking. So if those guys can do bernia and Raquelme can just resect the sack without a stitch, maybe none of this has to do with the stitch at all. These are stitchless, sutureless repairs that both have one thing in common, they caused injury. And so that got me thinking that maybe that's the key to how the hernias get fixed. Now, when you do an open repair, we go, we find the sac, we dissect it out, we divide the, we, we, we suture around the sack and then we cut off the end of the sacking. And, and probably that stitch dissolved. We know the stitch dissolves the way we usevicro, right? So what happens is it's not the stitch, it's the fact that we cut the sac and those ends scar. So that's how an inguinal open inguinal hernia repair works. It's not your stitch. And in fact, Munther Haddad from Leeds is uh from the UK, um, has published his series on doing open. Division of the sac without ligation, and they have the same recurrence rate. And the reason they argue about not ligating is that they believe that when you cut it and let go, it retracts back into the abdomen and allows the muscles to shut or close, but then when you ligate it, you're leaving. You're creating a new hernia sac, just smaller. You're, you're having something that's still vaginating into the muscle. So they cut it and let it go back in. The point being here is that all of these people have sort of shown is that the key to a good hernia repair is injury, not the stitch. So we wanted to see if that's true laparoscopically, and uh uh these are my residents back when I was at Rainbow Babies in in Cleveland, and we did this study called stitch versus scar. We wanted to determine if a hernia closure is reliant on the stitch. We want to understand the the role of injury. So these are New Zealand white rabbits, and they have a congenital inguinal hernia. And what we did is we randomized. On one side, we put a stitch. On the other side, we first made injury and then we put a stitch, so we made an anterior injury only. We didn't go near the cord structures, but we cut anteriorly and then we put a stitch. And then at that time, because I was still doing seal, we did a seal repair. And we survived them at 2 weeks and then we survived them again at 4 weeks. So We first went in with the laparoscope and barely any insufflation, 4 millimeters of mercury to see what it looked like, and then we cut out the stitches on both sides. And then we increase the pressure very, very, very, very high. Pretty much Blew up the rapids. I mean, really high pressure. Yeah. So at 2 weeks out, the suture was removed, and this is what we found on the suture repair alone side. Uh, 75% of them popped right open when you cut out the stitch. But on the side where we caused injury, 87% stayed closed, so a small percentage opened, but then we waited 4 weeks and we did the same thing. So, uh, on the side with suture alone, even more open. So only 17% stayed closed after 4 weeks out. And guess what happened on the injury side. 100% of them were reperitalized. Even when we cut the stitch out. So the injury is what causes the repair much more than the suture. So what we do now is we add peritoneal injury every single time we do a lap hernia repair. We then compared different sutures and we found that Between a dissolvable suture, of vicro, a non-dissolvable monophyline prolene, or braided non-absorbable, this the braided non-absorbable work the best, OK? So, the other study that I forgot to put in here is that um Ian Glenn and Nick Bruns, my research fellows from last year, did a repeated this exact study with Vicro. So the point is, if I can cut the stitch out and 100% they repaired and analyzed, you probably don't need to use a non-absorbable braided suture. So we tried that, and the results of the study were a little flawed. So The good news was The side where we used an absorbable and the side where we used a non-absorbable, the failure rate was the same. The problem was the failure rate was high on both. So we think that it was probably a technical error because Both sides went high up on failure for getting burned. No, yes, they both were getting burned, and no, sorry, the one side was just a suture ligation without a burn. The other side was a burn with a viral suture. And when we cut them out, both sides opened the same, so. All right, so how do we do it now? This is the whole technique. I think this says audio marks. Let's see. But my, I did, but my computer is muted. Should I unmute it or will it play? OK, let's see how it goes. Oh. Uh, we are. Be No, no audio. It's OK. So what we do is we bend the tip of the needle. Um, I actually made these little benders to make it more of a gentle bend, but you can use just needle drivers. And for you guys today, we'll show you both of those. And then I take a 3-0 pulling suture and I cut off the needle. Now, here you have the 30 pullings and you see they naturally bend at the ends, so we cut them where they bend, so they're perfectly straight. If you go to YouTube and type in Ponski hernia, uh, you'll find this video. And then we take the tips of those and we uh put them through the the tip of the needle. And we pull, we pull it back out through the end, and we keep going until we have the loop. Now, don't pull the loop all the way into the needle cause it won't, you always push back out. You want a little bit of the loop there. Then we put a little incision. I make a 3 millimeter nick in the umbilicus, just 3 millimeters. And then I put in a 3 millimeter trocar. This is a 3 millimeter step trocar. And here's the hernia. I will look at it, and then once I confirm there's a hernia, I make a stab incision. Now, I never used to make this extra stab incision until our peritoneal injury study. So now I need to cause peritoneal injury, and there's the study. Now, some people have talked about using a needle to go in and injure the the the peritoneum anteriorly. I haven't been that crafty yet, but we still use a a Maryland or a hook pottery. So I'm going to keep showing you throughout the video where everything is. There's the cord, there's the vessels, and there's the vase. And so I Bur burn only anteriorly, away from everything. I don't go near the chord structures. And then I use my little local anesthetic with a 25 gauge needle. I use it as a finder. To identify exactly where 12 o'clock is, and then I make a little nick. So that's 12 o'clock right where the 12 o'clock position is on the internal ring. Now, I inject local. And I come in from the side and I lift the peritoneum off of the cord structures. Again, some people say, oh, but then now you can't see the cord structures. That's OK. You don't need to see them. As long as you see nothing between your peritoneum and your needle, you're safe. So you go in laterally. I always, I, I stand on the patient's left side and always go lateral first, and I go over the court. Now, some people stand on the side of the hernia. I stand always on the patient's left, so I'm using my right hand. And then I pop out once I feel like I've crossed over at least the the vessels, if not the vessels and the vase. And I pushed my suture through. We use prolene initially because it's very easy to push through a needle, but we're gonna eventually switch it out to a braided suture at the end. But the braided sutures are hard to use during this part, so we start with the prole. And then through the same skin incision but going medially, I pass the needle. You can see there's nothing between the perineum and the needle. And I pull the suture tighter on my needle, and then I push the second suture through. And remove the needle. Now I pull up on the first one, which remember is snared around the base of that other program. And then I You can pull it all the way through. And now I have this loop all the way around. Now I could just tie this and be done. But because we showed that the braided non-absorbable worked the best, we exchange it and removed the the prolene and exchange it with an ethabo. Now, I cut the loop of the ethaba and doubly ligate. The critical point here is that in babies, I don't cut the loop. I just pull it all the way through and singlely ligate instead of doubly ligate because they spit the knots. The babies spit the knots, and so I don't like to have two big knots, but in the older kids, I have two knots. I double, I, I divide it. And doubly ligate. Does everyone understand that? I don't know if in the virtual audience, if you want me to explain that more, let me know. And that's what it looks like. Make sure you evacuate the air. You push the air in the scrotum into the abdomen before you ligate it down. I was going to ask you, pause for a second, so before you tie them, you totally desflate. Yes, no, I don't totally desufflate. I watch as I'm doing it, but I have my assistant pushing down on the scrotum to hold the air in while I ligate. Yeah, it's a good question. I'm afraid if I totally desufflate, I might grab something in there. So I'm insufflated, but I push in. And if you leave a little bit of air, it's no big deal. You can either aspirate out or just wait. I want to make sure one little thing is clear. The reason I wrote down at the bottom, YouTube Ponski hernia, I am not calling this a Ponski hernia. This is the Takahara technique. The reason I wrote that is those are the search terms if you go to YouTube to find this video. Uh, so I just want to make that clear. I'm not taking credit for this. Um And then, uh, another question too is what pressure do you are you insufflating throughout the whole case? Um, I, unless it's a little baby, I just use the usuals, the 15 millimeters of mercury. If it's a little baby, I might use 12 or 10. Um, and then, um, I usually, uh, we'll just show this here. I closed the 3 millimeter and then these I just glue closed. Usually don't have to close the skin. Let's see OK. So there's 2 ways to deal with the sack. You can close it like I just did, or you can remove it. So, this is the argument of the removing it, and for some reason, sometimes when I play this video, it stops at an inopportune time, but we'll see if it works today. So, This is the Mario Requeme or the Munther Haddad theory, is that the sac is holding there's not a defect in the muscle. The sac is keeping the muscles stented open because it's in the way of them being able to close. I almost think like a gastroschisis is the same way. The fascia would close if you would just remove the bowel. I think the hernia would close if If you, the muscles would, would shutter close. Hey, Abby. The muscles would shutter close if you could just remove the sac. So this is sort of an example, I think, of how I think it should work, OK? Let me show that again because it worked. I'm happy. So, if you remove the sac, The muscles should close. OK. That's the Mario Roqueme. It's so funny whenever I give this talk to naysayers, like I gave it to the Adult Hernia Society, the video froze right when the door is supposed to close. So, so it stays open even when I remove the towel every single time I show this video. So. This is Mario Raquelme, and Mario, I don't know if you're online. He's been on the last couple of years to give comments, but I forgot to tell him this time. He does a laparoscopic sac excision. He leaves it like that with no stitch, which is very similar to um if you're doing an orchidopexy, right? And we don't close those, and they do fine. So yes, we, we have a few questions. So, um, Victor says he doesn't really understand the double knot nonsense. Yes, OK, and then you want to cover that. Let me do that first. And by the way, can you fan over? This is Abby Schlager. He's the one I was telling you about. He's my partner. Abby's joined us here. So he's the one I was telling him about how you went in and found that the hernia was gone. How many years later was it? About 3 years later, 3 years later. So. We, we, and Sophia believes you believe that hernias close, right? Well, what's your belief, huh, that patent processes do close, not necessarily if it's developed into a hernia, but if there's still a patent processes and asymptomatic. So it's fascinating, but that's from what I read. Not from my own personal experience. I believed in potentially really young kids like preemies are within the first few months because of hernias, laparoscopy didn't have bilateral anymore. So I was willing to believe it for a couple of months. I definitively would not have believed it, you know, at this point. I thought I was going to find. You mean in an older patient. In an older patient after the first few months of life. I definitely would not have believed it if it didn't happen yesterday. Yeah. It's incredible. I mean that one case and Steve Schweitzberg, I, he told me that he has been keeping track of patients that he went in, incidentally found a patent prosthesis, and then operated on them again for something else and it was gone. I didn't believe him, but now that you're saying that, maybe, maybe I do believe. Um, so, Sorry, so The way, the way it looks when you've passed, remember, so you, you put in your, I'm gonna draw the whole thing here. You put in your first loop like this. And then you go another loop that goes down through this first one. So when you pull up on this one, it drags this one around. OK. So now I'm going to draw what it looks like after that point. So after that point, here's your patent processes. You have your one strand going here, a loop. And going back like this again. OK. So, in your skin incision, this really should look like this. This should be your sort of your skin incision here. And your threads come out like this, right? You I then exchange this with an eel bond, and the way I do that is I pass and An ethabond through here, through this loop. So I'm, I'm holding it up with my fingers, and then I pull on these, and this loop then drags. The ethic bond retrograde. That's not my invention. I want to give credit to Keith Jorgeson. This was Keith Jorgeson's modification to take the prolene and exchange it with an ether bond. And when you're done, Um, it looks the same, but it's just with an haban. Now, Victor, here's the point I was making. What I do, and again, this is Keith Jorgeson's invention also, is divide this here. I cut So now I have 4 strands coming up, right? I have, so I tie these two together and I tie these two together. So you do the ligate, so you have 2 closures. Does that make sense, Victor, before I go on? In a baby, In a baby when I have the suture. Now that's fair enough, he says. OK, in a baby though. The biggest complication is that I've had two patients that I've had that have spit out the knots because their skin is so thin, they have no subcu, so the knots under the skin, and they've gotten a suture granuloma. So because I don't want two knots under the skin. I just pull one of these strands through. So then I'm left with, you just basically um I pull up on this here. I pull up on one of these, so it pulls it through, and then I just am left with a single ligation. And I just tie it down. So I either cut and doubly ligate the older kids or I pull one strand through and do a single ligation in the younger kids. And what's the suture size again you are using for the new ne? So I use a 3-0 prolene to pass things, to snare and all that, but my final stitch is a 2-0 etha bond. Your question, I think you're hinting at is, can I use a smaller suture in the babies? I'm not that smart, so no, I haven't thought that far, but maybe, I mean, I, I I'll tell you this, Rauf. If right now to this point, since I've done single knot ligations without two knots, I have not had a kid get a granuloma yet. If it happens to me, maybe I'll downsize or Use a vicro. Because we believe that the perineal injury is enough, so the vico should just hold things together, or you could do Mario Rorome's technique. Yeah, I was just going to say there was one other above Victor's question, and this is sort of my question too. He have good eyes. Well, I saw it earlier. That's fine. That's why I saw the question. I said, oh, I have the same question, OK, because that's one of my concerns is using something permanent, and I've had some kids who have done it. Other hospitals come to me with, and I think they were prolenes. They were having the knots are kind of bothering them. Yes, so Ethelban might be totally different. Yes, it is, you know, do an open heart as they use PDS. So that's why I wondered, instead of the vicro, instead of haban, can you exchange it for a PDS that's going to go away with the injury? I don't know. Or is that monofilament going to bother them for those 12 weeks or longer? So I will tell you, let me answer that in a few ways. Number one, that's why I hate prole. It's almost like spears, the tails shooting out through the skin. You can feel it. The ethebos are soft and the the knot goes, you can't feel after a while. Um, the, the vicro or the PDS thing, I would usevicro probably before because we, I think the braideds cause a little more of an injury than the monofilaments, but If I really believed what I am telling you right now, I would be using a dissolvable suture. I'm 90% sure that it works, but I'm not 100%, and so I haven't had the courage yet to switch to Vicryl. I will tell you that people that have come to this course are using Vicryl, and I have to wait to see their long-term results. But it's with you who've done a lot. How many are complaining of the knot 0. Have you ever had any come to you complaining about? But have you had anyone complain about the knot? Right, that's why we do that on purpose and we close our phone lines and we don't ask that. No, but I mean, that's a great quote. Most of them are babies, so yeah. So Did you address Khalid Shrief, who says if this is the situation, then laparoscopic ligation of the Of the sac without sac removal is deficient because recurrence is inevitable once the suture is absorbed, is it not? Say it again. Say the question again. Yeah. So it's more of a statement. He says if this is in fact the situation. Yes, then laparoscopic ligation of the sac, without sac removal is deficient because recurrence is inevitable once the sutures are. No, you have to do the injury. So if you just ligate, I will tell you CK Young just ligates. He doesn't, he was not causing injury and he's done, I think he said 2000 in Hong Kong, not him, but the whole group. I don't know if that's the right number, and they have had a few recurrences out of thousands, and that's without any injury. So, the stitch alone is either holding things closed forever or eroding through the sack, which is cutting it like a guillotine and ligating it like a ston does. Um, Or I mean or it will occur, but he hasn't had many recurrences, so Just ligating is pretty darn good. Adding injury. I think it is much better because even if the stitch does pull through, it doesn't seem to matter because we've shown in the rabbits that it's totally reperitonealized, not with sac excision, just with causing an anterior injury. Now doing a sac excision. Seems to have the same results. My problem with that is I think that if this, this, I think if the world started doing complete sac excision, we might see some injuries. I, I don't know. And maybe one day I'll start doing them. I, I did one very similar that I'm gonna show you, but I, I prefer percutaneous, but I'm not hard fast in my ways and maybe you'll see me next year and I'll be doing a complete sac excision. I don't know if anyone else here has a comment about that, but. With the sack excision, aren't you still leaving the hole open or not? You are. It's like an orchidipexy, but the point is that removing the towel. That you've removed the sac, which, which once you decrease your, once you remove your insufflation, the muscles should shutter close. That's the thinking. They shouldn't have a floor defect. Correct. There should be no muscle defect. It's that it's that the sac is going between the muscles and keeping them open. If you just remove it, the muscles will close to their normal place where they were where they should be. That's the thinking. And his His data is It's pretty impressive with with that. Now, I put this very old picture here because I realized that when I get pictures off of Google, I'm only allowed to use ones that have usage rights where I'm allowed to share, and this was the only hydrocele picture I could find on the internet, so I have to take a picture of my next patient. But this is something I'm very excited about because this case just happened last week and Hopefully we'll be presenting this at a at a at a meeting, but there was a paper we read, and now I feel terrible, we'll find the name. There was a paper we read of a surgeon who had reported doing laparoscopic non-communicating hydroceles, and I was so intrigued by it. He sent me his video. I apologized to him. We'll get the name. I apologize. I I did not remember how he did it, so I'm sure my technique is not as good as his. I have to go back and look at his video, but, but we did a laparoscopic non-communicating hydrocele repair. Let me first talk about communicating hydroceals. I think that's the same as a hernia. So if it's a communicating hydrocele, there's a hole. I've done a lot of those, and the inevitable question that everyone asks is, do you get postoperative hydrocele? Almost never. I don't wanna say never cause I have had one girl with a canal of nook hydrocele that just dissolved away after about a month after surgery. But even in patients that come in with a communicating hydrocele, um, I've never had them get a postoperative hydrocele. Yeah, Mark, you said there was a question. Well, a couple of things. So Victor says, Todd, do you remember the case of the reactive reactive hydrocele I sent you last year after a hernia lap repair? Any similar experience on anyone? He had a, he had a hydrocele post-op. Say it again. He said he sent you a reactive hydrocele after lap repair last year after a hernia lap repair, yeah. Yeah, what happened? I vaguely remember what happened, Victor? Did it, did it go away or did you have to do something? OK, because I've never had to do anything ever in 10 years. Adrian Kernow says complete sack excision or sack division, because if you remove a lot of the sac, then you're not stripping it off the vase. Great question. I think people do both. Some people make a circumferential ring around, but most of those people then go ahead and just pull off the sack, and yes, Adrian, you do have to remove it off the vase, and that's why I don't do it. I would love to have Mario. Last year Mario came online to defend his procedure, and I will just tell you, I'm a huge fan of his. I think he's brilliant, and I am toying with this. That's why I talk about it so much because it's intriguing to me. I just fear that you're going to get vase injuries because you do have to peel it off the vase, which is somewhat defeating the purpose of the lap repair of not having to manipulate the cord structures. So Victor said he had to make an open repair and found the stitch intact, but with a great inflammatory response. We'll see what he says later, how long he had to wait. That's an interesting case. I have not had that happen and talking to most people who have done a lot of lappingguinals, I don't think any of them that I've spoken to have ever had to operate on a postoperative hydrocele. Have you, Abby, OK, but what you were saying about, uh, as far as do you strip the vass, you essentially are because your hernia repair is making that window to the vast and the peritoneum anyway. All you're leaving is maybe 2 millimeters as it goes up in there. So you're pretty much size of the brown eyes, sorry, we're, we're having a hospital announcement. Yeah, so when you saw most of that hydro sac like up but not including the points of the bats, you're only leaving a few millimeters because just proximate to that you're gonna do your hernia repair where you do make a window between the bat. So you're essentially doing the same thing and you're open, you're gonna have a few millimeters. It's the same as open. No, it's that's, I think that's the point that you excise as much as possible, but I don't think. There's much of an advantage than of doing a lap because you're, you're putting the cord structures at the same risk as an open repair. OK, this is my video. I apologize, I edited it quickly for this course, but here's the video. So, we go in, um, And first of all, I want to ask everyone what would they do with this. This is the other side. Who would fix this? We have a, we have fifty-fifty here in the audience. I I usually actually don't fix the small ones, but this one seemed to go deep inside, so I did end up fixing it. I'll show you at the end. Yeah, yeah, yeah. So here, so this is the hydroseal. Look, I pushed the hydroseal in from the I'm pushing, and it's a non-communicating hydroseal. So I, what I did here is I, you know, Avi talked to me afterwards. He told me what he would have done different. Hold on. Could you have left it alone? How old is this kid? No. So this is a kid who deserved a repair because he's now had this for 2 years. I wait 2 years and he's had it for 2 years and it did not go away. And he had another indication to go, which I want to ask you guys about. We looked laparoscopically at his diaphragm, which I'll ask you about in a second. But so Avi said to me, you know what would be cool, I wonder if you could have dissected out the planes and almost removed it as a cyst intact. But I'm not as smart as Abby, so I'm the dumb surgeon who does this. So this is what I did, which I think worked really nicely. So I push it in And I drained it. So I pop in, I cauterize. And I'm anterior, so I'm away from the cord. Probably could have edit this a little more, wait for it, wait for it, ah, here we go. Yay. So I drained it and I was thinking maybe I'm done. I mean, make a big hole, but then I said, no, let's, let's do like that guy did in that paper that we'll try to find the name before the end of the course. What is it? Choi Choi. Choi from which which journal? So this is uh Um, Choi from South from Seoul, Korea, uh, fantastic paper, a Comparison between Totally laparoscopic hydroce let me pause this. Um, It's called a comparison between totally laparoscopic hydroceolectomy and scrotal incision hydroceolectomy, uh, for pediatric cord hydrocele. Um, anyways, um, so then I, I, I really want to show you. Um, maybe Mark, maybe we can post it on the chat. Uh, here, Sophia can do it. Hey, Sophia, can you post it in the chat? Um, now, he, the video is not in this article. We asked him to send us his video. I just don't have it, don't know where it is. I'll have to ask him for it again. But, uh, but here, you can see my video now, even though it's no Choi video. So, so here's the, here's the sack that I just, now, I looked at the chord structures and you'll see I've looked at it a million times to make sure. Let me, um, pause. Whoa. Yeah, uh oh. So bless you. So You can see here, does my pointer show up? Yeah, this is the vase. And these are the vessels, V vessels, and I even like really thinned this out to make sure it's not circling this way or anything, but I made sure that it was definitely going this direction, and so all of this stuff should be receptible because I can see the cord structures. And for those of you who don't know me, do not be respectful. Uh, please tell me that you think I'm crazy or whatever. That's, that's what makes this fun. Um, my partners certainly do. So, I was, I don't know what your scissors are like in your hospital, but ours don't work very well, so I was sort of gnawing with a little cautery and it didn't seem like I was making progress. So I switched instruments in a minute. Very cautious to make sure I'm not getting anywhere near the bats cause I think I just need a substantial injury rather than really removing the entire hydrocele. I mean, we don't do that when we're open. I don't. So I wasn't making progress with the scissors, and I kept looking. OK, vase, where's the vase? OK, there's the vase. It's curling. Look at that view. You see it curling in? So I definitely saw that I was safe way out here. So now I use hook cautery. And I'm very far away from the vase here. And I could have gone closer, but I felt like I didn't need to, and I didn't want to go anywhere near the vase, so I just stayed away at the tip. And now you have a hernia. Uh, you know, basically, uh, you know, basically, you could just be done because Mario Cuomo, but I, I like doing the, I like closing the perineum. Now you probably don't need to do this part. You probably could be done. But I hydro dissect. And then do the repair. I don't know how long I make you sit through this, but. So there's my needle passing after I hydro dissected. You can see how there's nothing between my needle. And the peritoneum, pushed my first suture out. And I'm gonna come immediately. And since I basically did a sac excision, I probably don't need to do this, but I did it anyways. Pop out. Put the needle through the loop and then pull. I push the needle against the abdominal wall. Otherwise, I've had the loop, even in my last course, it pops over the edge of the needle. So I touch the needle to something so it doesn't pop over it. And then I push the suture out of the second needle, pull the needle out, and if I pull up on the first suture, it's going to snare the second one through. Now I did show how to fix this one because believe it or not, these small ones are tough. Cause now, so I grabbed just a little bit of that anterior stuff and just give it a little buzz, cause you have to create an injury, but again, I'm very far away from the vase, OK? That's all I'm gonna do. And Then I do the repairs, so hydro dissection. Make sure you're definitely above the vessels, not below them, otherwise you'll lift the vessels up with the peritoneum. And this, this part's actually quite easy. You can see there's nothing between the peritoneum and my needle. The cord is not see-through, so Touch it to something. Pull the first one around tighter on the needle. Yes, so someone says, why not just burn it? You're right, I could. I just get, I feel like there's not much downside to putting a stitch, so I do it, but that's a great question. I could have been done by just burning it. Just this one here. Who would have just burned it and not stitched it? Ian says he would have done exactly what you said, um, uh, Theodore. Theodorus. Um, so yes, you're right, I probably didn't need to put the stitch, but I just do it. Ay, what would you do? Not, not repair it, burn it, or burn it and stitch it. Burn it and stitch it. OK. Yeah, I think. OK. All right. All right. So that's kind of a cool case, but um, so, We only have a little bit of time left, and I want to end on some controversy here about In a child, we do a high ligation. In adult, we do muscle or mesh, but what about the ones in the middle? And that's a big controversy. So we actually did a survey and asked how would you fix his hernia. So Avi, oh. He's a good one to ask. Now, how would you fix his hernia? Just don't know. You're undecided. OK, we'll get back to Avi in a second. You've actually convinced me in this case that I probably would go with um the lap repair first. The one recurrence I've had is in a giant 18 year old muscular. I was worried that maybe the reason why I had that one recurrence was because maybe he represents a different hernia. But then when we spoke about the fact that you quoted that the complications of like, uh, groin pain from mesh repairs is up in the 30 to 40% range, that's pretty compelling that. A benign operation like this is definitely worth a try, even if it means going back to avoid the potential lifelong pain and it seems like it is lifelong pain. the rate is that high. I didn't realize the rate was so high and you probably swayed me back into doing it. Yeah, now, at the American Hernia Society, when I gave this presentation, they were raising their hands saying that 30% that was quoted in the NIH study, um. That if you're a very proficient lap hernia surgeon, their numbers are lower. So that for the for the common general surgeon who does it, there's one, but someone who's like just a hernia surgeon, they think their numbers are not 30%. They think they're much lower. So, so who knows the actual number. So, we did a survey and divided it and looked at our answers and divided them up into two groups. And I will tell you that these two groups, um, Had these results. So, the group on the left, 86% of them said high ligation. In the in the same patient, the other group of surgeons we asked did almost all muscle or mesh repair. They both studied from the same anatomy books. But they had different fellowship training. So, how is that that we all the same case have vastly different answers on how we were treated? It's because of how we were trained, which clearly shows a void, a problem that we don't know how to treat these patients. And we're having a mix of all the different answers we have. Different choices here on how they would have managed that. Khalid says this depends on the integrity of the shutter mechanism. Yes, if you're going to remove the sac. So I showed this slide because this was how I felt presenting to the adult surgeons, telling them that they shouldn't be using mesh. And so I say, if you look at this kid, And he has this, it's a patent prosthesis vaginalis. And we think that it happens that that the testicle migrates down and you're laughing because you made that video, the testicle migrates down and the patent processes follows with it and and and herniates out. And so there's basically that's anatomically what it looks like. The muscles are all still there. They're the normal muscles, but there's something in the way of them laying on top of each other the way they're supposed to lay on top of each other. There's no actual hole. And so we do high ligation. Now, what about him? Anyone know who that is? All right. Abraham from The Walking Dead. Yeah. So, if Abraham had the same hernia, we would say, oh, well, that's an indirecting little hernia and that's a muscle problem and that needs mesh. Um. So I will tell you we're looking at this. I think there's a bimodal nature to hernias. We see them a lot in babies and we see them a lot in older adults. We don't see many adolescents. So is that because The the ones that adults get are acquired. They're not patent processes that they've had since birth, or they acquired defects and they have a different pathophysiology completely? Or does it have to do with the physiology of when bowel, the hole gets big, the bowel, when can bowel fit through it. So it either happens right away or when the hole gets bigger as they become adults, the hole gets big enough for bowel to fit through it. I don't know why they're bimodal, but they seem to be. And um The other thing that we found is that there is an inflection point around 29 years of age when direct hernias start developing in adults. We never see direct hernias, but around 29 years of age is when we started seeing a lot of direct hernias, which makes me think something happens with the floor around 29 years of age, and the pediatric indirect hernia becomes more of an adult muscle type of indirect that needs muscle or mesh. So maybe anyone under that age can be fine with just getting a high ligation. So for a direct hernia, you know, if you ask adults, they don't even always write in their note if it's direct or indirect because they treat them all exactly the same. They don't even care to distinguish. So direct gets mesh, indirect gets mesh. They don't distinguish. Um, When I tell Mike Rosen, who's a hernia surgeon, that I'm just going to do a high ligation, he says, that's like if you're saying that all you need to close. Let's see if this works. I guess not. Um, all you need to close is this here. Then that's saying that if you close that and you think it's closed, then you're telling me you would walk out here. He's saying, you're just closing the hole, but this is weak. And so this whole thing needs to be closed. Let's see if that works. Um, yeah, so the whole thing needs to be closed. But I say it's like this. It's like a fishing hole that, no, that's not true, Mike. This is all you need to close and this right next to it is totally fine and and and that doesn't need to be closed. So, I just want to ask everyone, who would do a high ligation in this kid? Everyone So when do we stop? At what age do we decide that we're gonna do a muscle or mesh repair? Usually people say maybe on this kid. And the question is why? Cause he's a couple inches taller than the one before him. Like, what is the determining factor of when someone gets a muscle or mesh repair? We don't really know and we're trying to figure that out. Is it their age? Is it their weight? Is it the size of the ring? So we did a retrospective review of adolescents getting high ligation, and we found that there was a 1.9% recurrence rate with open high ligation in a two-center study, Kansas City and Rainbow, and we found a 1.9% recurrence rate. So, We, I want to show you this case. This, this looks just like The videos I've shown you before were causing anterior injury. See how he grounded a little bit there, which is fine. And then, uh, he passes the needle, and what I'll tell you is, although this looks exactly the same, this patient's in their 60s, and this is because we've started a prospective trial studying the use of a lap high ligation in adult patients. Um, regardless of whether they're No, only indirect. You cannot do this for direct because it's a muscle problem. Um, and so, this is headed up by the, uh, group in Norway, and they've already done about two years' worth of, of hernias in adults. Um. I will show you something cool. We started this how to teach them. We started a 5-step training module where they watched a lecture first, then I flew to Norway and we trained on a simulator. Then I did the first case, then he did the second case and I watched him, and then I did what's called telementoring. So in the same room, I drew on a monitor to help guide him through the case. Then I went up to the 4th floor of the hospital and guided him how to do it, and then finally I came back to Akron and we did a whole day's worth of cases virtually with me drawing on the monitor, telling him how to do the case, and this is a video showing it, and I don't know if the audio will work here. Can you hear him, Mark? Sorry, um, So, this is me just talking to him and uh and drawing on the screen on the iPad and he's seeing it in Norway. So, To conclude in the right amount of time, um, although hernias are the most common operation, we still have a lot to learn. So I wanna open it up to questions for you guys, comments, um, and anyone in the audience who has a, a question about what we discussed here. Uh, I'll start with this one. This supports the open hernia repair, which gives you the chance to evaluate the integrity and strength of the posterior wall of the inguinal canal. If it is weak, then hernioplasty is needed. So, Khalid, I, you bring up a good question. Is it easier to evaluate the floor open or laparoscopically? I would tell you that I think it's actually maybe easier to do laparoscopically because you can see when you're insufflating the bulge of a weak floor. I'm not sure I'm correct, but that's my gut instinct. I don't know what everyone else here thinks. You think it's easier to evaluate the floor open or lap? I think it's subjective. I think throughout training we've all had people call direct, indirect floor feels a little bit weak, also depending on how much you dissected under the floor, what feels a little bit weak. Yeah, sort of subject to a lot of interpretations, I think. I don't know if you could hear what he said, Cleve, but basically he said that when you do it open, it's subjective. You can push on it and say, yeah, it feels weak, but laugh, there's no, it's pretty clear cut. It's either bulging up or not. But in an obese adult patient, you're not going to be able to make that distinction. You may not be able to get it to bulge if somebody's got. That's interesting. I don't know I don't The question, yeah, that's an interesting point. I don't know. Um, I agree with that statement. I think we weaken the floor with open dissection. I also agree that it's easier to evaluate the floor laparoscopically. This person says, Khaleen says, I'm sorry, but I think you cannot evaluate unless you palpate it. I guess we'll agree to disagree there. I don't think palpating it is necessary. I think you get a very nice evaluation by pushing with air. You're pushing with the insufflation and it lifts the perineum up, but your opinion is well respected, Khalid. I just don't know if I totally agree with it, but it's a great, a great argument, and I'm curious what other people think about that. It's a very, very, very good argument question. I can ask the adult surgeons the same thing if they, because remember they, they go in laparoscopically as well, and I wonder if they think you need to evaluate it open. Um, By the microscopically and always put a mesh in. I mean that's right, something like that. That's true. I'd be really interested to see what your study shows out of Scandinavia. I know it may change a lot. It may. I will tell you, as Avi said, his only recurrence was in a guy who was about 6'5 in the military. He's a Marine. Huge, strong guy, and we on the second look, it was as if no one was ever there, wide open. So what happened? I don't know. I mean, Craig Albanese thinks the failures are that the stitch pulls through too fast, um, before any healing had a chance to happen. So, by the way, when you put the stitch in, I burn a little on the inside of the canal and not right at the internal ring cause that's usually where the stitch will rest. I burn a little distal inside the sack so that they're not in the exact same plane. Globally, do you know if there's a world trend to repair inguinal hernias laparoscopically? Absolutely, Victor. It's Very surprising to me that I felt like trying to talk about lap hernias was an uphill battle that when I first debated this with Steve Rothenberg, who now does the lap, but we first debated this at IPEG in San Diego, in Hawaii, almost 10 years ago, and I think 90% of the audience was in agreement that we should do these open. We just did the debate last week or a few weeks ago in London, and I felt when I pulled the audience, I would say it was the reverse, that 70 to 80% of the audience seemed to raise their hand when I said, who's doing this laparoscopically? Maybe not. So but you're right, it was a mix and you're totally correct. But even at IPEG in Hawaii. To IPEG BAPS in London, there was a radical shift. Even at the most laparoscopic society, they were all doing it open, and now they're mostly doing it lab. At the last week we do an annual fellows course that we, the Children's National Medical Center does a pediatric surgery fellow course for graduating fellows, and we polled everyone, and I think it was 100% of the fellows said that they had done, or at least seemed like almost almost everyone's hand. Um, was, was up, um, saying that they do, um, they do lap hernias, so, um, I had a 4 year old recurrent hernia that had been repaired elsewhere as a 3 month old. The child had a 10 millimeter length of vase that was atrophic, but no mention that no mention that that was present at the initial surgery. I love that point. Thank you. I totally agree, and the great study to do is to look at preemie hernias and look at measuring the testicles in open versus lap, and I think That That's a great study. We don't know the recurrence rate long term, but we will be able to see the atrophy rate, and I think that without question. The lap repair will likely have a lower atrophy rate than the open repair. I agree with that. Um, Felix Sheer did a study where he looked at um Ultrasounds of the testicles after the lap repair and there was no deficiency in the blood flow to the testicle in any of the babies. People wonder that when you squeeze everything together, are you squeezing the vas and vessels? Sofia and Ruf, I would love to have a physics person go through this with us, that if you take a ring and there's something outside of the ring and you tighten the ring, does the stuff outside of the ring have any forces applied on it? I don't think so. I think they get caught up in it. But I don't think they're in the repair. And by the way, when you look laparoscopically after an open repair, it looks exactly the same. When you ligate the sac, you see scrunched up peritoneum with vessels and vass running right underneath it. So I don't think it's different. Anas says no hydrodissection, just pop in with the needle a few times to create the injury. It's interesting. I like that. And, and help the pneumop and help the pneumoperitum help with the dissection. We do skip over the vase and vessels all the time and so far we don't have hydroseals. The only complaint we get is that the knot, which disappears in the next visit. So we use only the camera port and in a few cases we need extra instruments if the peritoneum is too floppy or if it's an incarcerated hernia. I love that comment for like 5 reasons. First of all, you hit on something. Of course, I show you my easiest videos here. The hard ones are the little babies because their peritoneum is floppy. It's not taught. So when you're trying to pass your needle, It doesn't just stay tight when you're passing under it. It sort of moves with the needle, and sometimes you need an instrument to help create some counter tension on the peritoneum so that when you pass your needle, you pull, I pull the perineum backwards and pass the needle forward so it gives me some stretch, if that makes any sense. Um, the, the perineum, when it's floppy is tough. I love that people are thinking of a way to do this without the extra instrument. Some people told me that they've talked about putting in a needle tip bovie. poking it in and boing like. Through the groin. I, I don't know how it would work or um like the the the pea tip, like the Colorado tip. You put it in with a little bend and you just sort of go around through the incision there. Some people talk about cauterizing the tip of their needle, but it's so small. I mean, I think when you do a lap poric, you can't see those incisions. I agree, but it's nice to always try to make it better, obviously. I totally hear your point, and I agree with that. I'm very intrigued and I have to remember your name, Anas Shika. I love this idea about using air to insufflate. That is very cool. I've never tried that. And, and I want to know because I wonder how that will work compared. I've seen that in single pore apps when you make that, if you do a single port app and you make your retroperitoneal push with a with an instrument and then all of a sudden then the carbon dioxide starts getting into the retroperineum and your perineum slides off totally dissect it. Yeah, absolutely. I think it's a really cool gallbladder when you take it off the gallbladder faucet, let all that hair come up and it like it's so much easier. Yeah, yeah, yeah, yeah, yeah, it's nice. It's nice stuff. All right, I think the danger of stitching the vase and lap is higher. What is your opinion? I Well, let me say this. I think probably stitching the vase may be higher. I would say injury to the vase overall, just all comers, is probably higher in the open approach, but I think it is incredibly safe. It is very hard to stitch the vase because when you get the vase, if you put your needle under it, you see it. It's a big fire hose structure over your needle. It's not subtle, but I don't know the answer, and I'm not going to claim that I do. So I don't want anyone to think I'm saying I know which one is safer. I don't. It's personal preference, and if you feel safer doing one versus the other, go for it. I think that it is very safe operation though. So what's the best recipe to prevent recurrence of a lap hernia repair? sac trauma or sac excision, I don't know. I do sac trauma with a stitch, so I sort of cheat. I do both, the sac trauma and stitch, but I'm sure Mario would tell me that he thinks sac excision is better. So unfortunately, you're not going to get an answer. You're just going to get an opinion. And you said, oh, I want to answer a question that people often ask about how do you manage a recurrence. So I operate. I'm not, I want to make it very clear, I am not going to say my recurrence rate is, I'm not going to give it, I don't know what it is. I can tell you that in my career, I've only had one patient come back to me with a recurrence, and that was my first case that I did when I was doing the seal approach, and it recurred almost instantly. He had terrible leg pain. Something I did something wrong. He had terrible leg pain and then he recurred, and I went back and it was like, no, that was never there. That was with the seal thing. I don't know what I did. But since then, my first year, I have not had a patient come back to me for a recurrence. They may have gone to someone else, but not to me. So I think if they did come back with a recurrence, I would go back in laparoscopically again. And the reason I say that is the recurrence rate is so low that of it happening twice would seem to be very low, low chance. So. If it's too large of a hernia. Does anyone go deeper in anterior and laterally to include muscle? Yes, some people do that. Um, I've never done it, but that's a very intriguing question. I think that there's a there's a huge defect. Um, getting a little bit of muscle may help. The truth is, um, we're starting to try to figure out if there's a certain size that has a high recurrence rate that would benefit from a muscle or mesh repair. Don't, don't try to do this repair for a true defect, a direct hernia. That's, it's not going to work. All right, I think we're good. Um, so, yeah, yeah. What's the smallest kit you've done? How low will you go? I don't know how low I've gone, but I will do any age. So 2.5 kg baby. Oh yeah, smaller than that because I've done little preemies, yeah, yeah, because if you get in. You only need that tiny little space and it's percutaneous. There's not much you're doing on the inside, you just need to see it. So if you go in with the laparoscope, you see the hole. As long as you can get your scope down into the pelvis, it's, it's easy. Yeah, I would do any age. I use a varis needle for the initial insufflation, then use an 18 gauge angio cath in the right upper quadrant for insufflation. I then place a 2.8 millimeter seven degree scope through the umbilical ring without a port and a 1.8 millimeter insulated needle-tip probe with a cautery. Very cool. No ports, no sutures except for the ban. Adrian Know. That's really cool. What I would ask is if you can make a video of that and either send it to us or send it to me and I can post it or, or put it on YouTube. Um, I know that uh Miguel Gilfon in Chile also uses portless surgery. Um. I feel like I have a good balance of minimally invasive and safe where I'm doing it now, so I haven't felt the need to push, but I do like that people are trying to do this less invasively. So congratulations on that. I'd love to see that video. So we have our my case starts in 10 minutes. So we're going to head down to the operating room. I really appreciate everyone coming on. This was a great lively discussion. I hope everyone stays in touch and a little plug for JPS if you could go. On Facebook and join the Journal of Pediatric Surgery Facebook group or like the page and the Stay Current Facebook group and page. We can discuss these types of things a much more great deal. Thank you everybody and have a great morning, afternoon, or evening, whatever time it is for you. We'll see you next time. Thanks. Oh, wait, too late. Tomorrow's update course. I guess most of tomorrow we're having an update course where we talk about the 10 new biggest topics in pediatric surgery. I hope you join us tomorrow.