Dr. Konstantinos Papadakis - Unusual Pediatric Hernia Problems

OK, it looks like we're alive. All right. Thanks for everyone's patience. Uh, so, today, we feel incredibly lucky to be able to call upon one of our own, Doctor Gus Papadakis. We all know him well, but just a brief intro. Uh, he hails from Greece. He conducted his undergrad, uh, in physiology. At the UC Berkeley, his MD at the University of Vermont, and then surgical residency at Brown. Uh, following this, he actually split his pediatric surgery fellowship up. He was, uh, a unique, um, leader in that sense. He, uh, did one year at the floating hospital and then moved over to finish up with us at Boston Children's. Uh, in addition to that, he conducted an ethics fellowship through the Harvard Medical School, um, later on in his training. Um, we all know Gus is an incredible clinical teacher, and no matter how much of a call burden he shares or how many emocanulations he gets called to, he is incredibly generous with his time and sharing his clinical pearls and pitfalls with the fellows and the residents. And for this, we love operating with them. We love learning from you, Gus, and we're so grateful that you're here to share your pearls and pitfalls with, uh, pediatric inguinal hernias. Thank you. That's introduction only a mother can love. So, thank you very much. This is an honor and a privilege to be here with all the fellows, Doctor Fisherman, Doctor Chamber. Thank you all for letting me be up here. It's quite a privilege. Uh, I am. Gonna say that this is, I hope this is worth the wait. And I feel like this is, have you ever, there's a punch on this reminds me of, of, um, there's a, a general surgeon and a plastic surgeon who were kidnapped and they had to prove their, their worth to be let go. And the general surgeon says, just kill me before they start the PowerPoint presentation. So, I hope this, hope this is worth it in the end for you. Uh, and I'm dedicating this, or referencing to this to doctor. These are Doctor finds the slides that I'm using. So nothing to disclose, no conflict of interest. We're gonna talk about hydroceal hernias in different aspects that we see. So, we all sort of like know the idea of a, of a hernia. It's an obliterated process of vaginalis, um, and that should obliterate before the, before it becomes a hernia, or if it doesn't, then that's what, what a hernia is. There's a difference between whether it's called congenital when During the descent of the testes around the 7th or 9th month, that should close, and if it doesn't close, it stays open. If it stays open enough where it goes into the scrotum, that's called a congenital hernia. Sometimes there's just a process here, um, and the, and the distinction is that that process may grow over time and then it becomes an sort of an acquired indirect hernia. Through the prostheses or the canal of nck in females. Uh, again, inguinal hernia, uh, sometimes this continues down into the, in addition to the hydrocele, uh, and it's separate from the hernia sac, um, which is all an indirect hernia. Uh, and again, this can be, uh, a congenital hernia, and then it could be, you can see the tunica vaginalis which is closed and, uh, separate, but there's no more fluid around the, around the testicle which was, which includes that, I'm sorry, which is not a congenital hernia or is a, is a congenital hernia, uh, and not a hydrocele process. So, obviously, different forms of descent, you can have hydrocele of the cord, uh, gual hernia, which implies that the process is open, communicating hydrocele, um, and again, a scrotal hernia, which is in the old term. Called uh congenital. These should terrify you. These Uh, are scary to look at and they're scary to do. Uh, and if, if you're not afraid of these, and you haven't done enough surgery. Uh, premal hernias are very difficult. It's like sewing wet tissue paper, uh, together in Providence. Uh, uh, Doctor Lux used to say that this is like sewing or, or trying to sew, um, wet tissue paper together to, to moonbeams. Um This is what these big hydroce and hernias can entail. Half their digestive tract is sitting in the, in the scrotum. Um, they're not to be taken lightly. So Doctor Fines was a tremendous technical surgeon, uh, and these are his slides, uh, open up fascia, find scarpus, uh, get down to the cremaster, uh, fibers, I'm sorry, get down the external oblique. Uh, open the ring. Um, some people start, as we're adult surgeons, we talk about going from the external bleak to the ring. Uh, I was always taught to go from, sorry, I don't know why that's doing that. Uh, going from, from the ring itself, the opening to where you know, to where you don't open the ring. Um, Open up the, open up the ring, find the internal structures, uh, hernia sac along the cord. Elevate the cordon structures, uh, again, the sack is going to be intermedial to the vessels. High ligation of the cord, um, I'm sorry, allegation of hernia sack away from the cord in the retroperineum. Uh, twisting allegation, um, Doctor Fines used PDS. Everybody knows what that stands for. That's right. Perfect dam suture. Um, and again, it's a particular closure of your choice. Some newer way of doing this is obviously a laparoscopic repair depending on if you're comfortable with that. Uh, they do seem to be technically easier than doing this open, especially in preemies. It seems you can find the ring easier, uh, whether you do hydro dissection or not, um, with the, uh, vast and vessels. We're not going to talk about a direct hernia, uh, So we're gonna talk about indirect hernias. So, this doesn't necessarily look unusual. It looks like a mass in the scrotum, um. The interesting thing is about the history of this child is that he had a permeconium or perf neck. And what we found in the scrotum are all these calcifications. Uh, and that, that, again, a, a hernia with stuff in it, um, and meconium calcifications from, uh, pre, prenatal perforation. So these are what we'll talk about and what we'll go over. Again, they're Gradations of hydroceles, uh, some small, some big, um, and they can continue to be even into the abdomen, uh, which can be difficult to, to manage through a small ring. So, abdominal scrotal hydrocele, uh, sometimes the The tip to the or the uh the tip off to these is that sometimes there's a big abdominal mass in addition to having a big scrotal mass. Uh, and those can be taken out, uh, separately, uh, sorry, uh, together, uh, but sometimes you don't see it, so you start. I just see the cord, it doesn't go into the scrotum, uh, all the way, it doesn't involve the testicle, but it's usually of the cord itself. Sometimes you find masses in the structures. Uh, this, this patient had a history of neurofibromatosis and had a neurofibroma in the cord itself. Um, and this little orange piece, uh, is sometimes an adrenal rest, uh, Which can be taken down with a descent of the testicle. Sometimes it doesn't feel like a hernia, but the test, the testicle feels hard and firm. Uh, and this patient, unfortunately, had a tumor, uh, had a seminoma that was involved in that. Again, history, uh, other diagnosis you have to be careful with. Uh, epididymitis, uh, a scrotum that looks red and tender. Uh, what what most people do is get an ultrasound. Uh, if the ultrasound is not, Specific. Or cannot definitively tell you if he has flow, then we would talk about doing an operation. And this kid. You can see the testicle has a hor uh vertical eye. Uh, usually, torris testes have a horizontal eye, um, and are exquisitely tender. This one is at the same position as the other one. It's not lifted, it's not raised, uh, and it's in a, again, a vertical position. And this is what if you have to operate, this is what you see. Again, the board answer is if you can't get an ultrasound, then you would proceed with an operation. Obviously, there's different other special cases where you have to deal with lymphedema, um, and we Operated on this patient multiple times for this debulking of his leg. Um, this is pre-op and then oops. Uh, and then we have to deal with the hernia, um, separately or together. Blue dot sign. Does everybody know what that is? So, this is another patient. You can see the bluish dot or bluish hue of a testicle. Again, it's not red, but they present with pain, and it's difficult to sometimes tell between that and a torched testicle. The one clue is that you can see this blue dot or the fact that the testicle itself is in a normal eye position, so it's vertical again. If you can prove that this patient has that, then sometimes you don't have to operate. This is basically a tors dependence testes, uh, and that itself, usually use NSAIDs and it's more uh symptomatic nature. You don't necessarily need a surgery for that. That's what it looks like and I don't know if everybody takes them, but I, when I see it, we usually just take it out and excise them. Uh, so, an inguinal mass is not always a hernia, uh, depending on what you feel. This is outside the scrotum. Obviously, it could be the testicle has different places to descend, uh, and this is an instance where there's ectopic testes. Uh, mass is visible. Um, this was seen on ultrasound, oops, sorry, this was seen on ultrasound, uh, But they can be brought in with a, with an archiplexy. And obviously, sometimes there's other things in the hernia sac that we don't expect. This may not be a surprise if you know the patient obviously had a previous uh VP shunt, so this is not that unusual, but it can present in the hernia itself. So, more abdominal masses, these present with inguinal, inguinal masses, but this is obviously above the, the pelvic brim, and this is a uh abdominal mass. Um, this child had neuropathy and multiple UTIs and had, uh, evidence of, of, of bladder thickening on ultrasound. And what we found on VCEG was actually a bladder ear. So, the top of the bladder actually can extend actually into the hernia sac or into the abdominal wall. Another, another Bladder issue could be bladder diverticulum. Um, again, it presents as a super abdominal mass or extra inguinal mass. Um, and you can see the diverticulum as it, uh, goes above the bladder and pushes on the abdominal wall. Again, this child also had neuropathy, so there's a high risk of suspicion for patients like this who have um bladder issues, and they, the ultrasound also shows that there's a thickening of the bladder wall. Uh, this is in the operation. This is the trigon of the bladder and then this is the diverticulum itself, um, through the bladder, through the bladder wall. Uh, Richter's hernia. So, sometimes, um, if you cannot reduce something, uh, if, obviously, this is, this is an abdominal approach, but, uh, you see something that's in the hernia sac or in the hernia in, in the internal ring, uh, and a richter hernia implies that there's an appendix there. You all know what a Latrece's hernia is? A traces of Meckles that's in the inguinal hernia sac or in the inguinal canal. I don't have a picture of that. varicocele. So, usually it's a bag of worms and that, that, that people feel. Um, we usually don't operate on them unless, unless they're symptomatic. Uh, in this patient, you have to look at the whole patient, uh, because you have a, have to have a Heine suspicion for increased pressure. And for this patient, This is what we're looking at. Um, and so, obviously, sometimes if there's an abdominal mass, uh, this could be varico could be a sign of having increased abdominal pressure and a tumor. This is unusual where it's an inferior scrotal mass, um, Again, uh Some minor neuropathy with um frequent UTIs. Which is unusual in a male. Uh, and on VCEG they found a, um, Accessory, uh, ureter. So there's off, off the ureter, it extended blindly down the base of the scrotum. That could be excised um through the perineum. Who knows what Sigal and hernia is? So spigal hernia is Lateral to the rectus at the semi-arcuate line. There's a natural weakness there. Uh, and it's rare, uh, but kids present with abdominal wall masses on the side. And there's a weakness there. Sometimes they're repaired with mesh. Um, Doctor Fines always used, uh, primary repair. And then for a different canal and neck, we talked about female hernias. Uh, same inguinal crease. Right next to a ring. Uh, and that will lead you to the the external ring and the external bleak. Again, intubate the external ring, open up. This is the obliterated process vaginalis. It's attached to the um inguinal hernia. Twisting allegation has sack. Doctor Fines always talked about having a double internal ring. Uh, Skanalakis described this in, in, um, Fetal Descent, and so he's always trying to find below the internal rings, uh, to Apply a purse string suture. And then once the purse string was done on the internal ring, uh, we would always open it. Sometimes you find a sliding hernia, so fallopian tube. Ovary. Which could be reduced. And then high ligation, reduction of the Sliding component And then dun dunking the The inal hernia underneath the The purse string suture. Sometimes there's external masses, uh, in a, in a female, and usually that is obviously a, um, usually it's, it's an ovary. Unfortunately, sometimes they're at higher risk for having, uh, torsion. And those need to be repaired sooner rather than later. This child presented with a painless mass, um, but she had 3 weeks of pain that was not addressed and came in with a, uh, I'm sorry, forced ovary. Uh, I don't, I'm not sure what everybody's practice is, but Doctor Fins used to say that, do you know what Feins means in Yiddish? Bilateral. So he used to do bilateral hernias on almost everybody. Uh, and you can tell this is a surgery because he, the other one sitting over here. So femoral hernia, though obviously they present with inferior inferior, um, below the inguinal canal, uh, masses, uh. Below the inguinal ligament, um, and the hernia sac is below that next to the femoral veins. Uh, his idea was actually to take this, uh, and convert it to an inguinal incision, uh, and close. inguinal hernia and then close the defect with the purse string and then attach the, uh, almost like a bassini repair we attach that to the lacunar ligament. This was Uh, in a famous room. Doctor Chamber has this in his office still. Uh, do you know what ambidextrous was? You know what ambidextrous is? So, equally effective with both hands. So when Fines was, was Fines was telling me, um, he called me ambisinneros, you know what that means? Equally ineffective with both hands. Or you're in a bad mood. Uh, so I don't know how I flew through those sites so quickly, but, um, Any questions? One thing I have to say is, um, I need to talk about this man. Uh, who we lost not too recently. Uh, he, I love this name for his boat, Hydro Seal. He always had boats. He's an avid fisherman, avid sportsman. Um, he, for those of you who don't know him, he was born in Newark, New Jersey, very proud New Jersey man. He had a sister and they basically grew up on a family dairy farm. The finest farm is, the sign was just recently taken down a few years ago. He went to Weakwick High School, which he's very proud of. Uh, he was a boxer. His one of his contemporaries was actually Philip Roth, the, the author. He used to sing the fight song for Weak Wick High, and I can't, first of all, you don't want me to sing. Second, the last thing is, is that he, the last line was always, we keep matzos in our locker. So there's a big Jewish population in, in Newark, New Jersey. He went religiously to their reunions. This is him in his, uh, high school yearbook. This is hard to read and I apologize for this, but these are some of his classmates, what they remember, they remember these students and uh they have, so they have favorite. Let's see, favorite haunts, happy recollections, uh, favorite pastime, and then aspirations. So, Neil finds. He his His favorite haunt was with Boots or Joan. Sonny was his favorite recollection, which actually was his dog. Sleeping with the boys, I found out, means just hanging out with your friends, doing probably some delinquent stuff. And then, you can see this list. There's a couple of millionaires here. One person wanted to gain weight, so that must be some hard times. And then there are a couple of millionaires here, but Fines picked multi-millionaire. He's the only one in this group who decided to go further. He always had aspirations for for bigger than most of us. He eventually went to Jefferson Medical School in filthy, PA. That's his words, not mine. Um, and he trained in Columbus, Ohio, Doctor Clatworthy, at the time of Zollinger. He had some incredible stories about that. He eventually was trained in both pedia, in all pediatric surgery, sat for thoracic boards, and was grandfathered in physiology boards. He had a dual position, uh, here at the, at, uh, a neurology faculty and obviously was part of the VA program, professor of surgery for children. He started at the original BCH at Boston City Hospital in 1964. Basically covered every hospital south of that for many, many years. If they called him, he would go. So, he was a program director at Floating Hospital which where we, where we met, um, and I am sort of the, the Greek that sunk the floating hospital. I am the last fellow at, at floating hospital, and thanks to Doctor Ziegler and Doctor Shamburger, I have the privilege of standing here before you and Doctor Fishman and I cannot be uh more overjoyed, uh, but I thank you for their patience and their understanding. Um, I know it was fine I was coming here, not me, but I'm happy to tag along. Uh, this is Doctor Fines with, uh, Ruben, which is a professor, which is his partner at uh BMC. Uh, they did some incredible work there. It's a very busy service, um, in addition to the BU service, I was there. His, uh, lovely wife, Christine. He is a painter. You, we've all seen his paintings around the hospital and, uh, in some of our offices. Uh, he would, from her, I talked to her a couple, a couple of weeks ago actually, and he, she told me that when she would paint, when he would paint for her, he was a self-taught oil painter. When she would, when he would paint for her, he would leave an X that she would have to find in the paintings. Uh, so, her paintings to her are very special to her. Uh, he had 2 boys, uh, 2 sons, actually had, unfortunately, had 3 kids, um, and he lost a daughter very young to a tragic accident. Um, and if that wasn't bad enough, he was the first one to respond to the trauma room. He was on, he was happened to be in the hospital, unfortunately, he brought his daughter in. There's a memorial to her at Sashore Hospital where the trauma room is, and there's still a science memorial, um, science scholarship under Susan Feinstein of the Derby Academy where she went to school. He knew tragedy, but also knew happiness. He was, uh, an avid fisherman, loved to be outdoors. He loved his old cars and his Range Rovers. He took multiple fishing trips, would take multiple people on his boat, which he loved until the end. This is where he used to live in Cohasset. He would refer to himself sometimes as Doctor Fines in Brooklyn and Cohasset. He's very happy about that. This was um his initial house in Cohasset in Jerusalem Road. This is how close it was to the water and the storm of '78, apparently the waves would go over the house. And his boat was parked in the back for the most part. This picture is important because this Next picture is a painting that he actually, he would take a lot, he would photograph things. He would take a lot of pictures and then he would paint this. He painted this and it's sitting up at the South Shore Hospital um doctor's lounge. Dedicated to Doctor Fines. He had great places to live. He lived in a historic place in, in, in Rhode Island, uh, after he moved to Didn't want to be in the water anymore with in Cohassetity moved to a lighthouse and Um, in Rhode Island in Barrington, at Nya Point, just above the, the Kamicot River. This was his view. He would take pictures, paint them, uh. And very generous with his time. He was also an entrepreneur, uh, you know, innovator. He had an interesting life. He was a lobsterman for a while, and he actually did a talk about, uh, the, the GI tract of the lobsters and life cycle of the lobsters. I'm not sure how what IRB approved getting BEes on lobsters, but it happened and he did it. And I have those slides. I just have to find where they came from. He's an avid traveler. He, uh, went to the Galapagos, took pictures of the blue-footed, blue-footed boobies. I always had interesting facts. He always had a jokes from people, some of whom I can tell, some of I can't. Um. But he was an incredible person. Uh, he was an innovator. He had multiple interests both in a surgical, uh, he was an incredibly technical surgeon. He was an incredible teacher. He's an artist in his own right, traveled the world. He was an oracle to most of us. He couldn't really tell you, predict the future, but sometimes he can tell you what's gonna happen in your case pretty, uh, spectacularly, uh, and he was a friend. And I will uh miss him dearly. So thank you very much. Sorry, it's a quick time Well, thanks, Gus, and, and uh for, for your wisdom and, and particularly for honoring Doctor Fines that we all miss. Um. You were really his 4th child. I, I have to say I, I, I, I wanna say I spent more time with him probably than my own father. This was a big loss. Yeah, I know, he, he definitely viewed you as his son. Well, um, and thank you for bringing back, uh, we all, you know, you can still go into the ORs here a few years later, and there are still plenty of nurses who will recall some of the jokes that he told, which is, are not appropriate to repeat, um, in, in, in this, um, day and age, um, didn't always stop him, uh, and, uh, and he, he really had incredible wisdom, and he was the guy, um, you know, even though world-famous, you know. Professors when they had something they didn't know, like, I've never seen this before. Everybody would go down to Neil and say, what do you think this is? And he usually knew. He usually had a picture of it, and he usually had a picture of it, uh, and, and so, um, uh, thank you for doing him this, this honor, uh, and for reviving his, uh, his, um, his slides and his, we all remember the, the Barry Manma talk and on the lobsters, so those of us who are around, um, I, I would like to open up to questions, um, on, uh, your, um, vast experience and expertise which you had the. Um, incredible experience of operating with him, uh, more, more than anybody, uh, and, uh, and, uh, learning from his wisdom. So, uh, for those who wanna take on, uh, uh, uh, the challenging cases, uh, when it comes to the groin and rare hernias, um, uh, Gus is a guy who, who, who, um, uh, who's seen it, uh, and done it. If there's any questions, um, please. I'll start. I, I, I, um You know, we're in a Era of transformation uh in the way kind of routine. Indirectingal hernias are handled in pediatrics, um. And um I thought it was sort of generational, and then I was just an old guy who wasn't sort of Taken on the laparoscopic approach, um, there are some people older than me who are doing that operation, uh, and, uh, I've had the pleasure of learning from some of our fellows and other faculty how to do it, um, but I didn't realize until last Sunday, the Sunday before, when I got my absent questions, uh, that people are. Collecting data, you know, not really long term data, but collecting data, uh, on, on the outcomes, complications of, uh, laparoscopic approaches versus, um, versus open approaches. And I must admit that I've always felt like my incision for an inal hernia is, uh, you know, less than 1 centimeter, uh, or about 1 centimeter. Um, there's, they take some Tylenol afterwards, um. And the location of the of the scar is not particularly cosmetically concerning, so I've been wondering what the big advantage is, but I um have wondered about those big premie, you know, bilateral wheelbarrow hernias like you showed, um, and in the ABSA questions this Sunday, if people aren't subscribed to the ABSA um Sunday questions that you get, um, it's like a great Continuing education in pediatric surgery. It's, it's effortless and you get 3 questions every Sunday morning, uh, and, uh, they're well referenced and, and, and well described, um, and, uh, they talked, they, they showed, you know, the, the data, uh, and, and, and there was an argument that for premal hernias that there's actually an advantage. Um, I don't know what your view on this is, um, but I'm, I'm wondering if I need to do it or, or have somebody else do those cases. Uh, my, my view is actually, I'm not as facile as, as I like to be, so I'm still learning, but I think it's much easier to do this from the inside than it is from the outside pre me. I'm not, I, I think it's, I, I think it, there's definitely a learning curve, uh, and as long as you can control the, the hydrocele afterwards, I think that's, I think it's a great approach. I just, I'm just not as good at it as I should be. So that's one of the things I wondered about. Obviously the hydrocele will eventually go away just like a congenital hydrocele if you, but, but I imagine there's gonna be a big hydrocele after doing that in a, in a preemie. There's a big, there's a bigger rate of residual hydrocele for sure. Uh, I don't know exactly what the numbers are, but they're quoting at least 15%. So do people aspirate those in the office when they sort of come back? Uh, yeah, I've seen it done in the past I've been the audience who has a lot of experience with that Farro. I know you do a lot of these. Is that something that is problematic. I, I mean, I, I'm not sure what the overall data is and 15% is interesting to know, but, um, uh, for the ones that are, you, you know, you do the repair and like, oh, there's still a big hydrocele there and you expect it just in the OR I've just made a little, you know, this hydrocele drainage incision or drainage in the OR, um, but that's just what I've done, and it seemed to work pretty well. I haven't had any recurrences. And I did a couple hernias up in Lexington Monday, and one of the families, and I was doing it, I, I did a little, a little one out of the 17 year old, and the family of the 17 year old asked me if I was gonna use mesh. What is your view on mesh in pediatric or adolescent young adult hernias? I have not used it. And I, and I think the, there's Multiple complications with mesh, especially for pain and um discomfort afterwards, and I, if I don't, if the, if I can fix it, I would rather use primary repairs than I would for mesh, but that's just me personally. Now, in a 20 year old, that might be different, but in a seventeen-year-old, I would hopefully not be able to have to use it. Well, that's, uh, that was actually a sort of segue to my, the one question I have, which is, you said you weren't gonna talk about direct hernias, but like, in my mind, I always think about mesh is used in adults because it's usually a direct hernia in adults. But like in peds, we're deal with indirect hernias. Like, have you ever seen a real direct hernia in a child that was like, not, you know, you do an inguinal hernia and you see a little weak floor, but a true direct hernia without an indirect hernia. Is that something, because I think about it in like adolescence, but I don't know if I need, if it really exists and I've, I've seen it, yeah, and I mean, I've used mesh infrequently, but I have seen that, that one, that one time where we had, we had to put it in because there was really nothing to repair. It was just a direct hernia, not indirect hernia, right. Yeah, that's, that's one of the issues about Laparoscopic approach in that people will lose the experience of doing them open, and that rare time when you get in there and it's a direct hernia, which does happen, but it's very, very, very, very rare. Um, I'm not sure people are gonna know how to repair it, and I'm not sure that laparoscopic approach is the way to do that. And uh the same thing for femoral hernia, which is a completely different approach, but um, nobody knows where Cooper's ligament is anymore, but that's the proper way to repair a femoral hernia. Uh, and, uh, it's interesting we showed that, uh, the way that, that Neil did it, uh, that's not, not the traditional, uh, Cooper ligament. Um, any of your questions or comments? Nothing there. Great. Well, thanks so much. Thank you very much. It's really been an honor. Thank you very much. Well, thank you, uh, for, for honoring us with, with, um, with Doctor Fine's memory. Thank you. Thank you.